Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries

Esponda, Georgina Miguel; Hartman, Sarah J.; Qureshi, Onaiza; Sadler, Euan; Cohen, Alex; Kakuma, Ritsuko

doi:10.1016/s2215-0366(19)30125-7

Cited by 85 publications

(95 citation statements)

References 65 publications

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“…The essential need for capacity building mechanisms that include adequate and ongoing support and supervision, has been highlighted as relevant by other programmes integrating mental health services at PHC [28]. Previous research indicates that rather than single trainings, apprenticeship models are required for effective implementation [29].…”

Section: Discussionmentioning

confidence: 99%

Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study

Esponda

Bohm-Levine

Rodríguez-Cuevas³

et al. 2020

Int J Ment Health Syst

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Background: Policies and programmes in Mexico promote the integration of mental health services into primary health care (PHC), however these services remain largely unavailable in the country. Since 2014 a non-governmental organisation has delivered a mental health programme at PHC clinics in the state of Chiapas, in partnership with the local Ministry of Health (MoH). The programme provides mental health services based on the mhGAP guidelines through multiple implementation strategies, including programme financing, infrastructure strengthening, highintensity training, and supervision. This study aimed to examine the implementation process and outcomes of this mental health programme to understand the extent to which mental health care integration has been achieved and to identify the successes and remaining challenges in order to inform the development and implementation of similar programmes. Methods: We used a mixed-methods convergent design. Quantitative data for the period between December 2016 and December 2017 were extracted from the organisation's health information system to capture process indicators, including the amount (dose) and quality (fidelity) of services delivered. We conducted two focus groups and 24 semistructured interviews with health providers and managers to ascertain implementation outcome data: penetration, fidelity, acceptability, appropriateness and feasibility. Quantitative and qualitative data were analysed using descriptive and framework analyses, respectively. Results: During the study period, health providers delivered mental health consultations to 486 adults diagnosed with a mood or anxiety disorder. Programme fidelity was limited given that talk-based interventions, which are required in all consultations according to programme guidelines, were only provided in 24% of consultations. Only 42% of service users attended more than 50% of scheduled mental health follow-up consultations, which also hindered fidelity. Low attendance is partially attributed to limited programme appropriateness, given that interventions to address social risk factors are not available. High levels of acceptability and feasibility enabled through strong support from the organisation were key programme strengths.

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Section: Discussionmentioning

confidence: 99%

Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study

Esponda

Bohm-Levine

Rodríguez-Cuevas³

et al. 2020

Int J Ment Health Syst

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“…We followed PRISMA guidelines (appendix pp [17][18]. Two of the 15 records were three-group studies and thus provided two data comparisons for meta-analysis.…”

Section: Figure 1: Study Selectionmentioning

confidence: 99%

“…A study 16 of behavioural activation in India found that women reporting intimate partner violence had more severe depressive symptoms than women not reporting intimate partner violence at follow-up, although the frequency of reported intimate partner violence decreased after the intervention. A systematic review 17 of primary care mental health programmes in LMICs highlighted complex service user needs, including social risk factors, as barriers to successful implementation.…”

Section: Introductionmentioning

confidence: 99%

Psychological interventions for common mental disorders in women experiencing intimate partner violence in low-income and middle-income countries: a systematic review and meta-analysis

Keynejad

Hanlon

Howard

2020

The Lancet Psychiatry

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Background Evidence on the effectiveness of psychological interventions for women with common mental disorders (CMDs) who also experience intimate partner violence is scarce. We aimed to test our hypothesis that exposure to intimate partner violence would reduce intervention effectiveness for CMDs in low-income and middle-income countries (LMICs).Methods For this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, trials registries, 3ie, Google Scholar, and forward and backward citations for studies published between database inception and Aug 16, 2019. All randomised controlled trials (RCTs) of psychological interventions for CMDs in LMICs which measured intimate partner violence were included, without language or date restrictions. We approached study authors to obtain unpublished aggregate subgroup data for women who did and did not report intimate partner violence. We did separate random-effects meta-analyses for anxiety, depression, post-traumatic stress disorder (PTSD), and psychological distress outcomes. Evidence from randomised controlled trials was synthesised as differences between standardised mean differences (SMDs) for change in symptoms, comparing women who did and who did not report intimate partner violence via random-effects meta-analyses. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42017078611. FindingsOf 8122 records identified, 21 were eligible and data were available for 15 RCTs, all of which had a low to moderate risk of overall bias. Anxiety (five interventions, 728 participants) showed a greater response to intervention among women reporting intimate partner violence than among those who did not (difference in standardised mean differences [dSMD] 0·31, 95% CI 0·04 to 0·57, I²=49·4%). No differences in response to intervention were seen in women reporting intimate partner violence for PTSD (eight interventions, n=1436; dSMD 0·14, 95% CI -0·06 to 0·33, I²=42·6%), depression (12 interventions, n=2940; 0·10, -0·04 to 0·25, I²=49·3%), and psychological distress (four interventions, n=1591; 0·07, -0·05 to 0·18, I²=0·0%, p=0·681).Interpretation Psychological interventions treat anxiety effectively in women with current or recent intimate partner violence exposure in LMICs when delivered by appropriately trained and supervised health-care staff, even when not tailored for this population or targeting intimate partner violence directly. Future research should investigate whether adapting evidence-based psychological interventions for CMDs to address intimate partner violence enhances their acceptability, feasibility, and effectiveness in LMICs.

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“…Stakeholder engagement (SE) is essential for successful implementation in global mental health (GMH) (1) and has been identified as a priority by prominent GMH initiatives (2, 3). SE has also been identified as an essential skill for GMH implementors (4). There is, however, little research that explicitly identifies barriers, drivers and best practices for SE in GMH.…”

Section: Introductionmentioning

confidence: 99%

Barriers and Drivers to Stakeholder Engagement in Global Mental Health Projects

Murphy

Qureshi

Endale

et al. 2020

Preprint

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Background: Engagement with diverse stakeholders, including policy makers, care providers and end users, 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 n=29 recipients of global Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of Grand Challenges Canada-funded projects. We used framework analysis to identify key themes related to implementation barriers and facilitators. This paper reports on barriers and facilitators to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this volume. Results: Barriers and drivers to stakeholder engagement were identified across four themes: 1) Contextual Considerations, 2) Resources, 3) Participation, Uptake and Empowerment, and 3) 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 facilitators. Stigma at the institutional and individual level was also identified as a substantial barrier to engagement. Conclusion: Stakeholder engagement is critical to successful implementation of global mental health interventions, particularly for promoting scale-up and sustainability. The findings of this study are relevant to implementors in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement in several ways. Investing in high-quality formative research, supporting capacity building in methods such as integrated knowledge translation and participatory priority-setting, investing in longer-term funding schemes to support sustainable partnerships and scale-up and supporting researchers to build skills in policy engagement would help to foster successful engagement and thus support effective implementation of global mental health innovations.

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Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries

Cited by 85 publications

References 65 publications

Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study

Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study

Psychological interventions for common mental disorders in women experiencing intimate partner violence in low-income and middle-income countries: a systematic review and meta-analysis

Barriers and Drivers to Stakeholder Engagement in Global Mental Health Projects

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