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Hiltensperger R, Ryan G, Ben-Dor IA, Charles A, Epple E, Kalha J, Korde P, Kotera Y, Mpango R, Moran G, Mueller-Stierlin AS, Nixdorf R, Ramesh M, Shamba D, Slade M, Puschner B, Nakku J. Implementation of peer support for people with severe mental health conditions in high-, middle- and low-income-countries: a theory of change approach. BMC Health Serv Res 2024; 24:480. [PMID: 38637776 PMCID: PMC11027518 DOI: 10.1186/s12913-024-10990-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/14/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Stakeholder engagement is essential to the design, implementation and evaluation of complex mental health interventions like peer support. Theory of Change (ToC) is commonly used in global health research to help structure and promote stakeholder engagement throughout the project cycle. Stakeholder insights are especially important in the context of a multi-site trial, in which an intervention may need to be adapted for implementation across very different settings while maintaining fidelity to a core model. This paper describes the development of a ToC for a peer support intervention to be delivered to people with severe mental health conditions in five countries as part of the UPSIDES trial. METHODS One hundred thirty-four stakeholders from diverse backgrounds participated in a total of 17 workshops carried out at six UPSIDES implementing sites across high-, middle- and low-income settings (one site each in India, Israel, Uganda and Tanzania; two sites in Germany). The initial ToC maps created by stakeholders at each site were integrated into a cross-site ToC map, which was then revised to incorporate additional insights from the academic literature and updated iteratively through multiple rounds of feedback provided by the implementers. RESULTS The final ToC map divides the implementation of the UPSIDES peer support intervention into three main stages: preparation, implementation, and sustainability. The map also identifies three levels of actors involved in peer support: individuals (service users and peer support workers), organisations (and their staff members), and the public. In the UPSIDES trial, the ToC map proved especially helpful in characterising and distinguishing between (a) common features of peer support, (b) shared approaches to implementation and (c) informing adaptations to peer support or implementation to account for contextual differences. CONCLUSIONS UPSIDES is the first project to develop a multi-national ToC for a mental health peer support intervention. Stakeholder engagement in the ToC process helped to improve the cultural and contextual appropriateness of a complex intervention and ensure equivalence across sites for the purposes of a multi-site trial. It may serve as a blueprint for implementing similar interventions with a focus on recovery and social inclusion among people with mental ill-health across diverse settings. TRIAL REGISTRATION ISRCTN26008944 (Registration Date: 30/10/2019).
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Affiliation(s)
| | - Grace Ryan
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Inbar Adler Ben-Dor
- Department of Social Work, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Ashleigh Charles
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Ellen Epple
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | - Jasmine Kalha
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Palak Korde
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Yasuhiro Kotera
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Richard Mpango
- Butabika National Referral Hospital, Kampala, Uganda
- Department of Mental Health, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Galia Moran
- Department of Social Work, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | | | - Rebecca Nixdorf
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mary Ramesh
- Department of Health Systems Impact Evaluation and Policy, Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Donat Shamba
- Department of Health Systems Impact Evaluation and Policy, Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
- Health and Community Participation Division, Nord University, Namsos, Norway
| | - Bernd Puschner
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | - Juliet Nakku
- Butabika National Referral Hospital, Kampala, Uganda
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Mukherjee A, Yatirajula SK, Kallakuri S, Paslawar S, Lempp H, Raman U, Essue BM, Sagar R, Singh R, Peiris D, Norton R, Thornicroft G, Maulik PK. Using formative research to inform a mental health intervention for adolescents living in Indian slums: the ARTEMIS study. Child Adolesc Psychiatry Ment Health 2024; 18:14. [PMID: 38245796 PMCID: PMC10800058 DOI: 10.1186/s13034-024-00704-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/05/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Adolescents are vulnerable to stressors because of the rapid physical and mental changes that they go through during this life period. Young people residing in slum communities experience additional stressors due to living conditions, financial stress, and limited access to healthcare and social support services. The Adolescents' Resilience and Treatment nEeds for Mental Health in Indian Slums (ARTEMIS) study, is testing an intervention intended to improve mental health outcomes for adolescents living in urban slums in India combining an anti-stigma campaign with a digital health intervention to identify and manage depression, self-harm/suicide risk or other significant emotional complaints. METHODS In the formative phase, we developed tools and processes for the ARTEMIS intervention. The two intervention components (anti-stigma and digital health) were implemented in purposively selected slums from the two study sites of New Delhi and Vijayawada. A mixed methods formative evaluation was undertaken to improve the understanding of site-specific context, assess feasibility and acceptability of the two components and identify required improvements to be made in the intervention. In-depth interviews and focus groups with key stakeholders (adolescents, parents, community health workers, doctors, and peer leaders), along with quantitative data from the digital health platform, were analysed. RESULTS The anti-stigma campaign methods and materials were found to be acceptable and received overall positive feedback from adolescents. A total of 2752 adolescents were screened using the PHQ9 embedded into a digital application, 133 (4.8%) of whom were identified as at high-risk of depression and/or suicide. 57% (n = 75) of those at high risk were diagnosed and treated by primary health care (PHC) doctors, who were guided by an electronic decision support tool based on WHO's mhGAP algorithm, built into the digital health application. CONCLUSION The formative evaluation of the intervention strategy led to enhanced understanding of the context, acceptability, and feasibility of the intervention. Feedback from stakeholders helped to identify key areas for improvement in the intervention; strategies to improve implementation included engaging with parents, organising health camps in the sites and formation of peer groups. TRIAL REGISTRATION The trial has been registered in the Clinical Trial Registry India, which is included in the WHO list of Registries, Reference number: CTRI/2022/02/040307. Registered 18 February 2022.
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Affiliation(s)
| | | | | | | | - Heidi Lempp
- Centre for Rheumatic Diseases, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Usha Raman
- Department of Communication, University of Hyderabad, Hyderabad, India
| | - Beverley M Essue
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | | | - David Peiris
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Robyn Norton
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- The George Institute for Global Health, Imperial College London, London, UK
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Pallab K Maulik
- The George Institute for Global Health, New Delhi, India.
- The George Institute for Global Health, Imperial College London, London, UK.
- University of New South Wales, Sydney , Australia.
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van der Boor C, Andersen LS, Massazza A, Tol WA, Taban D, Roberts B, Ssebunnya J, Kinyanda E, May C, Nadkarni A, Fuhr D. Using theory of change to plan for the implementation of a psychological intervention addressing alcohol use disorder and psychological distress in Uganda. Glob Ment Health (Camb) 2024; 11:e6. [PMID: 38283880 PMCID: PMC10808976 DOI: 10.1017/gmh.2023.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/30/2024] Open
Abstract
In conflict-affected settings, prevalence of alcohol use disorders (AUDs) can be high. However, limited practical information exists on AUD management in low-income settings. Using a theory of change (ToC) approach, we aimed to identify pathways influencing the implementation and maintenance of a new transdiagnostic psychological intervention ("CHANGE"), targeting both psychological distress and AUDs in humanitarian settings. Three half-day workshops in Uganda engaged 41 stakeholders to develop a ToC map. ToC is a participatory program theory approach aiming to create a visual representation of how and why an intervention leads to specific outcomes. Additionally, five semi-structured interviews were conducted to explore experiences of stakeholders that participated in the ToC workshops. Two necessary pathways influencing the implementation and maintenance of CHANGE were identified: policy impact, and mental health service delivery. Barriers identified included policy gaps, limited recognition of social determinants and the need for integrated follow-up care. Interviewed participants valued ToC's participatory approach and expressed concerns about its adaptability in continuously changing contexts (e.g., humanitarian settings). Our study underscores ToC's value in delineating context-specific outcomes and identifies areas requiring further attention. It emphasizes the importance of early planning and stakeholder engagement for sustainable implementation of psychological interventions in humanitarian settings.
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Affiliation(s)
- Catharina van der Boor
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Lena S. Andersen
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Alessandro Massazza
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Wietse A. Tol
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Athena Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Joshua Ssebunnya
- Mental Health Focus Area, MRC/UVRI & LSHTM Uganda Research Unit/MRC Investigator, Entebbe, Uganda
| | - Eugene Kinyanda
- Mental Health Focus Area, MRC/UVRI & LSHTM Uganda Research Unit/MRC Investigator, Entebbe, Uganda
| | - Carl May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Abhijit Nadkarni
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Addictions and Related Research Group, Sangath, Goa, India
| | - Daniela Fuhr
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology, Bremen, Germany
- Health Sciences, University of Bremen, Bremen, Germany
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Mateo‐Arriero I, Lalovic A, Dowden G, Markey L, Cox KL, Flicker L, Bessarab D, Thompson S, Kickett C, Woods D, Pestell CF, Edgill P, Etherton‐Beer C, Smith K. Co-design of dementia prevention program for Aboriginal Australians (DAMPAA). Alzheimers Dement 2023; 19:4564-4571. [PMID: 36933191 PMCID: PMC10955769 DOI: 10.1002/alz.13032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Dementia is highly prevalent in older Aboriginal Australians, with several modifiable risk factors. Currently, there is limited evidence on how to prevent cognitive decline in Aboriginal Australians. METHODS Based on our Theory of Change (ToC) framework, we co-developed the Dementia risk management and prevention program for Aboriginal Australians (DAMPAA) aged over 45 years in partnership with Aboriginal community-controlled organizations (ACCOs) and Elders. Qualitative data were collected through ACCO staff workshops, Elders yarning, and governance groups to inform the protocol. Additionally, we conducted a small pilot study. RESULTS Expected DAMPAA ToC outcomes are: (1) improved daily function, (2) better cardiovascular risk management, (3) falls reduction, (4) improved quality of life, and (5) reduced cognitive decline. Attendance enablers are social interaction, environment, exercise type/level, and logistics. DISCUSSION Findings suggest that ToC is an effective collaborative approach for co-designing Aboriginal health programs.
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Affiliation(s)
- Irene Mateo‐Arriero
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Alexander Lalovic
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Glennette Dowden
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Lesley Markey
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Kay L. Cox
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
- West Australian Centre for Health and AgeingUniversity of Western AustraliaPerthWAAustralia
| | - Leon Flicker
- West Australian Centre for Health and AgeingUniversity of Western AustraliaPerthWAAustralia
| | - Dawn Bessarab
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Sandra Thompson
- Western Australian Centre for Rural HealthUniversity of Western AustraliaGeraldtonWAAustralia
| | | | - Deborah Woods
- Geraldton Regional Aboriginal Medical ServiceGeraldtonWAAustralia
| | - Carmela F. Pestell
- School of Psychological ScienceUniversity of Western AustraliaPerthWAAustralia
| | - Paula Edgill
- Derbarl Yerrigan Health ServiceEast PerthWAAustralia
| | | | - Kate Smith
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
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Breuer E, Morris A, Blanke L, Pearsall M, Rodriguez R, Miller BF, Naslund JA, Saxena S, Balsari S, Patel V. A theory of change for community-initiated mental health care in the United States. Glob Ment Health (Camb) 2023; 10:e56. [PMID: 37854428 PMCID: PMC10579655 DOI: 10.1017/gmh.2023.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023] Open
Abstract
Mental health service delivery needs radical reimagination in the United States where unmet needs for care remain large and most metrics on the burden of mental health problems have worsened, despite significant numbers of mental health professionals, spending on service provision and research. The COVID-19 pandemic has exacerbated the need for mental health care. One path to a radical reimagination is "Community Initiated Care (CIC)" which equips and empowers communities to address by providing brief psychosocial interventions by people in community settings. We co-developed a theory of change (ToC) for CIC with 24 stakeholders including representatives from community-based, advocacy, philanthropic and faith-based organizations to understand how CIC could be developed and adapted for specific contexts. We present a ToC which describes ways in which the CIC initiative can promote and strengthen mental health in communities in the United States with respect to community organization and leadership; community care and inclusion and normalizing mental health. We propose 10 strategies as part of CIC and propose a way forward for implementation and evaluation. This CIC model is a local, tailored approach which can expand the role of community members to strengthen our response to mental health needs in the United States.
