Reason for the visit

In our prior research, we designated StrongMinds (‘SM’) as one of our ‘top’ charities: it is one of the best opportunities we have evaluated, so far, for cost-effectively improving wellbeing in the world. We hadn’t conducted an in-person site visit before, and given that SM runs on-the-ground programmes, we thought a visit could help us better understand the programme and the people involved in it – in a way that reading studies and reports does not. We don’t expect site visits can, or should, be decisive for evaluation purposes (they are ‘anecdata’), but they can nevertheless be informative. What’s more, when enough donor money is at stake, checking for ourselves that the programme is operating as expected, seems appropriate due diligence.

About this document

This is written as my (Michael’s) personal reflections and primarily for internal purposes. Even though I am the Research Director, what I say does not necessarily represent the collective, considered views of HLI.

Overview of the visit

• 9:30-10:30 am: Arrival and introduction
  • I, Dr Michael Plant, accompanied by my partner, Jasmine, arrived at the StrongMinds (‘SM’) offices in Kampala and was greeted by the leadership team. They provided an overview of their programme and walked us through the client journey. I asked various questions throughout the day.
• 10:30-12:00 pm: Travel to meet SM facilitators
  • We travelled to a local community centre and met around 10 SM facilitators who shared their experiences. The group welcomed us with joyful singing and dancing and spoke highly of SM.
• 12:00-1:00 pm: Travel to a local market and meeting former clients 
  • At the market, we met about 20 former clients, including 3-5 couples who had gone through the SM programme separately, but at the same time. The clients expressed joy and gratitude towards SM.
• 1:00-4:00 pm: Travel and observation of therapy
  • In the Kireka-Banda community, we observed a group therapy session for adult women in its third week of the six-week programme. The session was led by a peer facilitator, and the district programme coordinator live-translated what was said into English.
  • The participants appeared visibly depressed, with little to no smiling, silence upon arrival, and quiet speech.
• 4:00-4:30 pm: Travel back and debrief with leadership team
  • We debriefed with the leadership team, addressing remaining questions and reflecting on the visit.
• 4:30 pm: Departure 

Reflections and insights

From what I saw and learnt, SM’s programme is highly structured, adhered to, and monitored. Each facilitator runs at least two groups four to five times a year, each lasting six weeks with a maximum of 10 participants. The facilitators follow a set programme, using notes and manuals for each session. Mental health scores are collected via SMS before and after the six-week programme, and clients share their ‘burden’ levels on a 0-3 scale at each session.

The structured nature of the programme means that facilitators, who may not be specialists, can nevertheless deliver the sessions. Although six weeks might be thought a short-course of therapy, I can believe the programme would be quite high intensity and impactful by bringing a local group of isolated people together regularly and providing peer support and psychoeducation. 

Notably, there were many men present and involved in the programme. These men had also been through the SM programme, generally in parallel with their female partners. There were about seven men in a group of about 20 past clients. Their openness about their experiences and the improvements in their relationships was particularly striking because men are often more reluctant to discuss mental health issues publicly – a significant vote of confidence in SM’s effectiveness.

SM and its facilitators seemed professional and dedicated  and the programme is a credible and well-executed effort to address depression at scale in LICs. I found them to be proficient implementers with a real focus on monitoring and evaluation. While cost-effectiveness remains to be definitively evaluated, I came away believing the programme had made a real difference: there was a striking and palpable disparity between the current clients (who barely spoke on arrival and seemed very down) to the past clients (who were joyful and exuberant and thankful to StrongMinds). Meeting the clients and facilitators in person was particularly moving and provided insights that cannot be fully appreciated through reports or data alone.

Personal stories and impact

I met past and current clients in three groups: past clients, now facilitators; past clients; and current clients. These accounts offer a qualitative, human perspective on the programme’s impact. I have not included any personal stories from current clients to respect their privacy and confidentially in ongoing sessions. They spoke some English, but their first language was Luganda. SM’s district programme coordinator and supervisors were bilingual and acted as translators.

Betty (past client turned facilitator)

Betty found SM in 2014 at a time when she was feeling suicidal due to unmanageable debts. She had been running a business buying bananas in bulk and reselling them, but her transport vehicle broke down, which she couldn’t afford to repair or replace. This loss led to her losing her home and becoming deeply ashamed, contemplating suicide. Her relationship with her husband also suffered, leading to their separation.

