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Effectively addressing mental health and substance use problems are important challenges faced globally. People experiencing such problems encounter many societal barriers that can affect their ability to participate as full members of society and have life expectancies much shorter than the general population. Policies to address mental health and substance use problems require the mobilization of multiple sectors, such as health, education, and justice. While there is strong evidence for programs and services that work, and there are policy directions aimed at achieving better service experiences and improved health and social outcomes, there is a lack of knowledge about how to get these policies and programs embedded effectively into daily practice – a process called implementation. The objective of this dissertation is to advance the understanding of implementation strategies for addressing such complex challenges through five original scientific contributions. The first is a critical interpretive synthesis of existing literature to generate a theoretical framework of the implementation process from the perspective of a policy goal by integrating findings from the public policy, implementation science and knowledge translation fields. Next is a two-part comparative case study exploring how policy implementation was structured and the strategies used in large, well-developed mental health systems. Last is a two-part in-depth examination of mental health policy implementation efforts in Ontario, Canada, beginning with an analysis of the development and implementation of the province’s mental health strategy, followed by an examination of the role that citizens and other stakeholder groups played in its implementation. Together these studies contribute theoretical, substantive and methodological insights toward understanding the effective implementation of policy directions for complex social challenges. Better implementation means more citizens can benefit from effective policies and programs that are needed across populations. / Thesis / Doctor of Philosophy (PhD) / People with mental health and substance use problems face many barriers that can affect their ability to participate in society. In order to make a positive impact on mental health, changes need to be made in a number of different areas such as health, education and justice. There is now research evidence about programs and policies that are effective, but there is a lack of understanding of how to get those changes into policy and practice so that people can benefit from them – a process called implementation. This thesis answers questions about implementation in mental health systems to help fill this gap. It contributes: 1) a new theory of implementation from the perspective of a policy goal; 2) insights about the infrastructure needed to support large-scale implementation; and 3) an understanding of how citizens and other stakeholders contribute to implementation by examining Ontario’s mental health and addictions strategy.

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This dissertation presents a systematic, integrated approach to the design and development of an evidence-based sensory supportive assistive technology for people with mental illness. A systematic integrated design approach and a set of modified design decision-making tools has been developed based on principles and theory of traditional engineering and design of assistive technologies. Specifically, the research provides a vehicle to quickly and successfully go from bench top to bedside and back by systematically integrating fundamental scientific discoveries, market research, and technology research and development in a rigorous and traceable way. An evidence base for the use of weighted blankets, weighted vests, and the novel deep pressure application system has been developed. Ten IRB approved human subjects studies, including pilot studies, with approximately 250 human subject participants were conducted. The studies collected a range of measures to explore safety, efficacy, function, design, research methodologies, and in situ protocols. The populations studied included typical adults, acute mentally ill adults in a locked mental health care facility, typical adults under stress, children with autism, and experts in the fields of research and use of DPTS modalities. These studies required the integration of multiple disciplines including engineering, nursing, occupational therapy, psychology, speech language pathology, entrepreneurship, and marketing. Through the implementation of the integrated design process and decision support tools, a novel deep pressure application system was developed: DeePAD. DeePAD was based on the scientific findings, responses, and experience gained from integrated clinical research studies. DeePAD has been verified to function in situ and has been verified to be adoptable. The Braided design approach and modified Pugh’s Method decision-making tools have resulted in the first critical step from general design principles and guidelines to a systematic integrated and traceable early stage design innovation methodology. This integrated multidisciplinary design approach has overcome the heterogeneity across cognitive, social, behavioral, and communication domains of people with mental illness while providing a ‘single user’ experience, thus reducing the risk of abandonment. This work is the first to provide design engineers a systematic, integrated design approach to develop adoptable evidence-based sensory supportive assistive technologies for people with mental illness and pervasive developmental disorders.

This study examines how yearly pre-performance examinations (PPEs) for collegiate student-athletes support holistic student-athlete health. Specifically, the study evaluates PPE documents within the ambient environment of intercollegiate athletics and uses ambient rhetoric to demonstrate how PPE documents reify values from the collegiate athletics environment that a student-athlete's physical health and athletic participation is more important than their mental well-being. I argue that the influences of the collegiate athletics environment on the PPE documents inhibits the documents from adequately fulfilling their role of identifying pre-existing health conditions. I highlight three key features of the PPE documents—an underrepresentation of mental health questions, a prioritization of athletic participation, and the use of binary question framing—that do not support student-athlete mental health. These three features on PPE documents discourage student-athletes from being truthful on the documents and guide them to choose between prioritizing their health or their athletics participation. Finally, I connect my scholarship to social justice in technical communication and advocate for the use of ambient rhetoric and the consideration of environment in future rhetoric of health and medicine studies that evaluate institutional medical documents. / Master of Arts / Collegiate student-athletes experience many mental health concerns at higher rates than their non-athlete peers and face unique barriers to treatment because of their status as athletes. Despite the ubiquity of mental health concerns among student-athlete populations, the National Collegiate Athletic Association (NCAA) and participating institutions prioritize athlete physical health over athlete mental health. This is evident on the pre-performance examinations (PPEs) that student-athletes must complete each year to participate in athletics, as these documents emphasize physical health and athletic participation far more than mental health. I argue that the use of a typical medical intake form like a PPE is not a useful tool for identifying mental health concerns in this environment because the documents are associated with contributing to athlete participation and do not emphasize athlete mental health. I evaluate the documents in the context of the collegiate athletics environment and explore how the document features inhibit their ability to support student-athlete mental health.

Thesis (M.S.)--Boston University

A pre-post-test, quasi-experimental study design with experimental and control groups was carried out in which measures of social climate were used to define and then change a mental health program. Two forms of the Community Oriented Program Evaluation Scale (COPES), which measures ten dimensions of mental health program social climate, e.g., autonomy, program clarity and personal growth, defined the program social climate according to a single taxonomy at three separate test administrations. The definitions were based on views about the program held by staff and clients. Using the COPES Forms, staff and clients defined the program as they saw it, and defined what their ideal program might look like. Systematic feedback about the program social climate was made to a focus group in the experimental site. The feedback resulted in a definition of the program. Review of the test results provided a means for making changes geared at emphasizing programmatic dimensions found to be lacking. New clinical routines were instituted in the experimental site. The post-test results established that the clinical changes significantly improved the worth and quality of the treatment experience. Measures of social climate helped define, then systematically change, a mental health program's social climate. The use of social climate measurement in this evaluation showed that the definitions contributed to its improvement, and its achievement of clinical and programmatic goals.