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Affiliation(s)
- Erica Breuer
- College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - Angelika Morris
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Miriam Pearsall
- National Academy for State Health Policy (NASHP), Portland, ME, USA
| | | | - Benjamin F. Miller
- Department of Psychiatry and Behavioural Sciences, Stanford School of Medicine, Palo Alto, CA, USA
| | - John A. Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Shekhar Saxena
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Satchit Balsari
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Votruba N, Praveen D, Mellers L, Rajan E, Thout SR, Arora V, Malik Y, Kashyap A, Majumdar S, Hirst J, Maulik PK. SMARThealth PRegnancy And Mental Health study: protocol for a situational analysis of perinatal mental health in women living in rural India. Front Glob Womens Health 2023; 4:1143880. [PMID: 37575961 PMCID: PMC10416114 DOI: 10.3389/fgwh.2023.1143880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction The situation for women experiencing mental health problems during pregnancy and postpartum in rural India is critical: a high burden of disease, a high estimated number of women are undiagnosed and untreated with mental health problems, a substantial gap in research on women's perinatal health, and severe stigma and discrimination. The SMARThealth Pregnancy study is a cluster randomised trial using a digital intervention to identify and manage anaemia, hypertension, and diabetes in the first year after birth in rural India. Within this study, the SMARThealth Pregnancy and Mental Health (PRAMH) study is a situational analysis to understand mental health problems during pregnancy and in the first year following birth in this population. Methods/design This situational analysis aims to analyse and to assess the context of perinatal mental health, health services, barriers, facilitators, and gaps in Siddipet district of Telangana state in India, to develop an implementation framework for a future intervention. A tested, standardised situational analysis tool will be adapted and applied to perinatal mental health in rural India. A desktop and policy review will be conducted to identify and analyse relevant mental health and pregnancy care policies at the national and state levels. We will conduct in-depth interviews with policymakers, planners, mental health professionals and other experts in perinatal mental health (n = 10-15). We will also conduct focus group discussions with key stakeholders, including women with perinatal mental health problems, their families and carers, and community health workers (n = 24-40). A theory of change workshop with key stakeholders will be conducted which will also serve as a priority setting exercise, and will clarify challenges and opportunities, priorities, and objectives for a pilot intervention study. The analysis of qualitive data will be done using thematic analysis. Based on the data analysis and synthesis of the findings, an implementation framework will be developed to guide development, testing and scale up of a contextually relevant intervention for perinatal mental health. Discussion The situational analysis will help to establish relationships with all relevant stakeholders, clarify the context and hypotheses for the pilot intervention and implementation.
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Affiliation(s)
- Nicole Votruba
- Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, Imperial College London, London, United Kingdom
| | - Devarsetty Praveen
- The George Institute for Global Health India, New Delhi, India
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Mellers
- Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Eldho Rajan
- The George Institute for Global Health India, New Delhi, India
| | | | - Varun Arora
- Post Graduate Institute of Medical Science, Rohtak, India
| | - Yogender Malik
- Department of Psychiatry, Institute of Mental Health (IMH), University of Health Sciences PGIMS, Rohtak, India
| | - Aditya Kashyap
- SVS Institute of Neurosciences, Government Medical College, Siddipet, India
| | - Sreya Majumdar
- The George Institute for Global Health India, New Delhi, India
| | - Jane Hirst
- Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, Imperial College London, London, United Kingdom
| | - Pallab K. Maulik
- The George Institute for Global Health India, New Delhi, India
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Abstract
The field of global mental health (GMH) has undergone profound changes over the past decade. Outgrowing its earlier agenda it has performed a reflexive turn, broadened towards a social paradigm and developed new modes of knowledge production, all of which reshaped 'mental health' as a global object of knowledge and care, and the epistemic politics of the field. Drawing on long-term ethnographic fieldwork among GMH experts and recent agenda-setting publications, I discuss how GMH advocates and critical observers alike have created conceptual and practical middle-grounds between different forms of mental health knowledge - across culture, epistemic power, lived experience, policy platforms and academic disciplines - framing their dynamic encounters as dialogue, adaptation, participation, co-production or integration. Ultimately, I argue, GMH today is focusing less on establishing mental health as a universal problem than on managing its inherent multiplicity through alignment and integration across different bodies of knowledge. Global knowledge, so conceived, is fluid and malleable and produced in open-ended knowledge practices, governed by what I call 'contingent universality'. It is not new that the concepts and practices of the psy-disciplines are malleable and multiple, internally and externally contested, rapidly changing over time and not easily transferrable across space. What is new is that within the increasingly heterogenous epistemic space of GMH, these features have become assets rather than liabilities. GMH knowledge achieves both global reach and local relevance precisely because 'mental health' can be many things; it can be expressed in a wide range of idioms and concepts, and its problems and solutions align easily with others, at many scales. These fluid and integrative knowledge practices call for renewed empirical, critical and collaborative engagement.
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Bunn M, Christopher E, Polutnik-Smith C, McCoy J, Hanneke R, King M, Ellis BH, Cardeli E, Weine S. Rehabilitation and Reintegration of Women and Children Returning from Violent Extremist Contexts: A Rapid Review to Inform Program and Policy Development. TERRORISM AND POLITICAL VIOLENCE 2023; 36:455-487. [PMID: 38784065 PMCID: PMC11114743 DOI: 10.1080/09546553.2023.2169143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
This rapid review used a systematic approach to examine the available literature on rehabilitation and reintegration (R&R) programs for women and children returning from contexts of violent extremism, examining common assumptions, inputs, activities and outcomes across diverse settings. Fifty-one documents including peer reviewed articles and grey literature were included in the analysis. The most common program activities identified included mental health services, community level social programs, promoting school and vocational enrollment, regular health services, and parenting training & education, though there was a lack of consensus around core program components. The analysis points to the need for a robust set of inputs and resources to implement R&R programs including government officials, child welfare, mental health professionals, teachers, law enforcement, healthcare, community leaders, and extended family. The review also uncovered a number of gaps. This includes the need to create clear and analytically distinct definitions of rehabilitation and reintegration that are applicable and relevant to key stakeholders, delineating age-appropriate activities and outcomes for young children, youth, and adults, defining frameworks for service delivery and coordination of stakeholders, and placing R&R programs within existing domains of public safety and restorative justice.
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Affiliation(s)
- Mary Bunn
- Department of Psychiatry, Center for Global Health, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Enryka Christopher
- Department of Psychiatry, Center for Global Health, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
- Trauma and Community Resilience Center, Department of Psychiatry, Boston Children’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Chloe Polutnik-Smith
- Department of Psychiatry, Center for Global Health, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - John McCoy
- Organization for the Prevention of Violence, Edmonton, Alberta, Canada
| | - Rosie Hanneke
- Information Services & Research Department, Library of the Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael King
- Organization for the Prevention of Violence, Edmonton, Alberta, Canada
| | - B. Heidi Ellis
- Trauma and Community Resilience Center, Department of Psychiatry, Boston Children’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Emma Cardeli
- Trauma and Community Resilience Center, Department of Psychiatry, Boston Children’s Hospital & Harvard Medical School, Boston, MA, USA
| | - Stevan Weine
- Department of Psychiatry, Center for Global Health, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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Girit S, Müller-Stierlin AS, Hiltensperger R, Wenzel L, Lohner M, Mahlke C, Nixdorf R, Puschner B. [Successful Implementation of Peer Support for People with Severe Mental Illness in Germany: a Theory of Change Approach]. Psychother Psychosom Med Psychol 2023; 73:70-77. [PMID: 35793668 DOI: 10.1055/a-1827-4040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Peer support is an established intervention in which people with mental illness receive support by trained peer support workers who have already overcome a mental health crisis. The implementation of peer support is complex due to interacting factors and can be achieved through the participatory Theory of Change method. Aim of this study is to develop a cross-site Theory of Change for the sustainable implementation of UPSIDES peer support in Germany. METHODS Based on site-specific Theories of Change workshops from Ulm and Hamburg in which 47 participants took part, a cross-site Theory of Change was designed and verified in three follow-up workshops with 12 participants. Participants' professional and experiential backgrounds were diverse, including peer support workers, hospital directors and managers, mental health professionals (psychiatrists, psychotherapists, nurses), and researchers. RESULTS The first pathway of the cross-site Theory of Change focuses on the training of peer support workers, whereas the second pathway emphasizes recognition and integration by mental health institutions and professionals. The third pathway specifies the building of a cross-professional care network to integrate various peer support services. Procedures to approach prospective peer clients are depicted in the fourth pathway. The fifth path addresses the clarification of the role description of peer support workers and the implementation in other institutions through cooperation. DISCUSSION Many of the identified implementation steps have been validated in comparable studies. The development of this Theory of Change by bringing together multiple perspectives of key stakeholders is an important basis for the sustainable implementation of UPSIDES peer support. Furthermore, it may serve as a blueprint for the implementation of similar interventions to advance scaling-up of evidence-based user-led and recovery-oriented interventions. CONCLUSION The Theory of Change approach is a well-accepted and feasible method, which can be recommended for the implementation of complex interventions such as UPSIDES peer support.
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Affiliation(s)
- Selina Girit
- Klinik für Psychiatrie und Psychotherapie II, Universität Ulm, Günzburg, Germany
| | | | - Ramona Hiltensperger
- Klinik für Psychiatrie und Psychotherapie II, Universität Ulm, Günzburg, Germany
| | - Lisa Wenzel
- Klinik für Psychiatrie und Psychotherapie II, Universität Ulm, Günzburg, Germany
| | - Manfred Lohner
- Klinik für Psychiatrie und Psychotherapie II, Universität Ulm, Günzburg, Germany
| | - Candelaria Mahlke
- AG sozialpsychiatrische und partizipative Forschung, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rebecca Nixdorf
- AG sozialpsychiatrische und partizipative Forschung, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Puschner
- Klinik für Psychiatrie und Psychotherapie II, Universität Ulm, Günzburg, Germany
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Petagna M, Marley C, Guerra C, Calia C, Reid C. Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review. Community Ment Health J 2023; 59:192-204. [PMID: 35579725 PMCID: PMC9813022 DOI: 10.1007/s10597-022-00981-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted. AIMS We evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation. METHODS Thirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health. RESULTS Twelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers. CONCLUSIONS Further attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit.
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Affiliation(s)
- Marta Petagna
- School of Health in Social Sciences, The University of Edinburgh, Edinburgh, UK
| | - Charles Marley
- School of Allied Health Science and Practice, The University of Adelaide, Engineering & Mathematical Sciences Building, North Terrace, 5001, Adelaide, Australia.
| | | | - Clara Calia
- School of Health in Social Sciences, The University of Edinburgh, Edinburgh, UK
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Chaudhuri A, Biswas N, Kumar S, Jyothi A, Gopinath R, Mor N, John P, Narayan T, Chatterjee M, Patel V. A theory of change roadmap for universal health coverage in India. Front Public Health 2022; 10:1040913. [PMID: 36530728 PMCID: PMC9751860 DOI: 10.3389/fpubh.2022.1040913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/03/2022] [Indexed: 12/04/2022] Open
Abstract
The Theory of Change (ToC) approach is one of the methodologies that the Lancet Citizens' Commission has chosen to build a roadmap to achieving Universal Healthcare (UHC) in India in the next 10 years. The work of the Citizens' Commission is organized around five workstreams: Finance, Human Resources for Health (HRH), Citizens' Engagement, Governance, and Technology. Five ToC workshops were conducted, one for each workstream. Individual workshop outputs were then brought together in two cross-workstream workshops where a sectoral Theory of Change for UHC was derived. Seventy-four participants, drawn from the Commission or invited for their expertise, and representing diverse stakeholders and sectors concerned with UHC, contributed to these workshops. A reimagined healthcare system achieves (1) enhanced transparency, accountability, and responsiveness; (2) improved quality of health services; (3) accessible, comprehensive, connected, and affordable care for all; (4) equitable, people-centered and safe health services; and (5) trust in the health system. For a mixed system like India's, achieving these high ideals will require all actors, public, private and civil society, to collaborate and bring about this transformation. During the consultation, paradigm shifts emerged, which were structural or systemic assumptions that were deemed necessary for the realization of all interventions. Critical points of consensus also emerged from the workshops, such as the need for citizen-centricity, greater efficiency in the use of public finances for health care, shifting to team-based managed care, empowerment of frontline health workers, the appropriate use of technology across all phases of patient care, and moving toward an articulation of positive health and wellbeing. Critical areas of contention that remained related to the role of the private sector, especially around financing and service delivery. Few issues for further consultation and research were noted, such as payment for performance across both public and private sectors, the use of accountability metrics across both public and private sectors, and the strategies for addressing structural barriers to realizing the proposed paradigm shifts. As the ToCs were developed in expert groups, citizens' consultations and consultations with administrative leaders were recommended to refine and ground the ToC, and therefore the roadmap to realize UHC, in people's lived reality.
