Implementing a mental health intervention in low-and-middle-income countries in Europe: is it all about resources?

Abstract

Background: There are limited resources for improving mental health care across Europe, especially in Low-and-Middle-Income Countries (LMICs) in South-eastern Europe with fewer specialist staff and less funding. Scaling up psychosocial interventions that utilise available time and resources more effectively could improve care for people with psychosis in these settings. One intervention is DIALOG+, delivered via an app on a tablet computer: patients identify life areas to improve and clinicians use a solution-focussed process to help improve these areas. This intervention was piloted across mental healthcare systems in European LMICs, and focus groups were conducted to explore whether such interventions could use available resources effectively to improve care for psychosis in these settings.Methods: Eleven focus groups were conducted with clinicians and patients with psychosis who used the intervention over three months during the pilot study, in Bosnia and Herzegovina, Kosovo United Nations Resolution, Montenegro, North Macedonia and Serbia. The Theoretical Domains Framework (TDF), which describes factors affecting engagement with healthcare interventions, structured topic guides and guided analysis. Codes from the data were mapped onto the TDF, analysed to identify barriers and facilitators, translated into English and checked for inter-rater reliability.Results: 25 clinicians and 23 patients participated in focus groups. Clinicians' barriers included limited time for sessions and difficulties working with acutely psychotic patients. Patients' barriers were burden of greater concentration when engaging with DIALOG+ and feeling tense or disturbed during the sessions. Facilitators included motivation to use DIALOG+, positive opinions shared by others, perceived benefits for practice and improving clinician-patient conversations, relationships and care.Conclusions: Barriers to using psychosocial interventions could be overcome even if resources cannot be increased. Despite limited time and other barriers to using DIALOG+, perceived benefits to practice and clinician-patient relationships suggest that psychosocial interventions can use available resources effectively to improve care for psychosis.

Improving treatment of patients with psychosis in low-and-middle-income countries in Southeast Europe: Results from a hybrid effectiveness-implementation, pragmatic, cluster-randomized clinical trial (IMPULSE)

“…The implementation strategy is a data-driven and theory informed document that was created before the trial to guide implementation of DIALOG+ [ 16 ]. The strategy was based on data from interviews and focus groups with stakeholders conducted prior to implementation of the intervention.…”

“…For example, during pretrial work the most common barrier was clinicians’ perceived lack of capability and skills to deliver DIALOG+ to patients with psychosis. As a potential solution, DIALOG+ training was modified: training materials were adapted and appropriate behavior change techniques were used to classify active ingredients of the intervention and to address the identified barriers to implementation [ 16 , 17 ]. Each clinician in the intervention arm received face-to-face training by a local research team member before the first DIALOG+ session, followed by top-up training after delivering the third session.…”

“…All procedures were approved by the following ethics committees: United Kingdom (Queen Mary University of London QMREC2204a, 16…”

Perceived sustainability of psychosocial treatment in low- and middle-income countries in South-Eastern Europe

“…The good structure and comprehensiveness of the intervention were also identified in a previously published article about DIALOG+. 13 Reoccurrence of this finding across different studies is a promising result which implies that sustainability of DIALOG+ might be feasible owing to its practicality and completeness over a broad scope. Other identified facilitators, such as DIALOG+ providing better insight into patients’ conditions, facilitating clinical work and improving therapeutic relationships, were also previously described in literature.…”