Background: Common mental illnesses are a major public health challenge. Two common mental illnesses, depression and anxiety, were respectively ranked the second and eighth major causes of disability in 2019. However, the mental health treatment gap in low- and middle-income countries (LMICs) is higher than 90%. Systematic reviews suggest that integrated models delivered by primary health or lay providers are effective at reducing symptoms and improving quality of life among those with mental illnesses in LMICs. However, integrated models have not been widely implemented in routine primary care and community settings, beyond researcher-controlled pilot studies in LMICs.
This integrated learning experience (ILE) contributes to key gaps in global mental health and implementation research by outlining implementation strategies (the ‘how’) and components of integrated models (the ‘what’) for people living with common mental illnesses in Latin America, a region composed of LMICs and selected high income countries (HICs) widely known for being early adopters of integrated models. Given current literature gaps, this study also provides an applied example of the assessment of contextual implementation factors and the selection of implementation strategies for integrated models for common mental illnesses in Guatemala, a LMIC in Central America where the burden due to common mental illnesses is high and the implementation of integrated models is low.
Methods: First, we conducted a scoping review to map and summarize the existing literature on integrated service models for common mental illnesses in primary care and community settings in Latin America. Second, we conducted a multi-methods assessment of the local context prior to selecting the implementation strategies for a collaborative care program for Maya T’zutujil young adults living with common mental illnesses in a rural municipal health district in Sololá, a rural department in Guatemala. We used data collected through the public health system to develop behavior-over-time (BOT) graphs outlining the number of primary care visits for common mental illnesses over time (2018-2022). We followed the Practical, Robust Implementation and Sustainability Model (PRISM) framework to conduct qualitative semi-structured interviews. Participants represented Ministry of Health coordinators and providers; community youth leaders with lived experience; and community providers. We performed matrix-based thematic analysis of interview transcripts. Third, we used group model building (GMB), a participatory systems thinking approach to inform the selection of implementation strategies for a primary care, community-based collaborative care program for common mental illnesses in rural Guatemala.
Results: First, our scoping review included 33 publications conducted in 6 countries (Belize, Brazil, Chile, Colombia, Mexico, Peru) about 18 programs commonly addressing depression (N=14, 77.78%). Four studies were experimental. The most and least common components were ‘team-based care’ (N=14, 77.78%) and ‘family/user engagement’ (N=1, 5.55%). The most and least common Expert Recommendations for Implementing Change (ERIC) categories were ‘supporting clinicians’ (N=17, 94.44%), mainly through task-sharing, and ‘changing infrastructure’ (N=4, 22.22%). We found wide heterogeneity across studies about combinations of components and implementation strategies.
Second, our multi-methods assessment showed that less than 1% of the total number of public health visits corresponded to common mental illnesses in the study health district. A collaborative care program could help to increase the number of visits. To enhance fit to the study health district, the program would need to ensure the users’ right to privacy and engage community providers (e.g. Maya providers, religious leaders) and Maya explanatory models of mental health. Infrastructural elements at the municipal health district, such as the availability of psychotropic medications, would need to be met to ensure the program’s implementation and sustainability.
Third, we identified two health-district subsystems influencing the implementation of public primary mental health services. At the community-level, we identified four subsystems. We identified 32 distinct implementation strategies representing the nine ERIC categories. Conclusion: This ILE indicates the need for additional studies focused on the participatory design and evaluation of implementation strategies that go beyond the provider-level (supply side of implementation) and focus on the community-level (demand side of implementation). Our results and methodologies may be utilized by researchers and implementers seeking to integrate mental health services in Guatemala and other LMICs.
| Identifer | oai:union.ndltd.org:columbia.edu/oai:academiccommons.columbia.edu:10.7916/11kd-t196 |
| Date | January 2023 |
| Creators | Paniagua Avila, Alejandra |
| Source Sets | Columbia University |
| Language | English |
| Detected Language | English |
| Type | Theses |
Page generated in 0.0022 seconds