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Affiliation(s)
| | | | - Shiv Kumar
- Catalyst Group, Swasti Health Catalyst, Bangalore, India
| | - Asha Jyothi
- Catalyst Group, Swasti Health Catalyst, Bangalore, India
| | | | - Nachiket Mor
- The Banyan Academy of Leadership in Mental Health, Thiruvidanthai, India
| | - Preethi John
- Global Business School for Health, University College London, London, United Kingdom
| | - Thelma Narayan
- Centre for Public Health and Equity (SOCHARA), Bangalore, India
| | | | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, United States,*Correspondence: Vikram Patel
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Babatunde GB, van Rensburg AJ, Bhana A, Petersen I. Identifying multilevel and multisectoral strategies to develop a Theory of Change for improving child and adolescent mental health services in a case-study district in South Africa. Child Adolesc Psychiatry Ment Health 2022; 16:45. [PMID: 35717400 PMCID: PMC9206219 DOI: 10.1186/s13034-022-00484-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The lack of child and adolescent mental health (CAMH) policies and implementation plans constitute major barriers to CAMH services in low resource settings. Engaging with on-the-ground stakeholders to identify possible contextually appropriate strategies for developing a CAMH collaborative system and inform CAMH plans and policies is important to ensure that resultant policies and plans are feasible and appropriate. Together with key stakeholders across multiple sectors, this study aims to (i) co-identify causal factors and potential strategies to overcome bottlenecks in one district in SA as a case study; and (ii) Co-develop a Theory of Change (ToC) for increasing access to CAMH services within the resource constraints of a remote resource-scarce district as a case study. METHODS A participatory workshop was held with key stakeholders (n = 40) from the Departments of Health (DoH), Basic Education (DBE), and Social Development (DSD) and three community-based organisations offering CAMH services in the district. The stakeholders identified context-specific causal factors and possible strategies to address the bottlenecks in the workshop. All the factors identified in the workshop were compared and consolidated. A ToC map was developed based on the data obtained from the workshop. The ToC was further refined by conducting a follow-up virtual workshop with stakeholders (n = 15). RESULTS Mapping out the strategies identified in the workshop facilitated the development of a ToC model for the resource-scarce context. Key multilevel and multisectoral task-sharing strategies emerged in support of the development of a collaborative system of care that includes the development of (i) community awareness programs and user-friendly CAMH psychoeducation and screening tools to strengthen mental health literacy and facilitate early identification at the community level; (ii) an intersectoral working group to facilitate intersectoral collaboration (iii) a functional district CAMH referral system, (iv) youth-friendly CAMH care packages. CONCLUSIONS In scarce-resource contexts, it is feasible to work collaboratively with key stakeholders across multiple sectors to identify feasible multilevel and multisectoral strategies that can be used to develop a ToC for improved access to CAMH services within a task-sharing approach.
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Affiliation(s)
- Gbotemi B. Babatunde
- grid.16463.360000 0001 0723 4123Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - André Janse van Rensburg
- grid.16463.360000 0001 0723 4123Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- grid.16463.360000 0001 0723 4123Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Inge Petersen
- grid.16463.360000 0001 0723 4123Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
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Brugulat-Serrat A, Chen Y, Demnitz N, Ashour A, Adrion E, Ilinca S, Kinchin I, Almirall-Sanchez A, Öz D, Karanja W, Pintado M, Rogers N, Browning A, Petkuté I, Lawlor B. Roadmap for change in sex and gender inequities in brain health: A global perspective. Int J Geriatr Psychiatry 2022; 37. [PMID: 35393642 DOI: 10.1002/gps.5710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Anna Brugulat-Serrat
- Global Brain Health Institute, University of California, San Francisco, California, USA
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Yaohua Chen
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- University.Lille, Inserm UMR-S1172, Lille Neurosciences & Cognition, Degenerative and Vascular Cognitive Disorders, CHU Lille, LiCEND, Lille, France
- Department of Geriatrics, CHU Lille, Lille, France
| | - Naiara Demnitz
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hvidovre Hospital, Hvidovre, Denmark
| | - Aya Ashour
- Global Brain Health Institute, University of California, San Francisco, California, USA
- Department of Neurology, Ain Shams University, Cairo, Egypt
| | - Emily Adrion
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- Global Health Policy Unit, University of Edinburgh, Scotland, UK
| | - Stefania Ilinca
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- European Centre for Social Welfare Policy and Research, Vienna, Austria
- World Health Organization Regional Office for Europe, Copenhagen, Europe
| | - Irina Kinchin
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- University of Technology Sydney, Ultimo, Sydney, New South Wales, Australia
| | | | - Didem Öz
- Global Brain Health Institute, University of California, San Francisco, California, USA
- Dokuz Eylul University Hospital, İzmir, Turkey
| | - Wambui Karanja
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Maritza Pintado
- Global Brain Health Institute, University of California, San Francisco, California, USA
- Cognitive impairment diagnostic unit and dementia prevention, Peruvian Institute of Neurosciences, Lima, Peru
- Research Department, Peruvian Institute of Neurosciences, Lima, Peru
| | - Nicole Rogers
- Global Brain Health Institute, University of California, San Francisco, California, USA
- Departamento de Neurociencia, Universidad de Chile, Santiago, Chile
| | - Anne Browning
- Global Brain Health Institute, University of California, San Francisco, California, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Ieva Petkuté
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- NGO "Socialiniai meno projektai", Vilnius, Lithuania
- Association "Dementia Lithuania", Vilnius, Lithuania
| | - Brian Lawlor
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
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Mbwayo A, Kumar M, Mathai M, Mutavi T, Nungari J, Gathara R, McKay M, Ssewamala F, Hoagwood K, Petersen I, Bhana A, Huang KY. Strengthening System and Implementation Research Capacity for Child Mental Health and Family Well-being in Sub-Saharan Africa. GLOBAL SOCIAL WELFARE : RESEARCH, POLICY & PRACTICE 2022; 9:37-53. [PMID: 35330916 PMCID: PMC8939896 DOI: 10.1007/s40609-021-00204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Children in Sub-Saharan Africa (SSA) experience high rates of mental health problems, and the region has limited access to mental health resources and research capacity to address the needs. Despite the success of numerous evidence-based interventions (EBIs) and emerging methodology from the field of implementation science for addressing child mental health needs, most EBIs and implementation science methodology have not been applied in SSA contexts. The SMART-Africa Center aims to address these child welfare, mental health, services, and EBI implementation research gaps by establishing a regional trans-disciplinary collaborative center and studying strategies to strengthening mental health system and implementation research capacity. Our paper describes the overall framework and strategies that SMART-Africa team developed to strengthen capacity in three SSA countries (Ghana, Kenya, and Uganda) while focusing on its contextualization for the Kenyan school-community mental health settings. Methods to document the progress and impacts are also described. METHODS The design of the system and research strengthening activities is guided by a SMART-Africa Capacity Building framework. Two areas of capacity are focused. Mental health system capacity focuses on building political wills, leadership, transdisciplinary partnership, and stakeholders' global competency in evidence child mental health policy, intervention, and service implementation research. Implementation research capacity building focuses on building researchers' implementation research competency by carrying out an EBI implementation research (using a Hybrid Type II effectiveness-implementation). For illustration purpose, we describe how the system strengthening strategies has been applied in Kenya, and how the mixed methods design applied to assess the value and impacts of the capacity building activities. Feedback data and evaluation data collection using qualitative and quantitative methods for both areas of capacity building are still ongoing. Data will be analyzed and compared across countries in 2020-2021. CONCLUSION Our work has shown some feasibility of applying the theory-guided system strengthening model in improving child mental health service system and research capacity in one of the three SMART-Africa partnering countries. Our mental health landscape and resource mapping in Kenya also illustrated that capacity building in SSA countries involved complex dynamic, history, and some overlap efforts with multiple partnerships, and these are critical to consider in training activity and evaluation design.
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Affiliation(s)
- Anne Mbwayo
- University of Nairobi, Department of Psychiatry, Nairobi, Kenya
| | - Manasi Kumar
- University of Nairobi, Department of Psychiatry, Nairobi, Kenya
| | - Muthoni Mathai
- University of Nairobi, Department of Psychiatry, Nairobi, Kenya
| | - Teresia Mutavi
- University of Nairobi, Department of Psychiatry, Nairobi, Kenya
| | | | | | - Mary McKay
- Washington University in St. Louis, St. Louis, USA
| | | | | | | | - Arvin Bhana
- South African Medical Research Council, Cape Town, South Africa
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Using Theory of Change to inform the design of the HIV+D intervention for integrating the management of depression in routine HIV care in Uganda. PLoS One 2021; 16:e0259425. [PMID: 34847165 PMCID: PMC8631669 DOI: 10.1371/journal.pone.0259425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 10/19/2021] [Indexed: 11/19/2022] Open
Abstract
There is growing recognition of the burden of depression in people living with HIV/AIDS (PLWHA), associated with negative behavioural and clinical outcomes. Unfortunately, most HIV care providers in sub-Saharan Africa do not routinely provide mental health services to address this problem. This article describes the process of developing a model for integrating the management of depression in HIV care in Uganda. Theory of Change (ToC) methodology was used to guide the process of developing the model. Three successive ToC workshops were held with a multi-disciplinary group of 38 stakeholders within Wakiso district, in the Central region of Uganda. The first 2 workshops were for generating practical ideas for a feasible and acceptable model of integrating the management of depression in HIV care at all levels of care within the district healthcare system; while the third and final workshop was for consensus building. Following meaningful brainstorming and discussions, the stakeholders suggested improved mental wellbeing among PLWHA as the ultimate outcome of the program. This would be preceded by short-term and intermediate outcomes including reduced morbidity among persons with HIV attributable to depression, allocation of more resources towards management of depression, increased help-seeking among depressed PLWHA and more health workers detecting and managing depression. These would be achieved following several interventions undertaken at all levels of care. The participants further identified some indicators of successful implementation such as emphasis of depression management in the district healthcare plans, increased demand for anti-depressants etc; as well as various assumptions underlying the intervention. All these were graphically aligned in a causal pathway, leading to a ToC map, contextualizing and summarizing the intervention model. The ToC was a valuable methodology that brought together stakeholders to identify key strategies for development of a comprehensible contextualized intervention model for managing depression within HIV care in Uganda; allowing greater stakeholder engagement and buy-in.
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Seward N, Hanlon C, Hinrichs-Kraples S, Lund C, Murdoch J, Taylor Salisbury T, Verhey R, Shidhaye R, Thornicroft G, Araya R, Sevdalis N. A guide to systems-level, participatory, theory-informed implementation research in global health. BMJ Glob Health 2021; 6:e005365. [PMID: 34969685 PMCID: PMC8718460 DOI: 10.1136/bmjgh-2021-005365] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Implementation research is a multidisciplinary field that addresses the complex phenomenon of how context influences our ability to deliver evidence-informed healthcare. There is increasing realisation of the importance of applying robust implementation research to scale-up life-saving interventions that meet health-related sustainable development goals. However, the lack of high-quality implementation research is impeding our ability to meet these targets, globally. Within implementation research, theory refers to the proposed hypothesis and/or explanation of how an intervention is expected to interact with the local context and actors to bring about change. Although there is increasing interest in applying theory to understand how and why implementation programmes work in real-world settings, global health actors still tend to favour impact evaluations conducted in controlled environments. This may, in part, be due to the relative novelty as well as methodological complexity of implementation research and the need to draw on divergent disciplines, including epidemiology, implementation science and social sciences. Because of this, implementation research is faced with a particular set of challenges about how to reconcile different ways of thinking and constructing knowledge about healthcare interventions. To help translate some of the ambiguity surrounding how divergent theoretical approaches and methods contribute to implementation research, we draw on our multidisciplinary expertise in the field, particularly in global health. We offer an overview of the different theoretical approaches and describe how they are applied to continuously select, monitor and evaluate implementation strategies throughout the different phases of implementation research. In doing so, we offer a relatively brief, user-focused guide to help global health actors implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.
