Mental Health Promotion and Awareness
Although distinct in principle, mental health promotion and awareness-raising activities often overlapped in practice. These were combined into a single category described by interview participants as comprising activities or interventions conducted to improve the knowledge, awareness, and understanding of mental health and illness among patients, communities, policymakers and other stakeholders in their projects.
Awareness-raising activities to increase community knowledge and demand for care were challenging to implement in settings where services were limited or not easily accessible. Participants reflected on how this might impact their ability to deliver on the expectations of those requiring support and referral services:
“Identifying people with [mental health conditions] is not the end, it’s just the beginning. Where do you refer them? We have to refer them to the clinic. Who is going to treat them? Is the health system ready to address [the need for services]? Because what I’m seeing here, in most of the projects, of course we’re trying to raise awareness and identify people with mental health problems, but the system is not really prepared to address the issues." (Participant 19)
Drivers for the successful implementation of mental health promotion included recruiting providers who were based in the communities where they worked. Grantees felt this would also be a more sustainable approach to improving mental health awareness long after project activities ended, as these providers would be able to continue to support their communities. Motivation was identified as another barrier for the continuation of mental health promotion, as providers felt empowered by the positive impact of their work through their interactions with beneficiaries.
Reframing mental health in culturally appropriate terms was discussed as a way to prevent stigma through awareness-related activities. Participants pressed on the importance of promoting mental health in ways that were deemed locally acceptable. In the following quote, a participant reveals how they side-stepped the problem of stigma by framing their promotion activities as ‘resiliency services’:
“--, we’re not selling the services as mental health services. We’re selling them as wellness services and resiliency services as coping with chronic health disease [sic]. You know because there is stigma around mental health in the country.” (Participant 9)
Detection of Mental Illness
Participants described this theme as comprising activities implemented to detect psychiatric symptoms or diagnose mental disorders among patients or community members. The most common mechanisms for detection mentioned in interviews were assessment tools administered by trained formal or informal providers, using either paper forms or mHealth applications.
A major challenge in the implementation of mental health detection was the lack of appropriate human resources. As described further by Endale et al. 2020 in an accompanying paper, this was related to barriers in retaining providers, stigma associated with working in mental health services, and the absence of specialists needed to conduct diagnostic evaluations.
Challenges related to the lack of understanding of cultural variations and idioms of distress also led to concerns over identifying valid screening tools for the target population. In one interview, a participant explained how they had to expand their efforts at detection from health centres to the general population, as mental health literacy is low (15) and some diagnoses do not fit with local approaches to mental health:
“So because help-seeking is really low and because awareness of primary care providers is really low, we couldn’t [sic] we asked them to screen everybody who came to the primary care centres instead of people who were symptomatic or people who would like come in and say, ‘Hey I’m depressed,’ because that doesn’t happen in [country name],” (Participant 12)
Some projects also reported having insufficient research expertise within their team to conduct validity and reliability analyses of their screening tools. Incorrect cut-offs for mental health diagnoses in tools can lead to either false positives or negatives. Moreover, participants outlined how it was especially difficult to identify locally appropriate tools for less common conditions (e.g., behavioural disorders):
"… for the scale-up, that became a problem, because people with mild to moderate depression, people who scored [below the cut-off] needed to utilize the intervention as well. And in some cases we had people who even scored [quite a bit below the cut-off score] who had genuine problems and needed to get–, to receive services. Which obviously has a lot to do with the sensitivity and specificity of the screening tool." (Participant 22)
One participant reported that incentive schemes and team-building activities were useful in motivating frontline providers. Concerted efforts to incentivize collaborative working were found to mitigate professional issues (e.g. negative competition or disagreements) and achieve higher screening rates.
Participants also stressed the need for an integrated approach to adapt and improve detection, calling attention to the need to include key beneficiaries in both the initial design and the later implementation stages. Examples of approaches included integrating screening into routine community detection efforts for other health conditions (e.g. Interactive Voice Response for maternal health) and making the screening forms and questions easily accessible to providers in health settings, such as by laminating questions and framing them on clinic walls.
Using technology to make detection easier for providers emerged as another key driver. Participants highlighted mobile health (mHealth) applications as a way to make screening easier, faster and less vulnerable to human error. The role of technology in managing data more effectively was also mentioned, particularly in regards to promoting a more efficient monitoring and evaluation system compared to using paper forms and filing systems:
“... developing the app was instrumental in being able to screen this number of people, because the data management, data cleaning all of that was just all electronic and in real-time. So I think that really helped.” (Participant 7)
Treatment of Mental Illness
The theme of treatment referred to participants’ self-reported experiences in implementing interventions provided to people diagnosed with mental disorders (or their relatives) during the timeframe of their grants. These interventions were aimed at alleviating psychiatric symptomology, supporting people to self-manage their symptoms and promoting wellbeing.
Several participants highlighted major barriers related to the feasibility of implementing ‘novel’ treatment modalities or intervention designs (i.e. those that have been recently recommended in global literature) in their settings. While there may be international pressure to adopt new interventions, participants argued that it might not be realistic to implement in specific contexts. For settings struggling with limited resources, these challenges can impede efforts to scale up or sustain project activities. Others found it challenging to find the right balance between delivering interventions with fidelity and making room for adaptations to improve local appropriateness. Projects that struggled to implement ideal treatment protocols found inconsistencies between what global literature purported and their own treatment approach outcomes. According to two interviewees, the differences occurred due to the interventions being ‘Western’ in their approach, making them difficult to adapt to vastly different belief systems:
"There’s so much of these therapies that are really western in thinking, right? And they’re not, it’s not that they’re contradictory to the culture but they’re a little bit more progressive than the ordinary thinking." (Participant 9)
Some participants found it difficult to integrate mental health into health care settings. They ascribed a number of challenges to the inefficient care pathways in which they were working, including finding appropriate referrals for patients, the lack of qualified mental health professionals and services (particularly in rural settings), and inefficient existing mental health services. These inefficient care pathways added to the burden on their project workforce and limited the scope of their interventions.
