Developing a Theory of Change model of service user and caregiver involvement in mental health system strengthening in primary health care in rural Ethiopia

Analyzing the usage of theories of change for routine immunization programs -- a review of impact evaluations from LMICs

BACKGROUND

In this article we analyzed the extent of the usage of Theories of Change (TOCs) and causal pathways in the evaluation of immunization programs to identify the challenges to generating evidence on how interventions improve immunization.

METHODS

We analyzed the use of the TOC in impact evaluations (IEs) of immunization interventions published after 2010, and its associated articles. The review includes studies from Evidence Gap Map and Yale review that were conducted in May and March of 2020, respectively. We synthesized data on six domains using NVIVO - program theory, context, assumptions, usage of TOC, use in evaluation, and description causal pathways.

RESULTS

Our review included 47 large-scale and 45 small-to medium-scale interventions. Of the included studies, 19% used a TOC, 56% described a causal pathway or used a conceptual diagram with varying degrees of detail, and 25% of the IEs did not provide any information on how their intervention was expected to affect change. Only 19 of the 92 IEs explicitly outlined any assumptions associated with the implementation of the interventions. Forty studies measured the outputs or intermediate outcomes leading to improved immunization coverage.

CONCLUSION

Future implementers and evaluators need to develop clear TOCs that are based on established theory and have clearly articulated the underlying assumptions. Large-scale health system strengthening initiatives implemented by governments, also need to build TOCs and integrate them into their results frameworks. Additionally, there is a need to combine both impact and process evaluations to understand the how context affects the causal pathways.

Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper

BACKGROUND

Global evidence on psychosis is dominated by studies conducted in Western, high-income countries. The objectives of the Study of Context Of Psychoses to improve outcomes in Ethiopia (SCOPE) are (1) to generate rigorous evidence of psychosis experience, epidemiology and impacts in Ethiopia that will illuminate aetiological understanding and (2) inform development and testing of interventions for earlier identification and improved first contact care that are scalable, inclusive of difficult-to-reach populations and optimise recovery.

METHODS

The setting is sub-cities of Addis Ababa and rural districts in south-central Ethiopia covering 1.1 million people and including rural, urban and homeless populations. SCOPE comprises (1) formative work to understand care pathways and community resources (resource mapping); examine family context and communication (ethnography); develop valid measures of family communication and personal recovery; and establish platforms for community engagement and involvement of people with lived experience; (2a) a population-based incidence study, (2b) a case-control study and (2c) a cohort study with 12 months follow-up involving 440 people with psychosis (390 rural/Addis Ababa; 50 who are homeless), 390 relatives and 390 controls. We will test hypotheses about incidence rates in rural vs. urban populations and men vs. women; potential aetiological role of khat (a commonly chewed plant with amphetamine-like properties) and traumatic exposures in psychosis; determine profiles of needs at first contact and predictors of outcome; (3) participatory workshops to develop programme theory and inform co-development of interventions, and (4) evaluation of the impact of early identification strategies on engagement with care (interrupted time series study). Findings will inform development of (5) a protocol for (5a) a feasibility cluster randomised controlled trial of interventions for people with recent-onset psychosis in rural settings and (5b) two uncontrolled pilot studies to test acceptability, feasibility of co-developed interventions in urban and homeless populations.

Adapting brief problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence in rural Ethiopia

OBJECTIVE

To adapt an evidence-based psychological intervention for pregnant women experiencing depressive symptoms and intimate partner violence (IPV) in rural Ethiopia.

METHOD

We conducted a desk review of contextual factors in Sodo, Ethiopia, followed by qualitative interviews with 16 pregnant women and 12 antenatal care (ANC) providers. We engaged stakeholders through participatory theory of change (ToC) workshops, to select the intervention and articulate a programme theory. We used "ADAPT" guidance to adapt the intervention to the context, before mapping potential harms in a "dark logic model".

RESULTS

Brief problem-solving therapy developed for South Africa was the most contextually relevant model. We adapted the delivery format (participants prioritised confidentiality and brevity) and training and supervision (addressing IPV). Consensus long-term outcomes in our ToC were ANC providers skilled in detecting and responding to emotional difficulties and IPV, women receiving appropriate support, and emotional difficulties improving. Our dark logic model highlighted the risk of more severe IPV and mental health symptoms not being referred appropriately.

CONCLUSION

Although intervention adaptation is recommended, the process is rarely reported in depth. We comprehensively describe how contextual considerations, stakeholder engagement, programme theory, and adaptation can tailor psychological interventions for the target population in a low-income, rural setting.