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Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Department of Health Service and Population Research, King's College London, London, UK
| | - Charlotte Hanlon
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Crick Lund
- King's College London, London, UK
- University of Cape Town, Rondebosch, South Africa
| | - Jamie Murdoch
- University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | | | - Ruth Verhey
- Research Support Centre, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rahul Shidhaye
- Pravara Institute of Medical Sciences, Loni, Maharashtra, India
| | | | | | - Nick Sevdalis
- Health Service & Population Research Department, King's College London, London, UK
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Abstract
Background
Evidence from high- and middle-income countries indicates that psychological interventions (PSIs) can improve the well-being of people with bipolar disorder. However, there is no evidence from low-income countries. Cultural and contextual adaptation is recommended to ensure that PSIs are feasible and acceptable when transferred to new settings, and to maximise effectiveness.
Aims
To develop a manualised PSI for people with bipolar disorder in rural Ethiopia.
Method
We used the Medical Research Council framework for the development and evaluation of complex interventions and integrated a participatory theory-of-change (ToC) approach. We conducted a mental health expert workshop (n = 12), four independent ToC workshops and a final workshop with all participants. The four independent ToC workshops comprised people with bipolar disorder and caregivers (n = 19), male community leaders (n = 8), female community leaders (n = 11) and primary care workers (n = 21).
Results
During the workshops, participants collaborated on the development of a ToC roadmap to achieve the shared goal of improved quality of life and reduced family burden for people with bipolar disorder. The developed PSI had five sessions: needs assessment and goal-setting; psychoeducation about bipolar disorder and its causes; treatment; promotion of well-being, including sleep hygiene and problem-solving techniques; and behavioural techniques to reduce anxiety and prevent relapse. Participants suggested that the intervention sessions be linked with patients’ monthly scheduled healthcare follow-ups, to reduce economic barriers to access.
Conclusions
We developed a contextually appropriate PSI for people with bipolar disorder in rural Ethiopia. This intervention will now be piloted for feasibility and acceptability before its wider implementation.
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Breuer E, Comas-Herrera A, Freeman E, Albanese E, Alladi S, Amour R, Evans-Lacko S, Ferri CP, Govia I, Iveth Astudillo García C, Knapp M, Lefevre M, López-Ortega M, Lund C, Musyimi C, Ndetei D, Oliveira D, Palmer T, Pattabiraman M, Sani TP, Taylor D, Taylor E, Theresia I, Thomas PT, Turana Y, Weidner W, Schneider M. Beyond the project: Building a strategic theory of change to address dementia care, treatment and support gaps across seven middle-income countries. DEMENTIA 2021; 21:114-135. [PMID: 34196585 DOI: 10.1177/14713012211029105] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evidence from middle-income countries indicates high and increasing prevalence of dementia and need for services. However, there has been little investment in care, treatment or support for people living with dementia and their carers. The Strengthening Responses to Dementia in Developing Countries (STRiDE) project aims to build both research capacity and evidence on dementia care and services in Brazil, Indonesia, India, Jamaica, Kenya, Mexico and South Africa. This article presents the Theory of Change (ToC) approach we used to co-design our research project and to develop a strategic direction for dementia care, treatment and support, with stakeholders. ToC makes explicit the process underlying how a programme will achieve its impact. We developed ToCs in each country and across the STRiDE project with researchers, practitioners, people living with dementia, carers and policymakers at different levels of government. This involved (1) an initial ToC workshop with all project partners (43 participants); (2) ToC workshops in each STRiDE country (22-49 participants in each); (3) comparison between country-specific and overall project ToCs; (4) review of ToCs in light of WHO dementia guidelines and action plan and (5) a final review. Our experiences suggest ToC is an effective way to generate a shared vision for dementia care, treatment and support among diverse stakeholders. However, the project contribution should be clearly delineated and use additional strategies to ensure appropriate participation from people living with dementia and their carers in the ToC process.
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Affiliation(s)
- Erica Breuer
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia; Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, South Africa
| | - Adelina Comas-Herrera
- Care Policy and Evaluation Centre, 4905London School of Economics and Political Science, London, UK
| | - Emily Freeman
- Care Policy and Evaluation Centre, 4905London School of Economics and Political Science, London, UK
| | - Emiliano Albanese
- Universià della Svizzerra Italiana, Lugano; Faculty of Medicine, University of Geneva, Switzerland
| | - Suvarna Alladi
- 29148National institute of Mental Health and Neuro Sciences, India
| | - Rochelle Amour
- Caribbean Institute for Health Research, 54657The University of the West Indies, Jamaica
| | - Sara Evans-Lacko
- Care Policy and Evaluation Centre, 4905London School of Economics and Political Science, UK
| | - Cleusa P Ferri
- Department of Psychiatry, 28105Universidade Federal de São Paulo, Brazil
| | - Ishtar Govia
- Caribbean Institute for Health Research, The University of the West Indies, Jamaica
| | | | - Martin Knapp
- Care Policy and Evaluation Centre, 4905London School of Economics and Political Science, UK
| | | | | | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | | | - David Ndetei
- Department of Psychiatry; 107854University of Nairobi; Africa Mental Health Research and Training Foundation, Kenya
| | - Deborah Oliveira
- Department of Psychiatry, 28105Universidade Federal de São Paulo, Brazil
| | - Tiffany Palmer
- Caribbean Institute for Health Research, 54657The University of the West Indies, Jamaica
| | | | - Tara Puspitarini Sani
- Alzheimer Indonesia and Department of Neurology, School of Medicine and Health Sciences, 64732Atma Jaya Catholic University of Indonesia, Indonesia
| | | | | | | | | | - Yuda Turana
- Alzheimer Indonesia; Department of Neurology, School of Medicine and Health Sciences, 64732Atma Jaya Catholic University of Indonesia, Indonesia
| | | | - Marguerite Schneider
- Alan J. Flisher Centre for Public Mental Health, 37716University of Cape Town, South Africa
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Marchal B, Abejirinde IOO, Sulaberidze L, Chikovani I, Uchaneishvili M, Shengelia N, Diaconu K, Vassall A, Zoidze A, Giralt AN, Witter S. How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia. BMJ Open 2021; 11:e047948. [PMID: 34187826 PMCID: PMC8245474 DOI: 10.1136/bmjopen-2020-047948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. METHODS Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. SETTING The study was conducted in Tbilisi, Georgia. PARTICIPANTS A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. RESULTS Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. CONCLUSIONS Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy.
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Affiliation(s)
- Bruno Marchal
- Health Systems and Health Policy Research Group, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Ibukun-Oluwa Omolade Abejirinde
- Health Systems and Health Policy Research Group, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Lela Sulaberidze
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | - Ivdity Chikovani
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | | | - Natia Shengelia
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Akaki Zoidze
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | - Ariadna Nebot Giralt
- Health Systems and Health Policy Research Group, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
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Murphy J, Qureshi O, Endale T, Esponda GM, Pathare S, Eaton J, De Silva M, Ryan G. Barriers and drivers to stakeholder engagement in global mental health projects. Int J Ment Health Syst 2021; 15:30. [PMID: 33812375 PMCID: PMC8019163 DOI: 10.1186/s13033-021-00458-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background Engagement with diverse stakeholders, including policy makers, care providers and service users and communities, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature. Methods We conducted semi-structured qualitative interviews with 29 recipients of Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of projects. We used framework analysis to identify key themes related to implementation barriers and drivers. This paper reports on barriers and drivers to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this journal. Results Barriers and drivers to stakeholder engagement were identified across four themes: (1) Contextual Considerations, (2) Resources, (3) Participation, Uptake and Empowerment, and (4) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as drivers. Stigma at the institutional, community and individual level was also identified as a substantial barrier to engagement. Conclusion The findings of this study are relevant to implementers in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement by investing in high-quality formative research, supporting capacity building for policy engagement, investing in longer-term funding schemes to support sustainable partnerships and scale-up, thus fostering successful engagement and supporting effective implementation of global mental health innovations.
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Affiliation(s)
- Jill Murphy
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 2255 Westbrook Mall, Vancouver, BC, V6T 2A1, Canada.
| | - Onaiza Qureshi
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Tarik Endale
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Georgina Miguel Esponda
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Soumitra Pathare
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, 411004, India
| | - Julian Eaton
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Mary De Silva
- Wellcome Trust, 215 Euston Road, London, NW1 2BE, UK
| | - Grace Ryan
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
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EVITA 2.0, an updated framework for understanding evidence-based mental health policy agenda-setting: tested and informed by key informant interviews in a multilevel comparative case study. Health Res Policy Syst 2021; 19:35. [PMID: 33691696 PMCID: PMC7948345 DOI: 10.1186/s12961-020-00651-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background Mental health remains a neglected issue on the global health policy agenda, particularly in low- and middle-income countries (LMIC), and the translation of research evidence into policy and practice is slow. The new EVITA framework was developed to improve mental health evidence uptake and policy agenda-setting in LMICs. In addition, behavioural science methods may be able to support knowledge translation to policy. Methods Using a mixed-methods study design, we applied and tested the newly developed EVITA 1.1 framework against three case studies related to South Africa at the district, national and international levels. In-depth interviews with 26 experts were conducted between August and November 2019, transcribed, coded and analysed in NVivo, using iterative categorization. The data were analysed against both the EVITA framework and the MINDSPACE framework for behavioural insights. Results In our case study comparison, we found that (1) research translation to the policy agenda occurs in a complex, fluid system which includes multiple “research clouds”, “policy spheres” and other networks; (2) mental health research policy agenda-setting is based on key individuals and intermediaries and their interrelationships; and (3) key challenges and strategies for successful research to policy agenda impact are known, but are frequently not strategically implemented, such as including all stakeholders to overcome the policy implementation gap. Our data also suggest that behavioural science methods can be strategically applied to support knowledge translation to policy agenda-setting. Conclusion We found that the EVITA framework is useful for understanding and improving mental health research policy interrelationships to support evidence uptake to the policy agenda, and that behavioural science methods are effective support mechanisms. The revised EVITA 2.0 framework therefore includes behavioural insights, for improved mental health policy agenda-setting in LMICs. More research is needed to understand whether EVITA can be applied to other LMICs and to high-income contexts.
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Qureshi O, Endale T, Ryan G, Miguel-Esponda G, Iyer SN, Eaton J, De Silva M, Murphy J. Barriers and drivers to service delivery in global mental health projects. Int J Ment Health Syst 2021; 15:14. [PMID: 33487170 PMCID: PMC7827991 DOI: 10.1186/s13033-020-00427-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research in global mental health (GMH) has previously documented how contextual factors like political instability, poverty and poorly-funded health infrastructure continue to compromise effective and equitable mental health service delivery. There is a need to develop more feasible and evidence-based solutions through implementation research. This paper, one in a series pertaining to implementation in GMH projects worldwide, focuses on implementation factors influencing mental health service delivery. METHODS This is a qualitative study carried out as part of a Theory of Change-driven evaluation of Grand Challenges Canada's (GCC's) Global Mental Health portfolio. Purposive sampling was used to recruit twenty-nine GCC grantees for interviews. A semi-structured interview schedule was used to guide the interviews which were recorded and subsequently transcribed. Transcripts were double-coded and analyzed in NVivo 11 using framework analysis. This paper reports results related to detection and treatment of mental illness, mental health promotion and prevention of mental illness. RESULTS Key barriers included: lack of appropriate human resources and expertise for service delivery; lack of culturally appropriate screening tools and interventions; and difficulties integrating services with the existing mental health system. Formative research was a key driver facilitating the cultural adaptation of mental health detection, treatment, promotion and preventative approaches. Recruiting local providers and utilizing mHealth for improving screening, monitoring and data management were also found to be successful approaches in reducing workforce burden, improving sustainability, mental health literacy, participant engagement and uptake. CONCLUSIONS The study identifies a number of key barriers to and drivers of successful service delivery from the perspective of grantees implementing GMH projects. Findings highlight several opportunities to mitigate common challenges, providing recommendations for strengthening systems- and project-level approaches for delivering mental health services. Further, more inclusive research is required to inform guidance around service delivery for successful implementation, better utilization of funding and improving mental health outcomes among vulnerable populations in low-resource settings.