"..we learn that there are [sic] lack of services in both early identification and also intervention for the [participants] with [mental health conditions]. And because the services there, they only focus [sic] in the big cities." (Participant 26)
Some participants shared challenges they faced as a result of underestimating the level of demand for their services. In most cases, the level of demand did not seem to match the epidemiological evidence for uptake or the experiences of previous studies conducted in similar settings. Unexpectedly high levels of demand could over-burden the existing workforce, exceeding the limited capacity of the service providers and generating more pressure for additional funding to keep services running beyond the timeframe of the grant:
“They have expressed a great need for the program and had [sic] expressed to us that we should continue the program, which is making life difficult for us, because now we are trying to find how we can generate funds to keep the program going…” (Participant 17)
Participants also identified a series of common challenges (summarised in Table 1) related to the technical aspects of implementing treatment interventions for mental disorders.
Summary of additional findings on the technical challenges faced by interviewees in the delivery of mental health interventions
• Limited financial and human resources and expertise to troubleshoot technical issues
• Service disruptions due to infrastructure issues, e.g. poor network service in rural areas
• Some interventions required service users and their caretakers to use mHealth. This required technical expertise that they may not possess
‘..there could be a very fancy technological app that could capture everything […] but that would cost so much, that would need a lot of human expertise, that – that (sic) might not be able to scale it up in for example other resource-poor settings’ (Participant)
• Barriers to implementation and travel due to challenging terrain and geography, e.g. rural or mountainous areas
• Unanticipated delays due to the extended periods of time needed to train, deliver interventions and motivate stakeholders to participate
• Difficulties in cooperating with bureaucratic and conventional systems, e.g. a disruption in service delivery if administrative processes are not adhered to correctly and drug procurement problems
‘And some of them, our service users were shepherds which, you know shepherds they come down from the mountains for the services, and then they go back. So it’s very difficult to actually reach them’ (Participant)
‘..making sure that there is a supply of drugs is very important. Quite a lot of time is spent with the government trying to see how they can increase that flow’ (Participant)
• Implementing in populations with financial limitations kept their stakeholders from participating when they required money for travel or additional tests
‘..for some of the participants who were living far from the centers it was a challenge to have them come to the sessions because some of them don’t move around a lot’ (Participant)
The local adaptation of materials required to implement the interventions was found to be essential for successful implementation and participant uptake. Interviewees identified multi-modal methods that improved project acceptability to stakeholders. The methods identified include, (1) engaging with service users in the development stages, (2) tailoring the intervention to participant needs, (3) maintaining the dignity of services users, (4) integrating within existing cultural practices and (5) building in strong systems of support that were empowering and beneficial to end-users beyond the scope of the project:
‘I think part of that is kind of recuperating cultural practices that may be in part disintegrating due to the change but also to create support networks between people’ (Participant 18)
Stakeholder-driven promotion is another driver that enhanced implementation success through improved engagement within the targeted populations. As described further by Murphy J et al. 2020 in an accompanying paper, integrating positive treatment outcomes into dissemination efforts drastically improved chances of the intervention’s success in increasing participant acceptance, adherence and the uptake of services.
‘People can see, you know, the quick outcomes of this intervention. But this has been the role of advertising. Successful cases played the most important role’ (Participant 20)
Closely linked to the sub-theme of service uptake was using the increased demand for services to garner buy-in from a larger pool of stakeholders, including policymakers, in order to build the intervention delivery into a sustainable and scalable model. One interviewee also explained that this might sometimes require being flexible and deviating from the intervention protocol.
Aligning service delivery within existing care pathways was also perceived to have a significant impact on implementation success. Interviewees discussed how training and using lay workers that were already connected to local services to deliver their interventions could address human resource gaps, in addition to allowing for referrals and the provision of support to end-users. Because of these learnings, the need for integrating mental healthcare into locally applicable and socially supportive referral networks was identified as an important driver for greater reach, impact and success of service delivery.
‘So for us then… it made sense to go with the social franchising model and family care […] kind of combines the best of all those social franchising operations around the country. So they have networks everywhere’ (Participant 9)
Involving family members in treatment activities for benefiaries played a significant role in implementation success. Involving families helped to reduce the burden on limited human resources, empowered families and gave them the skills and confidence to better care for their relatives. Involving family members also encouraged the building of sustainable support systems between different participating family units within the same areas.
‘..So we are shifting the task even from the [name of lay health workers] to the families. And that’s a sustainable and scalable model’ (Participant 6)
Only one participant flagged the engagement of family members as a barrier, and this may be specific to service delivery approaches for substance use disorders. These considerations are important to note for disorders that are comparatively more socially stigmatizing than other mental health conditions in certain settings.
“…and it also disrupts the session, in the sense that the family members might not talk about a lot of things that might come up because the man is sitting in [at the] back, saying things which he might not like [sic] might mean” (Participant 17)
Health technology solutions, while challenging to maintain, were also identified as an important driver, providing flexibility to implementers in adapting their interventions, sharing lessons learned, and utilizing more efficient systems of monitoring and evaluating projects. For some, mHealth solutions supported a larger coverage of interventions and detection efforts, and provided projects with a platform for learning how to improve their services:
“We moved to smartphones, and we get – that has given us so much more flexibility in terms of, you know, enhancing our interventions, making like applications, getting all of the information to them for health providers to use for their own learning and for the learning of the community when they go and visit those people […] So I think that there have been these facilitators mainly.” (Participant 24)