The importance of occupation for individuals' independent living, especially those with mental illnesses, is widely recognized. However, the implementation of evidence-based practices such as IPS remains under-studied in LMICs. In Iran, there is a lack of comprehensive evidence-based occupational programs specifically designed for people with SMI.This study seeks to address this gap by sharing our experience in implementing IPS in Iran, despite the challenges posed by limited resources. By documenting our efforts and the obstacles encountered, we aim to contribute to the growing body of knowledge on effective occupational interventions in LMICs, ultimately improving the quality of care for individuals with SMI in low-resource settings.
Service Development and Adaptation:
Iranian cultural and social context:
In our experience, we observed nearly 90% of service users were men, which can be attributed to some cultural beliefs and norms. In some families, employment is not prioritized for women, and they may be engaged in home-based jobs that are often overlooked when calculating employment rates. We also observed a higher dropout rate among female clients. This could be attributed to the existence of predefined gender roles in our community that emphasize home-based jobs for women, potentially diverting their focus from seeking employment through our service.
Additionally, we found that most of our clients had a high-school diploma or university degree, suggesting that higher education might contribute to increased motivation for seeking employment. The attitude of family members and clinicians also plays a significant role in referring clients to our service.
One notable barrier we encountered was the attitude of clients and theirfamilies toward occupational pursuits. Clients and their families often have the expectation that the service provider will take an active role in finding them a suitable employment. This dynamic suggests that traditionally, they have adopted a more passive attitude towards the employment process, relying on a charity-based model rather than one focused on empowerment.This factor can influence the client’s willingness to engage in the service. A study conducted in India, emphasized the influential role of family members [9]. Another study notrd that the perspective of families may be different from the patients [10]. Moreover, family members as advocators can influence policymakers and peers [11].
In our study, female clients dropped out of the service. Perhaps, the females had some other described roles in our community that emphasize home-based jobs.
Implementation Challenges and Solutions:
Collaboration with stakeholders
During our experience, we encountered challenges in engaging and motivating occupational therapists who possess the necessary skills to provide the service. Factors such as stigma attached to working with people with mental illness and inadequate income can contribute to this issue. Consequently, we made the decision to train clinicians from other disciplines, namely psychologists and social workers, to deliver the service. As demonstrated by Chimara et al, the prevailing institutional model of mental health services in LMICs often leads occupational therapists to prioritize service provision within institutions rather than in community settings. [7]. In contrast, social workers and psychologists displayed greater motivation to engage, learn, and participate in our program. The study proposed that in settings with limited human resources and funding, training clinicians from related disciplines could be a viable solution. By broadening the pool of professionals involved, we aimed to address the challenges posed by limited occupational therapist engagement and ultimately enhance the delivery of the service in our low-resource context.
The successful implementation of IPS relies heavily on the attitudes of stakeholders involved. One significant barrier that can impede progress is the neglectful attitude of specialists towards IPS. To address this challenge, one effective strategy is to regularly present and share success cases of IPS during meetings and discussions. [12].
Barriers to implementing IPS in low-resource settings
As multiple studies have highlighted, the long-term sustainability of this service is contingent upon having accessible funding [13]. Financial challenges have resulted in the discontinuation of numerous programs worldwide. In the current context, the absence of insurance coverage for this service can exacerbate the funding problem.
In some countries, the government takes the responsibility of providing funds for this type of service [3]. Such commitments from the government can greatly contribute to the long-term sustainability and accessibility of the service, ensuring its availability to those who need it most. Continued advocacy efforts and demonstrating the positive impact of the service may help in garnering government support, insurance coverage, or seeking alternative funding sources for its sustainability.
Evaluation and Outcome Measures:
The fidelity and effectiveness of IPS implementation in Iran
The IPS Fidelity Scale is widely recommended as an appropriate tool to assess fidelity in the development and implementation of this service. While we made efforts to adhere to this scale during the development process, we believe that it should be revised to better align with the context and needs of our country. In a qualitative study conducted by Vukadin, the use of the IPS fidelity scale was identified as a barrier to implementing the service. This was attributed to the perceived rigidity of the scale, which may not fully account for the specific nuances and challenges of our country's context [12]. By tailoring the fidelity scale to our specific context, we can better capture the essential elements and indicators of successful implementation of IPS. This will enable us to assess fidelity and make necessary adjustments to optimize the service’s effectiveness in our context more accurately.
Long-term sustainability and scalability of IPS programs in the Iranian context
Limited resources and funds; and inadequate payment for occupational specialists are noted as critical barriers to implementing IPS. On the other hand, providing this service requires spending time, cost, and energy. Therefore, the authors suggest identifying the predictors of better outcomes, especially in LMICs. This would enable the adoption of a modified version of the program that is more cost-effective, as well as the selection of clients who are more likely to benefit significantly from the service.
We believe the support of charitable organizations is essential in providing the necessary resources and funding for the service. Charitable organizations often prioritize initiatives that align with their mission and values, and their support can significantly contribute to the continued operation and growth of the service. Building strong partnerships with these organizations, engaging in effective communication, and demonstrating the positive impact of the service can help secure ongoing support.
Future Directions:
To scale up IPS services nationwide and ensure its sustainability, supportive policies should be established, recognizing the importance of community-based mental health services, and endorsing IPS implementation. Collaboration among stakeholders, including mental health professionals, government agencies, insurance organizations, charitable foundations, and community-based organizations, is crucial. Policymakers should be engaged to shape policies, allocate resources, and provide support for implementation. Further studies should focus on stakeholder experiences, developing a national fidelity scale for LMICs, and conducting randomized control trials to assess IPS effectiveness.
Addressing these policy implications, recommendations, and areas of further study can help facilitate the development, scaling up, and sustainability of IPS services nationwide in LMICs. Promoting knowledge exchange and fostering collaboration between LMICs and international Individual Placement and Support (IPS) initiatives holds great potential for mutual benefit. By building partnerships and engaging in cross-cultural learning, valuable insights can be gained, leading to the development of innovative approaches and the improvement of outcomes for individuals seeking employment support.