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Affiliation(s)
- Onaiza Qureshi
- Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Tarik Endale
- Department of Counseling and Clinical Psychology, Teachers College, Colombia University, 525 W 120th St, New York, NY 10027 USA
| | - Grace Ryan
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Georgina Miguel-Esponda
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Srividya N. Iyer
- Department of Psychiatry, McGill University, 845 Sherbrooke St W, Montreal, QC H3A 0G4 Canada
- Douglas Research Centre, 6875 Boulevard LaSalle, Montreal, QC H4H 1R3 Canada
| | - Julian Eaton
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
- CBM UK, 8 Oakington Business Park, Dry Drayton Rd, Oakington, CB24 3DQ UK
| | - Mary De Silva
- Health of Population Health, Wellcome Trust, 215 Euston Rd, Bloomsbury, London, NW1 2BE UK
| | - Jill Murphy
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 2255 Westbrook Mall, Vancouver, BC V6T 2A1 Canada
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Semrau M, Ali O, Deribe K, Mengiste A, Tesfaye A, Kinfe M, Bremner SA, Hounsome N, Kelly-Hope LA, MacGregor H, Taddese HB, Banteyerga H, HaileMariam D, Negussu N, Fekadu A, Davey G. EnDPoINT: protocol for an implementation research study to integrate a holistic package of physical health, mental health and psychosocial care for podoconiosis, lymphatic filariasis and leprosy into routine health services in Ethiopia. BMJ Open 2020; 10:e037675. [PMID: 33060082 PMCID: PMC7566734 DOI: 10.1136/bmjopen-2020-037675] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Neglected tropical diseases (NTDs) causing lower limb lymphoedema such as podoconiosis, lymphatic filariasis (LF) and leprosy are common in Ethiopia. Routine health services for morbidity management and disability prevention (MMDP) of lymphoedema caused by these conditions are still lacking, even though it imposes a huge burden on affected individuals and their communities in terms of physical and mental health, and psychosocial and economic outcomes. This calls for an integrated, holistic approach to MMDP across these three diseases. METHODS AND ANALYSIS The 'Excellence in Disability Prevention Integrated across NTDs' (EnDPoINT) implementation research study aims to assess the integration and scale-up of a holistic package of care-including physical health, mental health and psychosocial care-into routine health services for people with lymphoedema caused by podoconiosis, LF and leprosy in selected districts in Awi zone in the North-West of Ethiopia. The study is being carried out over three phases using a wide range of mixed methodologies. Phase 1 involves the development of a comprehensive holistic care package and strategies for its integration into the routine health services across the three diseases, and to examine the factors that influence integration and the roles of key health system actors. Phase 2 involves a pilot study conducted in one subdistrict in Awi zone, to establish the care package's adoption, feasibility, acceptability, fidelity, potential effectiveness, its readiness for scale-up, costs of the interventions and the suitability of the training and training materials. Phase 3 involves scale-up of the care package in three whole districts, as well as its evaluation in regard to coverage, implementation, clinical (physical health, mental health and psychosocial) and economic outcomes. ETHICS AND DISSEMINATION Ethics approval for the study has been obtained in the UK and Ethiopia. The results will be disseminated through publications in scientific journals, conference presentations, policy briefs and workshops.
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Affiliation(s)
- Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
| | - Oumer Ali
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Kebede Deribe
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Abraham Tesfaye
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Stephen A Bremner
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Natalia Hounsome
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
| | - Louise A Kelly-Hope
- Centre for Neglected Tropical Diseases, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Hayley MacGregor
- Health and Development Cluster, Institute of Development Studies, University of Sussex, Brighton, UK
| | - Henock B Taddese
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Hailom Banteyerga
- College of Humanities, Language Studies, Journalism and Communication, Addis Ababa University, Addis Ababa, Ethiopia
| | - Damen HaileMariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nebiyu Negussu
- Neglected Tropical Diseases, Disease Prevention and Control Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK
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Luitel NP, Breuer E, Adhikari A, Kohrt BA, Lund C, Komproe IH, Jordans MJD. Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study. BJPsych Open 2020; 6:e77. [PMID: 32718381 PMCID: PMC7443901 DOI: 10.1192/bjo.2020.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal. AIMS To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP. METHOD A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers. RESULTS The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors. CONCLUSIONS Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.
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Affiliation(s)
| | - Erica Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Department of Medicine and Public Health, University of Newcastle, Australia
| | - Anup Adhikari
- Transcultural Psychosocial Organization (TPO), Nepal
| | - Brandon A Kohrt
- Department of Psychiatry, George Washington University, USA; and Transcultural Psychosocial Organization (TPO), Nepal
| | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Ivan H Komproe
- Faculty of Social and Behavioural Sciences, Utrecht University; and Research and Development Department, HealthNet TPO, Amsterdam, the Netherlands
| | - Mark J D Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Faculty of Social and Behavioural Sciences, Department of Anthropology, University of Amsterdam, the Netherlands; and Transcultural Psychosocial Organization (TPO), Nepal
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Abayneh S, Lempp H, Alem A, Kohrt BA, Fekadu A, Hanlon C. Developing a Theory of Change model of service user and caregiver involvement in mental health system strengthening in primary health care in rural Ethiopia. Int J Ment Health Syst 2020; 14:51. [PMID: 32760440 PMCID: PMC7379363 DOI: 10.1186/s13033-020-00383-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 07/18/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The involvement of service users and caregivers is recommended as a strategy to strengthen health systems and scale up quality mental healthcare equitably, particularly in low-and-middle-income countries. Service user and caregiver involvement is complex, and its meaningful implementation seems to be a worldwide challenge. Theory of Change (ToC) has been recommended to guide the development, implementation and evaluation of such complex interventions. This paper aims to describe a ToC model for service user and caregiver involvement in a primary mental health care in rural Ethiopia. METHODS The ToC was developed in two workshops conducted in (i) Addis Ababa with purposively selected psychiatrists (n = 4) and multidisciplinary researchers (n = 3), and (ii) a rural district in south-central Ethiopia (Sodo), with community stakeholders (n = 24). Information from the workshops (provisional ToC maps, minutes, audio recordings), and inputs from a previous qualitative study were triangulated to develop the detailed ToC map. This ToC map was further refined with written feedback and further consultative meetings with the research team (n = 6) and community stakeholders (n = 35). RESULTS The experiential knowledge and professional expertise of ToC participants combined to produce a ToC map that incorporated key components (community, health organisation, service user and caregiver), necessary interventions, preconditions, assumptions and indicators towards the long-term outcomes. The participatory nature of ToC by itself raised awareness of the possibilities for servicer user and caregiver involvement, promoted co-working and stimulated immediate commitments to mobilise support for a grass roots service user organization. CONCLUSIONS The ToC workshops provided an opportunity to co-produce a ToC for service user and caregiver involvement in mental health system strengthening linked to the planned model for scale-up of mental health care in Ethiopia. The next steps will be to pilot a multi-faceted intervention based on the ToC and link locally generated evidence to published evidence and theories to refine the ToC for broader transferability to other mental health settings.
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Affiliation(s)
- Sisay Abayneh
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, WHO Collaborating Centre in Mental Health Research and Capacity Building, Addis Ababa, Ethiopia
| | - Heidi Lempp
- Faculty of Life Sciences and Medicine, Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, King’s College London, Weston Education Centre 10, Cutcombe Rd, London, SE5 9RJ UK
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, WHO Collaborating Centre in Mental Health Research and Capacity Building, Addis Ababa, Ethiopia
| | - Brandon A. Kohrt
- Department of Psychiatry, George Washington University, Washington, DC USA
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, WHO Collaborating Centre in Mental Health Research and Capacity Building, Addis Ababa, Ethiopia
- College of Health Sciences, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, WHO Collaborating Centre in Mental Health Research and Capacity Building, Addis Ababa, Ethiopia
- College of Health Sciences, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
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Five Challenges in the Design and Conduct of IS Trials for HIV Prevention and Treatment. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S261-S270. [PMID: 31764262 DOI: 10.1097/qai.0000000000002192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implementation science (IS) trials in HIV treatment and prevention evaluate implementation strategies that deliver health-enhancing tools such as antiretroviral medicines or prevention technologies to those who need them, rather than evaluating the tools themselves. METHOD Opinion piece drawing on a non-systematic review of HIV prevention and treatment trials to inform an assessment of 5 key challenges for IS trials. RESULTS Randomized controlled trials (RCTs) are an appropriate design for IS but must address 5 challenges. IS trials must be feasible to deliver, which will require addressing challenges in maintaining multisectoral partnerships, strengthening routine data, and clarifying ethical principles. IS trials should be informative, evaluating implementation strategies that are well designed and adequately described, and measuring implementation outcomes, coverage of tools, and, when appropriate, epidemiological impacts. IS trials should be rigorous, striving for internally valid estimates of effect by adopting best practices, and deploying optimal nonrandomized designs where randomization is not feasible. IS trials should be relevant, considering and documenting how "real-life" is the implementation monitoring and whether research participants are representative of the target population. Finally, IS trials should be useful, deploying process evaluations to provide results that can be used in onward decision-making. CONCLUSIONS IS trials can help ensure that efficacious tools for HIV prevention and treatment have maximum impact in the real world. These trials will be an important component of this scientific agenda if they are feasible to deliver and if their results are informative, rigorous, relevant, and useful.
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Fuhr DC, Acarturk C, Uygun E, McGrath M, Ilkkursun Z, Kaykha S, Sondorp E, Sijbrandij M, Ventevogel P, Cuijpers P, Roberts B. Pathways towards scaling up Problem Management Plus in Turkey: a theory of change workshop. Confl Health 2020; 14:22. [PMID: 32391076 PMCID: PMC7197136 DOI: 10.1186/s13031-020-00278-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022] Open
Abstract
Background A considerable evidence base has been produced in recent years highlighting the effectiveness of brief scalable psychological interventions for people living in communities exposed to adversity. However, practical guidance on how to scale up these interventions to wider populations does not exist. In this paper we report on the use of Theory of Change (ToC) to plan the scale up of the World Health Organization’s flagship low intensity psychological intervention “Problem Management Plus” (PM+) for Syrian refugees in Turkey. Methods We conducted a one-day ToC workshop in Istanbul. ToC is a participatory planning process used in the development, implementation and evaluation of projects. It is similar to driver diagrams or logic models in that it offers a tool to visually present the components needed to reach a desired long-term outcome or impact. The overall aim of ToC is to understand the change process of a complex intervention and to map out causal pathways through which an intervention or strategy has an effect. Results Twenty-four stakeholders (including governmental officials, mental health providers, officials from international/national non-governmental organisations, conflict and health researchers) participated in the ToC workshop. A ToC map was produced identifying three key elements of scaling up (the resource team; the innovation and the health system; and the user organisation) which are represented in three distinct causal pathways. Context-specific barriers related to the health system and the political environment were identified, and possible strategies for overcoming these challenges were suggested. Conclusion ToC is a valuable methodology to develop an integrated framework for scaling up. The results highlight that the scaling up of PM+ for Syrian refugees in Turkey needs careful planning and investment from different stakeholders at the national level. Our paper provides a theoretical foundation of the scaling up of PM+, and exemplifies for the first time the use of ToC in planning the scaling up of an evidence-based psychological intervention in global mental health.