With the encouragement of her SM group, Betty began washing clothes to earn money and gradually repaid her debts. Listening to other group members’s stories helped her shift her perspective by showing her that others had even more severe problems. This support network was crucial in her emotional recovery. Her homework assignment from therapy was to reach out to her estranged husband, which she did, and they reconciled. Together, they have started a new business, and their relationship has improved significantly.

Nora (past client)

Nora was visibly distressed when approached by SM staff in the market. She had lost her job during the COVID-19 pandemic and was struggling to support her family while her husband drank heavily. Nora attended an SM meeting where she learned about the signs of depression, realising she had many of them. Initially hesitant to share her story, she was reassured by the confidentiality promised by the group.

Through therapy, Nora understood the impact of her anger on her family and worked on changing her behaviour. Her husband’s support became evident when he bought her a new phone after she lost hers, a gesture that meant a lot to her. They even visited his family, which was a significant step for them, indicating a stronger, more supportive relationship. Nora made an emotional plea to SM to continue their work, highlighting the profound change the therapy had brought to her life and family dynamics.

Key questions and reassurances

90% completion rate

Could SM really achieve, as the internal data they shared with us shows, a 90% completion rate for their six-week programme, i.e. 90% of those who join do all six sessions? Based on the visit, this high adherence rate seems plausible due to several factors:

• Short duration and high demand: The programme’s short duration of just six weeks makes it manageable for participants to commit. Each area runs the course in designated cycles with limited slots, ensuring high demand.
• Local sessions: Sessions are held in local areas where participants work or live, making attendance convenient.
• Continuous monitoring and social accountability: The group’s social dynamics and continuous monitoring encourage regular attendance. Each session begins with a roll call, and participants are asked to rate their burden levels on a 0-3 scale, fostering accountability.
• Supportive environment: Homework assignments and the supportive group environment further motivate participants to complete the programme. Sessions are 90 minutes long, allowing participants to fit them into their daily routines, even bringing children if necessary (as observed with four children among ten women).

Accuracy of self-reports and understanding response scales

How reliable are the self-reported data on mental health outcomes from the participants? In the therapy sessions, participants used a 0-3 burden scale to indicate their levels of distress.This scale was explained with visual aids and in the local language, ensuring participants understand how to use it correctly. From observation, participants had no problem using this scale and self-reported burden levels corresponded with their visible emotional states, suggesting accurate self-reporting.

SM also employs an external organisation to collect follow-up data on mental health outcomes and client satisfaction at two and six months post-therapy. This external data collection adds an additional layer of reliability to the self-reported data.

Partners for scaling strategy

SM collaborates with other NGOs that provide programmes focused on areas such as maternal health or HIV. These programmes incorporate a mental health component from SM to enhance their overall effectiveness. SM and the partner co-create and implement the programme, although the exact number of people treated through these partnerships who can be causally attributed to SM’s work remains unclear.

SM reported that incorporating mental health elements from their toolkit improved adherence to HIV programmes, and this was an important proof-case for how, as they put it “our programme makes your programme better”. 

We did not get a clear sense of what an adapted programme through a partner would look like, and how effective it would be. To gain a better understanding, we need to examine specific examples. As SM is not directly implementing these programmes, the cost per client treated via partners is presumably lower than if SM did it themselves. However, the effectiveness of treatment for individuals might also be lower.

Possible implications and research topics

Some specific areas for the HLI research team to look into.

• Mental health education and awareness: evaluating the impact of SM on reducing stigma and improving mental health outcomes in communities with low initial awareness. 
• Integration and cost-effectiveness of partner programmes: analysing the cost-effectiveness of SM’s programme delivered through partnerships with other NGOs and exploring how it affects the overall effectiveness for participants.
• Peer support networks: investigating how the peer support network within SM’s programme contributes to participants’ recovery and sustained mental health improvements post-therapy.

The visit reinforced the value of the StrongMinds programme and its approach to community mental health. Continued support and research will be crucial in enhancing its impact and ensuring its sustainability.

Author: Dr Michael Plant

19 April 2024