Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice

Abstract

In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline a framework of questions exploring key cultural and ethical dimensions of mhGAP planning, adaptation, training, and implementation. This framework is meant to guide mhGAP activity taking place around the world. Our approach is informed by recent research on cultural formulation and adaptation, and aligned with key components of the WHO implementation research guide (Peters, D. H., Tran, N. T., & Adam, T. (2013). Implementation research in health: a practical guide. Implementation research in health: a practical guide.). The framework covers three broad domains: (1) Concepts of wellness and illness—how to examine cultural norms, knowledge, values and attitudes in relation to the “culture of the mhGAP”; (2) Systems of care—identifying formal and informal systems of care in the cultural context of practice.; and (3) Ethical space: examining issues related to power dynamics, communication, and decision-making. Systematic consideration of these issues can guide integration of cultural knowledge, structural competence, and ethics in implementation efforts.

The use, misuse and overuse of the ‘low-income and middle-income countries’ category

“…While this movement was lauded by many, others noted that the universal adoption of these models risked neglecting local views on distress and healing that had served the needs of many communities around the world and ignoring the numerous limitations (and harms) of these models. Efforts continue to be made to find a way to avoid the problems associated with these ‘western’ modes of diagnosis and care while working to identify their strengths and integrate local approaches to healing and care 28 29. It is this type of critical engagement with approaches that is needed when using LMIC in global scholarship.…”

WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact

“…Domains included examining concepts of wellness and illness, exploring systems of care, recognising formal and informal care systems, and considering the ethical space of power dynamics and decision making. 13…”

Mental healthcare in primary and community-based settings: evidence beyond the WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide

“…However, stigma, cultural differences and differing perspective on treatments can be barriers to mhGAP-IG implementation and use 17 39. Following the recommendation to locally adapt the mhGAP-IG is not always described; a recent framework has been published, which guides mhGAP-IG cultural and contextual adaptation 48. While we previously identified 15 studies reporting local mhGAP-IG adaptation or contextualisation,17 39 only three non-mhGAP-IG studies identified by this review discussed intervention adaptation.…”