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Affiliation(s)
- Daniela C Fuhr
- 1Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine; Public Health and Policy, 15-17 Tavistock Place, London, UK
| | - Ceren Acarturk
- 2Department of Psychology, Koc University Istanbul, Istanbul, Turkey
| | - Ersin Uygun
- Refugee Mental Health Branch Outpatient Clinic of Bakirkoy Mental Health Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Michael McGrath
- 1Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine; Public Health and Policy, 15-17 Tavistock Place, London, UK.,4KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Zeynep Ilkkursun
- 2Department of Psychology, Koc University Istanbul, Istanbul, Turkey
| | - Sadaf Kaykha
- War Trauma Foundation, Amsterdam, The Netherlands
| | - Egbert Sondorp
- 4KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- 6Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Peter Ventevogel
- 7Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Pim Cuijpers
- 6Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bayard Roberts
- 1Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine; Public Health and Policy, 15-17 Tavistock Place, London, UK
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Chibanda D, Abas M, Musesengwa R, Merritt C, Sorsdahl K, Mangezi W, Bandawe C, Cowan F, Araya R, Gomo E, Gibson L, Weiss H, Hanlon C, Lund C. Mental health research capacity building in sub-Saharan Africa: the African Mental Health Research Initiative. Glob Ment Health (Camb) 2020; 7:e8. [PMID: 32346483 PMCID: PMC7176917 DOI: 10.1017/gmh.2019.32] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/22/2019] [Accepted: 12/11/2019] [Indexed: 12/12/2022] Open
Abstract
Mental, neurological and substance use (MNS) disorders are a leading, but neglected, cause of morbidity and mortality in sub-Saharan Africa. The treatment gap for MNS is vast with only 10% of people with MNS disorders in low-income countries accessing evidence-based treatments. Reasons for this include low awareness of the burden of MNS disorders and limited evidence to support development, adaptation and implementation of effective and feasible treatments. The overall goal of the African Mental Health Research Initiative (AMARI) is to build an African-led network of MNS researchers in Ethiopia, Malawi, South Africa and Zimbabwe, who are equipped to lead high quality mental health research programs that meet the needs of their countries, and to establish a sustainable career pipeline for these researchers with an emphasis on integrating MNS research into existing programs such as HIV/AIDS. This paper describes the process leading to the development of AMARI's objectives through a theory of change workshop, successes and challenges that have been faced by the consortium in the last 4 years, and the future role that AMARI could play in further building MNS research capacity by brining on board more institutions from low- and middle-income countries with an emphasis on developing an evidence-based training curriculum and a research-driven care service.
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Affiliation(s)
- Dixon Chibanda
- Department of Psychiatry, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Melanie Abas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rosemary Musesengwa
- Department of Psychiatry, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Chris Merritt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Katherine Sorsdahl
- Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Walter Mangezi
- Department of Psychiatry, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Frances Cowan
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ricardo Araya
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Exnevia Gomo
- Department of Immunology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Lorna Gibson
- Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Crick Lund
- Department of Mental Health, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
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Barnhart DA, Semrau KEA, Zigler CM, Molina RL, Delaney MM, Hirschhorn LR, Spiegelman D. Optimizing the development and evaluation of complex interventions: lessons learned from the BetterBirth Program and associated trial. Implement Sci Commun 2020; 1:29. [PMID: 32885188 PMCID: PMC7427863 DOI: 10.1186/s43058-020-00014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/27/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite extensive efforts to develop and refine intervention packages, complex interventions often fail to produce the desired health impacts in full-scale evaluations. A recent example of this phenomenon is BetterBirth, a complex intervention designed to implement the World Health Organization's Safe Childbirth Checklist and improve maternal and neonatal health. Using data from the BetterBirth Program and its associated trial as a case study, we identified lessons to assist in the development and evaluation of future complex interventions. METHODS BetterBirth was refined across three sequential development phases prior to being tested in a matched-pair, cluster randomized trial in Uttar Pradesh, India. We reviewed published and internal materials from all three development phases to identify barriers hindering the identification of an optimal intervention package and identified corresponding lessons learned. For each lesson, we describe its importance and provide an example motivated by the BetterBirth Program's development to illustrate how it could be applied to future studies. RESULTS We identified three lessons: (1) develop a robust theory of change (TOC); (2) define optimization outcomes, which are used to assess the effectiveness of the intervention across development phases, and corresponding criteria for success, which determine whether the intervention has been sufficiently optimized to warrant full-scale evaluation; and (3) create and capture variation in the implementation intensity of components. When applying these lessons to the BetterBirth intervention, we demonstrate how a TOC could have promoted more complete data collection. We propose an optimization outcome and related criteria for success and illustrate how they could have resulted in additional development phases prior to the full-scale trial. Finally, we show how variation in components' implementation intensities could have been used to identify effective intervention components. CONCLUSION These lessons learned can be applied during both early and advanced stages of complex intervention development and evaluation. By using examples from a real-world study to demonstrate the relevance of these lessons and illustrating how they can be applied in practice, we hope to encourage future researchers to collect and analyze data in a way that promotes more effective complex intervention development and evaluation. TRIAL REGISTRATION ClinicalTrials.gov, NCT02148952; registered on May 29, 2014.
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Affiliation(s)
| | - Katherine E. A. Semrau
- Ariadne Labs, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Corwin M. Zigler
- University of Texas, Austin, TX USA
- Dell Medical School, Austin, TX USA
| | - Rose L. Molina
- Ariadne Labs, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Megan Marx Delaney
- Harvard T.H. Chan School of Public Health, Boston, MA USA
- Ariadne Labs, Boston, MA USA
| | | | - Donna Spiegelman
- Harvard T.H. Chan School of Public Health, Boston, MA USA
- Center for Methods in Implementation and Prevention Science and Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
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Bemme D. Finding "What Works": Theory of Change, Contingent Universals, and Virtuous Failure in Global Mental Health. Cult Med Psychiatry 2019; 43:574-595. [PMID: 31230173 DOI: 10.1007/s11013-019-09637-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Global Mental Health has developed interventions that strive to work across great difference-variously conceptualized as cultural, socio-economic, geographic, or pertaining to the characteristics of health systems. This article discusses how the evaluation framework Theory of Change (ToC) facilitates the production of 'global' knowledge across such differences. Drawing on 14 months of multi-sited fieldwork among Global Mental Health actors in Europe, North America and South Africa, it traces the differential use of ToC in GMH interventions. While much critical scholarship of Global Health metrics holds that techniques of quantification rely on universals that necessarily betray the "real world", ToC unsettles these critiques. It comes into view as an epistemic and relational device that produces 'contingent universals'-concepts that are true and measurable until they stop working in the field, or until the parameters of 'what works' shift to a new iteration. As such, Theory of Change produces actionable-rather than true-knowledge attuned to open-ended change, both desirable (impact) and unforeseen (adaptation). Its effects, however, are ambiguous. ToC presents us with a horizoning technique that enables what I call "virtuous failure" within the evidence-based paradigm. It may equally harbor the potential to disrupt distinctions such as bricolage (tinkering) and design (planning) and their respective politics, as it may tie neatly into audit cultures, depending on its use. The article analyzes the novel stakes of reflexive evaluation techniques and calls on anthropology and critical Global Health for renewed empirical engagement.
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Affiliation(s)
- Dörte Bemme
- Department for Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, USA.
- Department of Psychiatry, Program for Global Mental Health, McGill University, Montreal, Canada.
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Breuer E, Hanlon C, Bhana A, Chisholm D, Silva MD, Fekadu A, Honikman S, Jordans M, Kathree T, Kigozi F, Luitel NP, Marx M, Medhin G, Murhar V, Ndyanabangi S, Patel V, Petersen I, Prince M, Raja S, Rathod SD, Shidhaye R, Ssebunnya J, Thornicroft G, Tomlinson M, Wolde-Giorgis T, Lund C. Partnerships in a Global Mental Health Research Programme-the Example of PRIME. GLOBAL SOCIAL WELFARE : RESEARCH, POLICY & PRACTICE 2019; 6:159-175. [PMID: 31984205 PMCID: PMC6980236 DOI: 10.1007/s40609-018-0128-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.
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Affiliation(s)
- Erica Breuer
- Alan J. Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Arvin Bhana
- South African Medical Research Council, Durban, South Africa
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Dan Chisholm
- Regional Office for Europe, World Health Organisation, Copenhagen, Denmark
| | | | - Abebaw Fekadu
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Brighton and Sussex Medical School, Brighton, UK
| | - Simone Honikman
- Perinatal Mental Health Project, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Mark Jordans
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Tasneem Kathree
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Fred Kigozi
- School of Medicine, Makerere University, Kampala, Uganda
| | | | - Maggie Marx
- Alan J. Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | | | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Martin Prince
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | | | - Sujit D. Rathod
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Graham Thornicroft
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Mark Tomlinson
- Alan J. Flisher Centre for Public Mental Health, Stellenbosch University, Stellenbosch, South Africa
| | | | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
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Murphy JK, Michalak EE, Colquhoun H, Woo C, Ng CH, Parikh SV, Culpepper L, Dewa CS, Greenshaw AJ, He Y, Kennedy SH, Li XM, Liu T, Soares CN, Wang Z, Xu Y, Chen J, Lam RW. Methodological approaches to situational analysis in global mental health: a scoping review. Glob Ment Health (Camb) 2019; 6:e11. [PMID: 31258925 PMCID: PMC6582459 DOI: 10.1017/gmh.2019.9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 04/08/2019] [Accepted: 05/22/2019] [Indexed: 12/31/2022] Open
Abstract
Global inequity in access to and availability of essential mental health services is well recognized. The mental health treatment gap is approximately 50% in all countries, with up to 90% of people in the lowest-income countries lacking access to required mental health services. Increased investment in global mental health (GMH) has increased innovation in mental health service delivery in LMICs. Situational analyses in areas where mental health services and systems are poorly developed and resourced are essential when planning for research and implementation, however, little guidance is available to inform methodological approaches to conducting these types of studies. This scoping review provides an analysis of methodological approaches to situational analysis in GMH, including an assessment of the extent to which situational analyses include equity in study designs. It is intended as a resource that identifies current gaps and areas for future development in GMH. Formative research, including situational analysis, is an essential first step in conducting robust implementation research, an essential area of study in GMH that will help to promote improved availability of, access to and reach of mental health services for people living with mental illness in low- and middle-income countries (LMICs). While strong leadership in this field exists, there remain significant opportunities for enhanced research representing different LMICs and regions.
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Affiliation(s)
- J. K. Murphy
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - E. E. Michalak
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - H. Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - C. Woo
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - C. H. Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - S. V. Parikh
- Department of Psychiatry and Health Management & Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - L. Culpepper
- Department of Family Medicine, Boston University, Boston, Massachusetts, USA
| | - C. S. Dewa
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, California, USA
| | - A. J. Greenshaw
- Department of Psychiatry, University of Alberta, Alberta, Canada
| | - Y. He
- Shanghai CDC for Mental Health, Division of Training and Health Education, Shanghai, China
| | - S. H. Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - X.-M. Li
- Department of Psychiatry, University of Alberta, Alberta, Canada
| | - T. Liu
- Peking University, Institute of Population Research, Beijing, China
| | - C. N. Soares
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Z. Wang
- Hongkou District Mental Health Center, Shanghai, China
| | - Y. Xu
- Department of Family Medicine, Boston University, Boston, Massachusetts, USA
| | - J. Chen
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine
| | - R. W. Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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Williams J, Sevdalis N, Gaughran F. Evaluation of a Physical health plan for people with psychosis: a protocol for a quality improvement study. Pilot Feasibility Stud 2019; 5:8. [PMID: 30675375 PMCID: PMC6334447 DOI: 10.1186/s40814-019-0396-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background People with serious mental illness (SMI) have poorer physical health and reduced lifespans compared to the general population. Reasons for this are complex, but one important area is the identification and treatment of physical health conditions. In England, services are structured into primary and secondary care; physical and mental secondary health services are separate. This often leads to a lack of co-ordination of care, with people missing the screening and treatment they need. People with SMI may find accessing physical health services more difficult due to the impact of their symptoms and/or a lack of social support. When they do access physical care, there may be ‘diagnostic overshadowing’ where physical health concerns are put down to a mental health diagnosis. Creating tools to support people with SMI to assume more control of their physical health may help to ameliorate some of these problems. The aim of this study is to evaluate the use of a service user-held Physical health plan (PHP) for secondary mental health service users to determine whether its use increases uptake of physical health services. Methods We will undertake a pilot quality improvement (QI) study to test the use of the PHP. The development of the PHP is described. A Theory of Change (ToC) has been developed which we will test to understand how the PHP is used, using focus groups at the beginning of the study. We will then pilot the use of the PHP for 6 months in two community mental health teams to find out how people use it, what actions are taken, and if it increases uptake of physical health care. We will use the RE-AIM implementation framework to guide the evaluation. After the pilot, we will undertake interviews with service users and clinical staff to elicit their views on using the PHP. Discussion This study uses QI methodology and an implementation framework to test a novel intervention for people with SMI. If successful, the intervention will support people with SMI to access physical health services. The study will inform the design of a larger-scale definitive RCT. Trial registration ClinicalTrials.gov Identifier: NCT03178279. Registered date: 05/06/2017 Electronic supplementary material The online version of this article (10.1186/s40814-019-0396-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julie Williams
- 1Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF UK
| | - Nick Sevdalis
- 2Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Fiona Gaughran
- 3Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,4National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
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Digital depression screening in HIV primary care in South Africa: mood in retroviral + application monitoring [MIR + IAM]. Glob Ment Health (Camb) 2019; 6:e2. [PMID: 30854218 PMCID: PMC6401371 DOI: 10.1017/gmh.2018.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/26/2018] [Accepted: 11/22/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Integrating mental health care into HIV services is critical to addressing the high unmet treatment needs for people living with HIV and comorbid major depressive disorder. Introducing routine mental health screening at the primary health care level is a much needed diagonal approach to enhancing HIV care. In low-resource settings with a shortage of mental health care providers, eMental Health may provide a novel opportunity to attenuate this treatment gap and strengthen the health system. OBJECTIVE To conduct formative health systems research on the implementation of routine depression screening using a digital tool - Mood in Retroviral Positive Individuals Application Monitoring (MIR + IAM) - in an HIV primary care setting in South Africa. METHODS A Theory of Change (ToC) approach was utilised through individual and group session interviews to design an intervention that is embedded in the local context. Ten experts and local stakeholders were selected from the UK and South Africa. Data were analysed thematically using Atlas.ti to identify interventions, assumptions, barriers and facilitators of implementation. FINDINGS The participants considered digital depression screening in HIV care services relevant for the improvement of mental health in this population. The six main themes identified from the ToC process were: (1) user experience including acceptability by patients, issues of patient privacy and digital literacy, and the need for a patient-centred tool; (2) benefits of the digital tool for data collection and health promotion; (3) availability of treatment after diagnosis; (4) human and physical resource capacity of primary health care; (5) training for lay health care workers; and (6) demonstration of the intervention's usefulness to generate interest from decision-makers. CONCLUSION Digital depression screening coupled with routine mental health data collection and analysis in HIV care is an applicable service that could improve the mental and physical health outcomes of this population. Careful consideration of the local health system capacity, including both workers and patients, is required. Future research to refine this intervention should focus on service users, government stakeholders and funders.
