Using workshops to develop theories of change in five low and middle income countries: lessons from the programme for improving mental health care (PRIME)

Breuer, Erica; Silva, Mary J De; Fekadu, Abebaw; Luitel, Nagendra P.; Murhar, Vaibhav; Nakku, Juliet; Petersen, Inge; Lund, Crick

doi:10.1186/1752-4458-8-15

Cited by 75 publications

(95 citation statements)

References 30 publications

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“…In fact, our approach shares with ToC the aim of exploring solutions to complex problems using a participatory approach and ensuring stakeholders buy-in and sense of ownership [59]. In both approaches, solutions to address the problem take into account the context, in particular existing needs, difficulties such as power relations, barriers to intervention and possible remedies to problems [60]. Yet, the CBSD approach differs from a ToC approach in the method used.…”

Section: Discussionmentioning

confidence: 99%

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

et al. 2016

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BackgroundAfghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context.MethodsWe employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015.ResultsWe identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently.ConclusionsOur model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions.

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Section: Discussionmentioning

confidence: 99%

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

et al. 2016

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“…19 We conducted four ToC workshops with national and district-level stakeholders including mental health specialists and primary care workers in order to develop the MHCP, and the related evaluation framework. 20 In the first two ToC workshops (district-level stakeholders, n = 14 and policymakers, n = 10), we determined short-term and intermediate outcomes, interventions and assumptions to achieve the overall impact of the district plan. Stakeholders in the last two ToC workshops (district-level stakeholders, n = 11 and policymakers, n = 8) defined indicators to measure each of the MHCP intermediate outcomes.…”

Section: Methodsmentioning

confidence: 99%

Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study

Luitel¹,

Breuer

Adhikari³

et al. 2020

BJPsych open

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Background The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal. Aims To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP. Method A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers. Results The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors. Conclusions Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.

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“…PRIME's research programme consists of three phases over a 6-year period: Inception Phase, Implementation Phase and Scaling Up Phase [14]. As part of the Inception Phase, formative research was conducted including literature reviews, a situation analysis of mental health systems [15], in-depth interviews and focus group discussions with stakeholders [16] and Theory of Change (ToC) workshops [17]. During the Inception Phase, the following systematic steps were followed in order to collect the cross-country data required for qualitative content analysis of stakeholder perceptions.…”

Section: Methodsmentioning

confidence: 99%

“…The findings of this formative research informed the PRIME partners' assessments of the various stakeholders included in the stakeholder analysis. The interviews in the formative research included questions about various stakeholders' perceptions of mental health, the feasibility and acceptability of integrating mental health into primary care and the packages of care that should be included in the PRIME mental health care plans [16,17,21].…”

Section: Characterising Stakeholders By Countrymentioning

confidence: 99%

Stakeholder analysis of the Programme for Improving Mental health carE (PRIME): baseline findings

Makan

Fekadu

Murhar

et al. 2015

Int J Ment Health Syst

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Background:The knowledge generated from evidence-based interventions in mental health systems research is seldom translated into policy and practice in low and middle-income countries (LMIC). Stakeholder analysis is a potentially useful tool in health policy and systems research to improve understanding of policy stakeholders and increase the likelihood of knowledge translation into policy and practice. The aim of this study was to conduct stakeholder analyses in the five countries participating in the Programme for Improving Mental health carE (PRIME); evaluate a template used for cross-country comparison of stakeholder analyses; and assess the utility of stakeholder analysis for future use in mental health policy and systems research in LMIC. Methods:Using an adapted stakeholder analysis instrument, PRIME country teams in Ethiopia, India, Nepal, South Africa and Uganda identified and characterised stakeholders in relation to the proposed action: scaling-up mental health services. Qualitative content analysis was conducted for stakeholder groups across countries, and a force field analysis was applied to the data.Results: Stakeholder analysis of PRIME has identified policy makers (WHO, Ministries of Health, non-health sector Ministries and Parliament), donors (DFID UK, DFID country offices and other donor agencies), mental health specialists, the media (national and district) and universities as the most powerful, and most supportive actors for scaling up mental health care in the respective PRIME countries. Force field analysis provided a means of evaluating cross-country stakeholder power and positions, particularly for prioritising potential stakeholder engagement in the programme. Conclusion:Stakeholder analysis has been helpful as a research uptake management tool to identify targeted and acceptable strategies for stimulating the demand for research amongst knowledge users, including policymakers and practitioners. Implementing these strategies amongst stakeholders at a country level will hopefully reduce the knowledge gap between research and policy, and improve health system outcomes for the programme.

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Using workshops to develop theories of change in five low and middle income countries: lessons from the programme for improving mental health care (PRIME)

Cited by 75 publications

References 30 publications

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study

Stakeholder analysis of the Programme for Improving Mental health carE (PRIME): baseline findings

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