Development and evaluation of a manualised mental health awareness and stigma reduction intervention for Black faith communities: study protocol for the ON TRAC feasibility study

INTRODUCTION

This paper presents the study protocol for a feasibility study of a manualised mental health awareness and stigma reduction intervention for Black faith communities, as part of the Outcomes and Needs of Traditional Religious And Complementary practitioners (ON TRAC) project. The primary objective is to assess the feasibility and acceptability of the intervention and the secondary objectives include assessment of the feasibility of: recruiting participants to take part in the intervention, delivering the intervention, and conducting qualitative assessments, and use of the selected scales. The findings from this study will be used to inform the development of a subsequent trial which will focus on exploring the potential impact of the intervention on stigma-related knowledge, attitudes, and behaviour.

METHODS AND ANALYSIS

The study uses a mixed-methods approach. A total of 80 participants from four Black Majority Churches in South London will be recruited. Randomisation of the participants will be at an individual level to either the intervention group (who will participate in the 10 week Mental Health Awareness Course intervention) or to the waiting list control group (who will receive the same intervention, 8 weeks after the intervention group). Outcomes for both arms will be collected at baseline, postintervention, and at 4 week follow-up. In addition, focus group discussions will be conducted with participants in the intervention group, a week following the end of the 10 week session course, to investigate the feasibility and acceptability of the mental health awareness course.

ETHICS AND DISSEMINATION

The results of this research will be disseminated at local, national, and international levels.

TRIAL REGISTRATION NUMBER

ISRCTN12253092.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

Evaluating the design of the Integrated Care for Older People: a theory of change approach

Introduction

Given the progressive aging of the population, there is an urgent need at the health system level to implement effective models to care for older people (OP). Healthy aging is imperative to reach the Sustainable Development Goals. The World Health Organization (WHO) developed the Integrated Care for Older People (ICOPE) strategy to address this challenge. Implementing ICOPE requires its adaption to a specific context. We propose a pathway for such adaptation through an evaluation of the design of ICOPE; thus, we aim to describe the Theory of Change (ToC) of ICOPE and evaluate it for its implementation in Mexico City.

Methods

Based on the WHO and published literature documentation, we drafted an initial ToC for ICOPE. Then, we validated the ToC with experts in ICOPE, after which we evaluated and refined it by discussing the causal pathway, intervention required to activate it, rationale, and assumptions in consecutive workshops with 91 stakeholders and healthcare workers, using the nominal group technique to reach a consensus.

Results

The resulting ToC has the potential to contribute to healthy aging by three expected impacts: (1) prevention, reversal, or delaying of the decline of intrinsic capacity (IC) in OP; (2) improvement of the quality of life of OP; and (3) increase of disability-free life expectancy. The ICOPE causal pathway had ten preconditions, including the availability of resources, identifying at-risk individuals, available treatments, and evaluating results.

Discussion

We adapted ICOPE to a specific implementation context by evaluating its ToC in a participatory process that allows us to identify challenges and address them, at least in terms of the guidelines to operate the strategy. As ICOPE is an approach for a primary healthcare system, its adoption in a community healthcare program is promising and feasible. Evaluation as a tool could contribute to the design of effective interventions. The evaluation of the design of ICOPE for its implementation contributes to the strength of its potential to improve care for OP. This design for implementing ICOPE has the potential to be applied to similar contexts, for example, in other lower-middle-income countries.

A theory of change roadmap for universal health coverage in India

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.

Using participatory action research to pilot a model of service user and caregiver involvement in mental health system strengthening in Ethiopian primary healthcare: a case study

Background

Little is known about actual involvement or how to achieve service user and caregiver in mental health systems strengthening in low-and middle-income countries. This study describes the processes and explores involvement experiences of participants in a pilot study of a new model of service user involvement in mental health system strengthening in a rural district in southern Ethiopia.

Methods

We applied a case study design using participatory action research (PAR). The PAR process comprised of three stages, each with iterative activities of plan, act, observe and reflect. Two stakeholder groups, a Research Advisory Group (RAG) and Research Participant Group (RPG), were established and collaborated in the PAR process. Data collection involved process documentation of meetings and activities: attendances, workshop minutes, discussion outputs, reflective notes, participatory observation of sessions, and in-depth interviews with 12 RPG members. We analyzed the process data descriptively. Thematic analysis was used for qualitative data. Triangulation and synthesis of findings was carried out to develop the case study.

Results

The stakeholder groups identified their top research priorities, developed an intervention and action plan and made a public presentation of preliminary findings. Key mechanisms used for inclusive participation included capacity building and bringing together diverse stakeholders, anchoring the study in established strong community involvement structures, and making use of participatory strategies and activities during the PAR process. Four themes were developed about experiences of involvement in PAR: (i) expectations and motivation, (ii) experiences of the dynamics of the PAR process, (iii) perceived impacts of involvement in the PAR process, and (iv) implementation challenges and future directions.