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Breuer E, Subba P, Luitel N, Jordans M, De Silva M, Marchal B, Lund C. Using qualitative comparative analysis and theory of change to unravel the effects of a mental health intervention on service utilisation in Nepal. BMJ Glob Health 2018; 3:e001023. [PMID: 30687522 PMCID: PMC6326347 DOI: 10.1136/bmjgh-2018-001023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/20/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022] Open
Abstract
Background The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme’s Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC. Methods We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5. Results The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers. Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities. Conclusions Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.
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Affiliation(s)
- Erica Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | | | - Mark Jordans
- Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | | | - Bruno Marchal
- Institute of Tropical Medicine, Antwerp, Belgium.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.,Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, UK
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Mutiso VN, Gitonga I, Musau A, Musyimi CW, Nandoya E, Rebello TJ, Pike KM, Ndetei DM. A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low- and middle-income country: a case study of Makueni County, Kenya. Int J Ment Health Syst 2018; 12:57. [PMID: 30356953 PMCID: PMC6191998 DOI: 10.1186/s13033-018-0234-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 10/06/2018] [Indexed: 12/26/2022] Open
Abstract
Background The World Health Organization developed the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) as guidelines for innovative utilization of available resources in low- and middle-income countries (LMICs) in order to accelerate the reduction of the mental health treatment gap. The mhGAP-IG calls for each country to contextualize the guide to their social, cultural and economic context. The objective of this paper is to describe a model for a stepwise approach for implementation of mhGAP-IG in a rural Kenyan setting using existing formal and informal community resources and health systems. Methods We conducted an analysis of mental health services in Makueni County, one of the 47 counties in Kenya, in order to understand the existing gaps and opportunities in a low-resource setting. We conducted stakeholder analysis and engagement through interactive dialogue in order for them to appreciate the importance of mental health to their communities. Through the process of participatory Theory of Change, the stakeholders gave their input on the process between the initiation and the end of the process for community mental health development, with the aim of achieving buy-in and collective ownership of the whole process. We adapted the mhGAP-IG to the local context and trained local human resources in skills necessary for the implementation of mhGAP-IG and for monitoring and evaluating the process using instruments with good psychometric properties that have been used in LMICs. Results We were able to demonstrate the feasibility of implementing the mhGAP-IG using existing and trained community human resources using a multi-stakeholder approach. We further demonstrated the feasibility to transit seamlessly from research to policy and practice uptake using our approach. Conclusions An inclusive model for low resource settings is feasible and has the potential to bridge the gap between research, policy and practice. A major limitation of our study is that we did not engage a health economist from the beginning in order to determine the cost-effectiveness of our proposed model, occasioned by lack of resources to hire a suitable one.
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Affiliation(s)
- Victoria N Mutiso
- Africa Mental Health Research and Training Foundation, Matumbato Road, Off Elgon Road, Mawensi Gardens, Nairobi, Kenya
| | - Isaiah Gitonga
- Africa Mental Health Research and Training Foundation, Matumbato Road, Off Elgon Road, Mawensi Gardens, Nairobi, Kenya
| | - Abednego Musau
- Africa Mental Health Research and Training Foundation, Matumbato Road, Off Elgon Road, Mawensi Gardens, Nairobi, Kenya
| | - Christine W Musyimi
- Africa Mental Health Research and Training Foundation, Matumbato Road, Off Elgon Road, Mawensi Gardens, Nairobi, Kenya
| | - Eric Nandoya
- Africa Mental Health Research and Training Foundation, Matumbato Road, Off Elgon Road, Mawensi Gardens, Nairobi, Kenya
| | | | - Kathleen M Pike
- 2Global Mental Health Program, Columbia University, New York, USA
| | - David M Ndetei
- Africa Mental Health Research and Training Foundation, Matumbato Road, Off Elgon Road, Mawensi Gardens, Nairobi, Kenya.,3University of Nairobi, Nairobi, Kenya
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Gilissen J, Pivodic L, Gastmans C, Vander Stichele R, Deliens L, Breuer E, Van den Block L. How to achieve the desired outcomes of advance care planning in nursing homes: a theory of change. BMC Geriatr 2018; 18:47. [PMID: 29444645 PMCID: PMC5813418 DOI: 10.1186/s12877-018-0723-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/23/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances. METHODS The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review. RESULTS We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents’ wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring. ONCLUSIONS The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.
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Affiliation(s)
- J. Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - L. Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - C. Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35, Box 7001, 3000 Leuven, Belgium
| | - R. Vander Stichele
- Department of Pharmacology, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - L. Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - E. Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - L. Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
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De Buck E, Hannes K, Cargo M, Van Remoortel H, Vande Veegaete A, Mosler HJ, Govender T, Vandekerckhove P, Young T. Engagement of stakeholders in the development of a Theory of Change for handwashing and sanitation behaviour change. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2018; 28:8-22. [PMID: 29260884 DOI: 10.1080/09603123.2017.1415306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A Theory of Change (ToC) is an approach to map programmes aimed at inducing change in a specific context, with the goal of increasing their impact. We applied this approach to the specific case of handwashing and sanitation practices in low- and middle-income countries and developed a ToC as part of a systematic review exercise. Different existing sources of information were used to inform the initial draft of the ToC. In addition, stakeholder involvement occurred and peer review took place. Our stakeholders included methodological (ToC/quantitative and qualitative research) and content experts (WASH (Water, Sanitation, Hygiene)/behaviour change), as well as end-users/practitioners, policy-makers and donors. In conclusion, the development of a ToC, and the involvement of stakeholders in its development, was critical in terms of understanding the context in which the promotional programmes are being implemented. We recommend ToC developers to work with stakeholders to create a ToC relevant for practice.
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Affiliation(s)
- Emmy De Buck
- a Centre for Evidence-Based Practice , Belgian Red Cross-Flanders , Mechelen , Belgium
- b Department of Public Health and Primary Care, Faculty of Medicine , KU Leuven , Leuven , Belgium
| | - Karin Hannes
- c Faculty of Social Sciences , KU Leuven , Leuven , Belgium
| | - Margaret Cargo
- d Centre for Population Health Research , University of South Australia , Adelaide , Australia
| | - Hans Van Remoortel
- a Centre for Evidence-Based Practice , Belgian Red Cross-Flanders , Mechelen , Belgium
| | - Axel Vande Veegaete
- a Centre for Evidence-Based Practice , Belgian Red Cross-Flanders , Mechelen , Belgium
| | | | - Thashlin Govender
- f Division of Community Health, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - Philippe Vandekerckhove
- a Centre for Evidence-Based Practice , Belgian Red Cross-Flanders , Mechelen , Belgium
- b Department of Public Health and Primary Care, Faculty of Medicine , KU Leuven , Leuven , Belgium
- g Faculty of Medicine and Health Sciences , University of Ghent , Ghent , Belgium
| | - Taryn Young
- h Centre for Evidence-Based Health Care, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
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Theory of change for complex mental health interventions: 10 lessons from the programme for improving mental healthcare. Glob Ment Health (Camb) 2018; 5:e24. [PMID: 30128160 PMCID: PMC6094401 DOI: 10.1017/gmh.2018.13] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/23/2018] [Accepted: 03/08/2018] [Indexed: 11/24/2022] Open
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Paina L, Wilkinson A, Tetui M, Ekirapa-Kiracho E, Barman D, Ahmed T, Mahmood SS, Bloom G, Knezovich J, George A, Bennett S. Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda. Health Res Policy Syst 2017; 15:109. [PMID: 29297374 PMCID: PMC5751673 DOI: 10.1186/s12961-017-0272-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening. Methods This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams’ experiences along four potential uses of ToCs, namely planning, communication, learning and accountability. Results The three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams’ experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams’ initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes. Conclusions The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement. Electronic supplementary material The online version of this article (doi:10.1186/s12961-017-0272-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ligia Paina
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States of America.
| | - Annie Wilkinson
- Institute of Development Studies, Library Road, Brighton, BN1 9RE, United Kingdom
| | - Moses Tetui
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.,Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Elizabeth Ekirapa-Kiracho
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda
| | - Debjani Barman
- IIHMR University, 1 Prabhu Dayal Marg, Sanganer, Jaipur, 302029, India
| | - Tanvir Ahmed
- Institute of Development Studies, Library Road, Brighton, BN1 9RE, United Kingdom.,Health System and Population Studies Division, ICDDR,B, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Shehrin Shaila Mahmood
- Health System and Population Studies Division, ICDDR,B, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Gerry Bloom
- Institute of Development Studies, Library Road, Brighton, BN1 9RE, United Kingdom
| | | | - Asha George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States of America
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Integrating mental health care into primary care systems in low- and middle-income countries: lessons from PRIME and AFFIRM. Glob Ment Health (Camb) 2017; 4:e7. [PMID: 28596908 PMCID: PMC5454718 DOI: 10.1017/gmh.2017.3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Trani JF, Ballard E, Bakhshi P, Hovmand P. Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan. Confl Health 2016; 10:25. [PMID: 27822297 PMCID: PMC5090881 DOI: 10.1186/s13031-016-0089-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 07/18/2016] [Indexed: 11/22/2022] Open
Abstract
Background Afghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context. Methods We employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015. Results We identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently. Conclusions Our model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions.
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Affiliation(s)
- Jean-Francois Trani
- Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130 USA
| | - Ellis Ballard
- Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130 USA
| | - Parul Bakhshi
- Program in Occupational Therapy, School of Medicine, Washington University in St Louis, St Louis, USA
| | - Peter Hovmand
- Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130 USA
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Herba CM, Glover V, Ramchandani PG, Rondon MB. Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries. Lancet Psychiatry 2016; 3:983-992. [PMID: 27650772 DOI: 10.1016/s2215-0366(16)30148-1] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/17/2016] [Accepted: 06/17/2016] [Indexed: 12/15/2022]
Abstract
Studies examining mechanisms underlying associations between maternal depression and adverse child outcomes (including behaviour, socioemotional adjustment, and emotion regulation) indicate that during pregnancy, maternal depression could affect child outcomes through altered placental function, epigenetic changes in the child, and stress reactivity. Infection and dietary deficiencies in the mother and the child, together with the child's genetic vulnerability, might also affect outcome. Postnatally, associations between maternal depression and child outcome are influenced by altered mother-child interactions, sociodemographic or environmental influences, and social support. Knowledge is scarce on mechanisms in low-income and middle-income countries where maternal depression is highly prevalent, and stressful factors that influence the development of perinatal maternal depression and adverse child outcome (eg, food insecurity, perinatal infections, crowded or rural living conditions, and interpersonal violence) are both more intense and more common than in high-income countries. We reviewed evidence and use the biopsychosocial model to illustrate risk factors, mediators and moderators underlying associations between maternal depression and child outcomes in low-income and middle-income countries.
