Background.This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and (2) an evaluation of implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention.Methods.This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors.Results.Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d  =  1.37), externalizing (d  =  0.85), and posttraumatic stress (d  =  1.71), and improvements in well-being (d  =  0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility.Conclusions.This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.

Findings support the feasibility of implementing IMR within ACT teams. Although there were few significant findings, effect sizes on some variables in this small-scale study and the dose-response relationships within ACT+IMR teams suggest this novel approach could be promising for improving recovery for people with serious mental illness. Further large-scale studies utilizing a hybrid effectiveness-implementation design could provide a promising direction in this area.

The study purpose was to assess the feasibility, advantages/disadvantages, and factors that hinder or facilitate the implementation of illness management and recovery (IMR) within assertive community treatment (ACT) teams. Method: A qualitative study was conducted with 11 ACT teams that implemented IMR. We conducted semistructured individual interviews with 17 persons enrolled in services and 55 ACT staff in individual and focus groups. Questions were designed to assess perceptions of IMR implementation, effects of IMR, staff training considerations, and recommendations. Data were analyzed using an inductive, consensus-building, thematic analysis, which included multiple research staff reviewing interview transcripts and field notes, developing and refining a codebook, constructing data summaries, and thematic synthesis. Results: The analysis revealed six major themes: (a) a generally positive fit exists between the two models and population served, (b) both people with serious mental illness and staff benefited from ACT ϩ IMR, (c) ACT teams encountered significant implementation barriers, (d) relationships and engagement with participants facilitated implementation, (e) taking a flexible approach to IMR and ACT improved implementation, and (f) programs should focus on greater integration of IMR within ACT teams. Conclusions and Implications for Practice: While there can be barriers to implementing IMR within ACT teams, there is generally a positive fit, it is feasible to implement, and it offers meaningful benefits. ACT teams should improve their recovery orientation by more widespread implementation of IMR. Future research on ACT ϩ IMR should include mixed-methods approaches, implementation methodologies to identify barriers and facilitators, and idiographic measures that capture the individualized recovery goals of people with serious mental illness.

Objective This study explored the facilitators, barriers, and strategies used to deliver a child mental health evidence-based treatment (EBT), trauma-focused cognitive behavioral therapy (TF-CBT), in a culturally responsive manner. In low- and middle-income countries most individuals with mental health problems do not receive treatment due to a shortage of mental health professionals. One approach to addressing this problem is task-sharing, in which lay counselors are trained to deliver mental health treatment. Combining this approach with a focus on EBT provides a strategy for bridging the mental health treatment gap. However, little is known how about western-developed EBTs are delivered in a culturally responsive manner. Method Semistructured qualitative interviews were conducted with 12 TF-CBT lay counselors involved in a large randomized controlled trial of TF-CBT in Kenya and Tanzania. An inductive approach was used to analyze the data. Results Lay counselors described the importance of being responsive to TF-CBT participants’ customs, beliefs, and socioeconomic conditions and highlighted the value of TF-CBT for their community. They also discussed the importance of partnering with other organizations to address unmet socioeconomic needs. Conclusion The findings from this study provide support for the acceptability and appropriateness of TF-CBT as a treatment approach for improving child mental health. Having a better understanding of the strategies used by lay counselors to ensure that treatment is relevant to the cultural and socioeconomic context of participants can help to inform the implementation of future EBTs.

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BackgroundMental health (MH) disorders in low and middle-income countries (LMICs) account for a large proportion of disease burden. While efficacious treatments exist, only 10% of those in need are able to access care. This treatment gap is fueled by structural determinants including inadequate resource allocation and prioritization, both rooted in a lack of research and policy capacity. The goal of the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP), based in Malawi and Tanzania, is to address those research and policy-based determinants.MethodsSHARP aims to (1) build implementation science skills and expertise among Malawian and Tanzanian researchers in the area of mental health; (2) ensure that Malawian and Tanzanian policymakers and providers have the knowledge and skills to effectively apply research findings on evidence-based mental health programs to routine practice; and (3) strengthen dialogue between researchers, policymakers, and providers leading to efficient and sustainable scale-up of mental health services in Malawi and Tanzania. SHARP comprises five capacity building components: introductory and advanced short courses, a multifaceted dialogue, on-the-job training, pilot grants, and “mentor the mentors” courses.DiscussionProgram evaluation includes measuring dose delivered and received, participant knowledge and satisfaction, as well as academic output (e.g., conference posters or presentations, manuscript submissions, grant applications). The SHARP Capacity Building Program aims to make a meaningful contribution in pursuit of a model of capacity building that could be replicated in other LMICs. If impactful, the SHARP Capacity Building Program could increase the knowledge, skills, and mentorship capabilities of researchers, policymakers, and providers regarding effective scale up of evidence-based MH treatment.

Background Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services. Methods Between June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers. Results Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow. Conclusion Findings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge. Trial registration This study reports finding of part of the formative phase of “The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building—A Clinic-Randomized Trial of Strategies to Integrate Depression Care in Malawi” registered as NCT03711786

Implementation strategies are systematic approaches to improve the uptake and sustainability of evidence-based interventions. They frequently focus on changing provider behavior through the provision of interventions such as training, coaching, and audit-and-feedback. Implementation strategies often impact intermediate behavioral outcomes like provider guideline adherence, in turn improving patient outcomes. Fidelity of implementation strategy delivery is defined as the extent to which an implementation strategy is carried out as it was designed. Implementation strategy fidelity measurement is under-developed and under-reported, with the quality of reporting decreasing over time. Benefits of fidelity measurement include the exploration of the extent to which observed effects are moderated by fidelity, and critical information about Type-III research errors, or the likelihood that null findings result from implementation strategy fidelity failure. Reviews of implementation strategy efficacy often report wide variation across studies, commonly calling for increased implementation strategy fidelity measurement to help explain variations. Despite the methodological benefits of rigorous fidelity measurement, implementation researchers face multi-level challenges and complexities. Challenges include the measurement of a complex variable, multiple data collection modalities with varying precision and costs, and the need for fidelity measurement to change in-step with adaptations. In this position paper, we weigh these costs and benefits and ultimately contend that implementation strategy fidelity measurement and reporting should be improved in trials of implementation strategies. We offer pragmatic solutions for researchers to make immediate improvements like the use of mixed methods or innovative data collection and analysis techniques, the inclusion of implementation strategy fidelity assessment in reporting guidelines, and the staged development of fidelity tools across the evolution of an implementation strategy. We also call for additional research into the barriers and facilitators of implementation strategy fidelity measurement to further clarify the best path forward.