Conclusions

This case study demonstrated the feasibility and acceptability of implementing a complex model of service-user involvement in mental health system strengthening in a resource constrained setting. More needs to be done to embed service-user involvement into routines of the primary healthcare system, alongside sustained support and strengthening multi-stakeholder collaboration at multiple levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00545-8.

Active inclusion of people living with dementia in planning for dementia care and services in low- and middle-income countries

Involving people living with dementia in service design and planning has become more common in high-income countries. It remains rare in low- and middle-income countries where two-thirds of the world's people with dementia live. In this commentary article, we explore the barriers to inclusion of people living with dementia in planning in low- and middle-income countries and make a case for the inclusion of people living with dementia in care and service planning. We suggest how this can be done at individual, community or national and state level using the following principles: 1) respecting the rights of people living with dementia to self-determination; 2) valuing people living with dementia's unique understanding of dementia; 3) creating a culture of active inclusion which creates a space for people living with dementia to participate and 4) ensuring appropriate accommodations are in place to maximise participation.

Low and unequal use of outpatient health services in public primary health care facilities in southern Ethiopia: a facility-based cross-sectional study

BACKGROUND

Outpatient department visits per individual for each year are one of the core indicators of healthcare delivery to assess accessibility or quality of services. In addition, this study aimed to assess health service utilisation and disease patterns in southern Ethiopia, by including the health authorities' suggestions to improve the services. No study has assessed this in Ethiopia previously.

METHODS

An institution-based cross-sectional design study was done in 65 primary health care units in Dale and Wonsho districts, in Sidama region, for all patients visiting health facilities from 1 July 2017 to 30 June 2018. We estimated the utilisation rate as visits per person per year, the odds ratio for health use and proportions of diseases' diagnoses. The results of our study were presented to local health authorities, and their suggestions for improvements were incorporated into the analysis.

RESULT

A total of 81,129 patients visited the health facilities. The annual outpatient health service utilisation was 0.18 (95% CI: 0.18-0.19) new visits per person per year. The health service utilisation rate per year for the rural population was lower than the urban utilisation by 91% (OR = 0.09; 95% CI: 0.08-0.09). Children in the age group of 5-14 years had lower odds of health service utilisation by 78% (OR = 0.22; 95% CI: 0.21-0.23), compared to children under 5 years of age. Females were four times (OR = 4.17; 95% CI: 4.09-4.25) more likely to utilise health services than males. Febrile illness constituted 17.9% (14,847 of 83,148) of the diagnoses in all age groups. Almost half of the febrile cases, 46.5% (3827 of 8233), were among children under 5 years of age. There were very few cases of non-communicable diseases diagnosed in the health facilities. The health authorities suggested improving diagnostic capacities at health centres, enhancing health professionals' skill and attitudes, and improving affordability and physical accessibility of the services.

CONCLUSION

The health service utilisation rate was low in Sidama. The use of health services was lower among rural residents, men, children and elderly, and health post users. Improving the quality, affordability and accessibility of the health services, by involving responsible stakeholders could increase service usage.

Developing a Framework to Increase Access to Mental Health Services for Children With Special Needs in Ethiopia

The availability and accessibility of Westernized mental health diagnostic processes and evidence-based treatments are limited in developing countries, such as Ethiopia (Kakuma et al., 2011; Hohenshil et al., 2013; Wondie, 2014; Zeleke et al., 2017b). Similar to other developing nations, there is (a) a lack of health care services for mental practices to build on, (b) limited services that are well-suited to the culture (Wondie, 2014; Zeleke et al., 2019), (c) limited scientific literature useful for documenting the needs of the Ethiopian public, and (d) too few mental health professional preparation programs (Zeleke et al., 2019). Whereas Western cultures generally follow the biomedical model conceptualization and treatment of disease, non-Western cultures, such as Ethiopia tend to adhere to traditional and religious views to explain the origin of mental illness (Kortmann, 1987; Jacobsson and Merdassa, 1991). Mental health symptoms may be attributed to supernatural causes or other spiritual crises, rather than a combination of biopsychosocial influences. As such, individuals seeking help with mental health symptoms in Ethiopia are mostly limited to family, friends and local community healers (Zeleke et al., 2017a, 2019). When individuals are brought to the few places providing Westernized mental health care, it is often only after exhausting other traditional and religious alternatives (Bekele et al., 2000). Even when there is a desire to seek Westernized services, socioeconomic circumstance, cultural factors (e.g., a focus on collectivism practices), negative attitudes toward mental illness, along with unfamiliarity and fear of these new practices, are noted barriers to receiving treatments. Beliefs passed down through cultural taboos go on to effect multiple generations. Not only do barriers affect individuals, but they also negatively impact the range of services for children, families and communities. With the ultimate goal of improving mental health care access for children, a full appreciation of the context is essential.