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Affiliation(s)
- Catherine M Herba
- Department of Psychology, Université du Québec à Montréal, Montréal, QC, Canada; CHU Sainte-Justine Research Center, Montréal, QC, Canada.
| | - Vivette Glover
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | | | - Marta B Rondon
- Mental Health and Psychiatry Unit, Department of Medicine, Cayetano Heredia Peruvian University, Lima, Peru
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Breuer E, Lee L, De Silva M, Lund C. Using theory of change to design and evaluate public health interventions: a systematic review. Implement Sci 2016; 11:63. [PMID: 27153985 PMCID: PMC4859947 DOI: 10.1186/s13012-016-0422-6] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 04/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the increasing popularity of the theory of change (ToC) approach, little is known about the extent to which ToC has been used in the design and evaluation of public health interventions. This review aims to determine how ToCs have been developed and used in the development and evaluation of public health interventions globally. METHODS We searched for papers reporting the use of "theory of change" in the development or evaluation of public health interventions in databases of peer-reviewed journal articles such as Scopus, Pubmed, PsychInfo, grey literature databases, Google and websites of development funders. We included papers of any date, language or study design. Both abstracts and full text papers were double screened. Data were extracted and narratively and quantitatively summarised. RESULTS A total of 62 papers were included in the review. Forty-nine (79 %) described the development of ToC, 18 (29 %) described the use of ToC in the development of the intervention and 49 (79 %) described the use of ToC in the evaluation of the intervention. Although a large number of papers were included in the review, their descriptions of the ToC development and use in intervention design and evaluation lacked detail. CONCLUSIONS The use of the ToC approach is widespread in the public health literature. Clear reporting of the ToC process and outputs is important to strengthen the body of literature on practical application of ToC in order to develop our understanding of the benefits and advantages of using ToC. We also propose a checklist for reporting on the use of ToC to ensure transparent reporting and recommend that our checklist is used and refined by authors reporting the ToC approach.
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Affiliation(s)
- Erica Breuer
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700 Cape Town, South Africa
| | - Lucy Lee
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Mary De Silva
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700 Cape Town, South Africa
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Chibanda D, Verhey R, Munetsi E, Cowan FM, Lund C. Using a theory driven approach to develop and evaluate a complex mental health intervention: the friendship bench project in Zimbabwe. Int J Ment Health Syst 2016; 10:16. [PMID: 26933448 PMCID: PMC4772526 DOI: 10.1186/s13033-016-0050-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 02/19/2016] [Indexed: 11/26/2022] Open
Abstract
Background There is a paucity of data on how to deliver complex interventions that seek to reduce the treatment gap for mental disorders, particularly in sub-Saharan Africa. The need for well-documented protocols which clearly describe the development and the scale-up of programs and interventions is necessary if such interventions are to be replicated elsewhere. This article describes the use of a theory of change (ToC) model to develop a brief psychological intervention for common mental disorders and its’ evaluation through a cluster randomized controlled trial in Zimbabwe. Methods A total of eight ToC workshops were held with a range of stakeholders over a 6-month period with a focus on four key components of the program: formative work, piloting, evaluation and scale-up. A ToC map was developed as part of the process with defined causal pathways leading to the desired impact. Interventions, indicators, assumptions and rationale for each point along the causal pathway were considered. Results Political buy-in from stakeholders together with key resources, which included human, facility/infrastructure, communication and supervision were identified as critical needs using the ToC approach. Ten (10) key interventions with specific indicators, assumptions and rationale formed part of the final ToC map, which graphically illustrated the causal pathway leading to the development of a psychological intervention and the successful implementation of a cluster randomized controlled trial. Conclusion ToC workshops can enhance stakeholder engagement through an iterative process leading to a shared vision that can improve outcomes of complex mental health interventions particularly where scaling up of the intervention is desired.
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Affiliation(s)
- Dixon Chibanda
- Department of Community medicine, Zimbabwe Aids Prevention Project-University of Zimbabwe, Harare, Zimbabwe
| | - Ruth Verhey
- Department of Community medicine, Zimbabwe Aids Prevention Project-University of Zimbabwe, Harare, Zimbabwe
| | - Epiphany Munetsi
- Department of Community medicine, Zimbabwe Aids Prevention Project-University of Zimbabwe, Harare, Zimbabwe
| | - Frances M Cowan
- Research Department of Infection and Population Health, University College London, London, UK ; Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Crick Lund
- Alan J Flisher Center for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Hanlon C, Fekadu A, Jordans M, Kigozi F, Petersen I, Shidhaye R, Honikman S, Lund C, Prince M, Raja S, Thornicroft G, Tomlinson M, Patel V. District mental healthcare plans for five low- and middle-income countries: commonalities, variations and evidence gaps. Br J Psychiatry 2016; 208 Suppl 56:s47-54. [PMID: 26447169 PMCID: PMC4698556 DOI: 10.1192/bjp.bp.114.153767] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 12/19/2014] [Indexed: 12/04/2022]
Abstract
BACKGROUND Little is known about the service and system interventions required for successful integration of mental healthcare into primary care across diverse low- and middle-income countries (LMIC). AIMS To examine the commonalities, variations and evidence gaps in district-level mental healthcare plans (MHCPs) developed in Ethiopia, India, Nepal, Uganda and South Africa for the PRogramme for Improving Mental health carE (PRIME). METHOD A comparative analysis of MHCP components and human resource requirements. RESULTS A core set of MHCP goals was seen across all countries. The MHCPs components to achieve those goals varied, with most similarity in countries within the same resource bracket (low income v. middle income). Human resources for advanced psychosocial interventions were only available in the existing health service in the best-resourced PRIME country. CONCLUSIONS Application of a standardised methodological approach to MHCP across five LMIC allowed identification of core and site-specific interventions needed for implementation.
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Affiliation(s)
- Charlotte Hanlon
- Correspondence: Charlotte Hanlon, Department of Psychiatry, 6th Floor College of Health Sciences Building, Tikur Anbessa Hospital, Addis Ababa, PO 9086, Ethiopia.
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Breuer E, De Silva MJ, Shidaye R, Petersen I, Nakku J, Jordans MJD, Fekadu A, Lund C. Planning and evaluating mental health services in low- and middle-income countries using theory of change. Br J Psychiatry 2016; 208 Suppl 56:s55-62. [PMID: 26447178 PMCID: PMC4698557 DOI: 10.1192/bjp.bp.114.153841] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/13/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings. AIMS To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME). METHOD ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13-22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members. RESULTS One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts. CONCLUSIONS ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.
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Affiliation(s)
- Erica Breuer
- Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Mary J. De Silva, BA, MSc, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK; Rahul Shidaye, MBBS, MD, Public Health Foundation of India, Bhopal, Madhya Pradesh, India and Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands; Inge Petersen, BSc, BSc(Hons), MSc, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Howard College Campus, Durban, South Africa; Juliet Nakku, MBChB, MMed, Butabika National Mental Hospital, Kampala, Uganda; Mark J. D. Jordans, MSc, PhD, HealthNet TPO, Amsterdam, The Netherlands and King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; Abebaw Fekadu, MD, PhD, MRCPsych, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK and Addis Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Crick Lund, BA, BSocSci, MA, MSocSci, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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Fekadu A, Hanlon C, Medhin G, Alem A, Selamu M, Giorgis TW, Shibre T, Teferra S, Tegegn T, Breuer E, Patel V, Tomlinson M, Thornicroft G, Prince M, Lund C. Development of a scalable mental healthcare plan for a rural district in Ethiopia. Br J Psychiatry 2016; 208 Suppl 56:s4-12. [PMID: 26447174 PMCID: PMC4698551 DOI: 10.1192/bjp.bp.114.153676] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/13/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority. AIMS To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. METHOD A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). RESULTS The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. CONCLUSIONS The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.
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Affiliation(s)
- Abebaw Fekadu
- Abebaw Fekadu, MD, PhD, MRCPsych, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience and Centre for Global Mental Health, Health Services and Population Research Department, King's College London, London, UK; Charlotte Hanlon, PhD, MRCPsych, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia and Centre for Global Mental Health, Health Services and Population Research Department, King's College London, London, UK; Girmay Medhin, PhD, Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia; Atalay Alem, MD, PhD, Medhin Selamu, MA, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia; Tedla W. Giorgis, PhD, Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia; Teshome Shibre, MD, PhD, Solomon Teferra, MD, PhD, Teketel Tegegn, MD, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Vikram Patel, PhD, MRCPsych, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK, Centre for Mental Health, the Public Health Foundation of India and Sangath, Alto-Porvorim, Goa India; Mark Tomlinson, PhD, Stellenbosch University and University of Cape Town, Cape Town, South Africa; Graham Thornicroft, PhD, FRCPsych, Martin Prince, MD, FRCPsych, Centre for Global Mental Health, Health Services and Population Research Department, King's College London, London, UK; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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Kigozi FN, Kizza D, Nakku J, Ssebunnya J, Ndyanabangi S, Nakiganda B, Lund C, Patel V. Development of a district mental healthcare plan in Uganda. Br J Psychiatry 2016; 208 Suppl 56:s40-6. [PMID: 26447171 PMCID: PMC4698555 DOI: 10.1192/bjp.bp.114.153742] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 04/16/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evidence is needed for the integration of mental health into primary care advocated by the national health sector strategic investment plan in Uganda. AIMS To describe the processes of developing a district mental healthcare plan (MHCP) in rural Uganda that facilitates integration of mental health into primary care. METHOD Mixed methods using a situational analysis, qualitative studies, theory of change workshops and partial piloting of the plan at two levels informed the MHCP. RESULTS A MHCP was developed with packages of care to facilitate integration at the organisational, facility and community levels of the district health system, including a specified human resource mix. The partial embedding period supports its practical application. Key barriers to scaling up the plan were identified. CONCLUSIONS A real-world plan for the district was developed with involvement of stakeholders. Pilot testing demonstrated its feasibility and implications for future scaling up.
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Affiliation(s)
- Fred N. Kigozi
- Correspondence: Fred Kigozi, Butabika National Referral and Teaching Mental Hospital, Makerere University, Kampala, Uganda.
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Petersen I, Fairall L, Bhana A, Kathree T, Selohilwe O, Brooke-Sumner C, Faris G, Breuer E, Sibanyoni N, Lund C, Patel V. Integrating mental health into chronic care in South Africa: the development of a district mental healthcare plan. Br J Psychiatry 2016; 208 Suppl 56:s29-39. [PMID: 26447176 PMCID: PMC4698554 DOI: 10.1192/bjp.bp.114.153726] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 01/19/2015] [Accepted: 01/21/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the fore the need for integrating mental health into chronic care at district level. AIMS To develop a district mental healthcare plan (MHCP) in South Africa that integrates mental healthcare for depression, alcohol use disorders and schizophrenia into chronic care. METHOD Mixed methods using a situation analysis, qualitative key informant interviews, theory of change workshops and piloting of the plan in one health facility informed the development of the MHCP. RESULTS Collaborative care packages for the three conditions were developed to enable integration at the organisational, facility and community levels, supported by a human resource mix and implementation tools. Potential barriers to the feasibility of implementation at scale were identified. CONCLUSIONS The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health. This strengthens the potential for future scale up.
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Affiliation(s)
- Inge Petersen
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Lara Fairall
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Arvin Bhana
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Tasneem Kathree
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - One Selohilwe
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Carrie Brooke-Sumner
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Gill Faris
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Erica Breuer
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Nomvula Sibanyoni
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Crick Lund
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
| | - Vikram Patel
- Inge Petersen, PhD, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Lara Fairall, PhD, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Arvin Bhana, PhD, Tasneem Kathree, MSocSci, One Selohilwe, MSocSci, Carrie Brooke-Sumner, MSc, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa; Gill Faris, MPhil, Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Nomvula Sibanyoni, MSocSci, National Department of Health, Pretoria, South Africa; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Vikram Patel, PhD, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK and Centre for Mental Health, the Public Health Foundation of India, India
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