Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study

Abstract

Background: Policies and programmes in Mexico promote the integration of mental health services into primary health care (PHC), however these services remain largely unavailable in the country. Since 2014 a non-governmental organisation has delivered a mental health programme at PHC clinics in the state of Chiapas, in partnership with the local Ministry of Health (MoH). The programme provides mental health services based on the mhGAP guidelines through multiple implementation strategies, including programme financing, infrastructure strengthening, highintensity training, and supervision. This study aimed to examine the implementation process and outcomes of this mental health programme to understand the extent to which mental health care integration has been achieved and to identify the successes and remaining challenges in order to inform the development and implementation of similar programmes. Methods: We used a mixed-methods convergent design. Quantitative data for the period between December 2016 and December 2017 were extracted from the organisation's health information system to capture process indicators, including the amount (dose) and quality (fidelity) of services delivered. We conducted two focus groups and 24 semistructured interviews with health providers and managers to ascertain implementation outcome data: penetration, fidelity, acceptability, appropriateness and feasibility. Quantitative and qualitative data were analysed using descriptive and framework analyses, respectively. Results: During the study period, health providers delivered mental health consultations to 486 adults diagnosed with a mood or anxiety disorder. Programme fidelity was limited given that talk-based interventions, which are required in all consultations according to programme guidelines, were only provided in 24% of consultations. Only 42% of service users attended more than 50% of scheduled mental health follow-up consultations, which also hindered fidelity. Low attendance is partially attributed to limited programme appropriateness, given that interventions to address social risk factors are not available. High levels of acceptability and feasibility enabled through strong support from the organisation were key programme strengths.

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

“…33 Different perspectives on appropriate treatment. [34][35][36] Rural residence, distance from health facilities, thinking that problems will self-resolve, concerns about treatment costs. 37 Resistance to treatment.…”

Strategies to adapt and implement health system guidelines and recommendations: a scoping review

“…Capacity-building of medical doctors (MDs) through high-intensity training and onsite supervision (Miguel-Esponda et al 2020) [ 69 ]…”

“…Lack of consistent funding was a noted barrier to the implementation of health system guidelines. Despite this, only a handful of articles reported accessing new funding sources as part of their implementation plan [ 66 – 69 ]. While seven studies were conducted in an LIC setting, reports of financial constraints were not limited to those within LICs.…”

Programa de Acción Mundial para Superar las Brechas en Salud Mental (mhGAP) en Chile: aprendizajes y desafíos para América Latina y el Caribe

“…Sin embargo, la aplicación de criterios de rigor en el componente cualitativo (28) y el uso de las mejores prácticas aconsejadas para estudios evaluativos mixtos (13) permiten mitigar estas potenciales limitaciones. El enfoque dado de sostenibilidad y el impacto positivo logrado enriquecen la experiencia acumulada por otros países que han aplicado el mhGAP en la Región (29)(30)(31).…”