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Bemme D, Roberts T, Ae-Ngibise KA, Gumbonzvanda N, Joag K, Kagee A, Machisa M, van der Westhuizen C, van Rensburg A, Willan S, Wuerth M, Aoun M, Jain S, Lund C, Mathias K, Read U, Taylor Salisbury T, Burgess RA. Mutuality as a method: advancing a social paradigm for global mental health through mutual learning. Soc Psychiatry Psychiatr Epidemiol 2024; 59:545-553. [PMID: 37393204 PMCID: PMC10944435 DOI: 10.1007/s00127-023-02493-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/23/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared. METHODS We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH. RESULTS Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South. CONCLUSION Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept.
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Affiliation(s)
| | | | | | | | | | - Ashraf Kagee
- Stellenbosch University, Stellenbosch, South Africa
| | | | | | - André van Rensburg
- University of Kwazulu-Natal, Centre for Rural Health, Durban, South Africa
| | - Samantha Willan
- South African Medical Research Council, Cape Town, South Africa
| | | | - May Aoun
- Save the Children, New York, USA
| | | | - Crick Lund
- King's College London, London, UK
- University of Cape Town, Cape Town, South Africa
| | - Kaaren Mathias
- University of Canterbury, Christchurch, New Zealand
- Burans, Herbertpur Christian Hospital, Atten Bagh, India
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Seward N, Hanlon C, Abdella A, Abrahams Z, Alem A, Araya R, Bachmann M, Bekele A, Bogale B, Brima N, Chibanda D, Curran R, Davies J, Beyene A, Fairall L, Farrant L, Frissa S, Gallagher J, Gao W, Gwyther L, Harding R, Kartha MR, Leather A, Lund C, Marx M, Nkhoma K, Murdoch J, Petersen I, Petrus R, van Rensburg A, Sandall J, Sevdalis N, Sheenan A, Tadesse A, Thornicroft G, Verhey R, Willott C, Prince M. HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies. Glob Health Action 2022; 15:1987044. [PMID: 35037844 PMCID: PMC8765245 DOI: 10.1080/16549716.2021.1987044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 09/25/2021] [Indexed: 12/03/2022] Open
Abstract
To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.
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Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed Abdella
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zulfa Abrahams
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Atalay Alem
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ricardo Araya
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Max Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Alemayehu Bekele
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Birke Bogale
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host Microbiome Interactions, King’s College London, London, UK
- Department of Dentistry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nataliya Brima
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Dixon Chibanda
- University of Zimbabwe, Harare, Zimbabwe
- Psychology Department, School of Applied Human Science College of Humanities, University of KwaZulu Natal, London, UK
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Justine Davies
- Centre for Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Andualem Beyene
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, Cape Town, South Africa
- King’s Global Health Institute, King’s College London, London, UK
| | - Lindsay Farrant
- Division of Family Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Souci Frissa
- King’s Global Health Institute, King’s College London, London, UK
| | - Jennifer Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host Microbiome Interactions, King’s College London, London, UK
| | - Wei Gao
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | - Liz Gwyther
- Division of Family Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | | | - Andrew Leather
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Maggie Marx
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Kennedy Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | - Jamie Murdoch
- Department of Population Health Science, Kings College London, London, UK
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Berea, Durban, South Africa
| | - Ruwayda Petrus
- Psychology Department, School of Applied Human Science College of Humanities, University of KwaZulu Natal, Berea, Durban, South Africa
| | - André van Rensburg
- Centre for Rural Health, University of KwaZulu-Natal, Berea, Durban, South Africa
| | - Jane Sandall
- Department of Women and Children’s Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Andrew Sheenan
- Department of Women and Children’s Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Amezene Tadesse
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Graham Thornicroft
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Chris Willott
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Martin Prince
- King’s Global Health Institute, King’s College London, London, UK
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Petersen I, van Rensburg A, Kigozi F, Semrau M, Hanlon C, Abdulmalik J, Kola L, Fekadu A, Gureje O, Gurung D, Jordans M, Mntambo N, Mugisha J, Muke S, Petrus R, Shidhaye R, Ssebunnya J, Tekola B, Upadhaya N, Patel V, Lund C, Thornicroft G. Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform. BJPsych Open 2019; 5:e69. [PMID: 31530322 PMCID: PMC6688466 DOI: 10.1192/bjo.2019.7] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/21/2019] [Accepted: 01/23/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs). AIMS To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs. METHOD Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks. RESULTS Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation. CONCLUSIONS Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important. DECLARATION OF INTEREST None.
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Affiliation(s)
- Inge Petersen
- Research Professor and Director, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - André van Rensburg
- Senior Researcher, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Fred Kigozi
- Senior Consultant Psychiatrist/Researcher, Butabika National Referral and Teaching Mental Hospital, Uganda
| | - Maya Semrau
- Research Fellow, Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London; and Global Health and Infection Department, Brighton and Sussex Medical School, UK
| | - Charlotte Hanlon
- Adjunct Associate Professor, Department of Psychiatry, Addis Ababa University, Ethiopia; and Reader in Global Mental Health, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Jibril Abdulmalik
- Senior Lecturer, Department of Psychiatry, University of Ibadan, Nigeria
| | - Lola Kola
- Researcher, Department of Psychiatry, University of Ibadan, Nigeria
| | - Abebaw Fekadu
- Professor in Global Mental Health, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Ethiopia; and Global Health & Infection Department, Brighton and Sussex Medical School, UK
| | - Oye Gureje
- Professor of Psychiatry and Director, WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, Department of Psychiatry, University of Ibadan, Nigeria; and Professor Extraordinary, Department of Psychiatry, Stellenbosch University, South Africa
| | - Dristy Gurung
- Research Coordinator, Transcultural Psychosocial Organisation, Nepal
| | - Mark Jordans
- Reader, Center for Global Mental Health, King's College London, UK
| | - Ntokozo Mntambo
- Researcher, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - James Mugisha
- Senior Lecturer, Department of Sociology, Kyambogo University and Butabika National Referral and Teaching Mental Hospital, Uganda
| | | | - Ruwayda Petrus
- Senior Lecturer, Department of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, South Africa
| | - Rahul Shidhaye
- Clinical Psychiatrist, Public Health Foundation of India and CAPHRI School for Public Health and Primary Care, Maastricht University, the Netherlands
| | - Joshua Ssebunnya
- Researcher, Butabika National Referral and Teaching Mental Hospital, Uganda
| | - Bethlehem Tekola
- Research Associate, Health Service & Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | | | - Vikram Patel
- Professor, Department of Global Health and Social Medicine, Harvard Medical School and Harvard TH Chan School of Public Health, Harvard University, USA; and Sangath and the Public Health Foundation of India, India
| | - Crick Lund
- Professor of Public Mental Health, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Professor of Global Mental Health and Development, Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Graham Thornicroft
- Professor of Community Psychiatry, Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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