Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks

Background Task-sharing is a promising strategy to expand mental healthcare in low-resource settings, especially in low- and middle-income countries (LMICs). Research on how to best implement task-sharing mental health interventions, however, is hampered by an incomplete understanding of the barriers and facilitators to their implementation. This review aims to systematically identify implementation barriers and facilitators in evidence-based task-sharing mental health interventions using an implementation science lens, organizing factors across a novel, integrated implementation science framework. Methods PubMed, PsychINFO, CINAHL, and Embase were used to identify English-language, peer-reviewed studies using search terms for three categories: “mental health,” “task-sharing,” and “LMIC.” Articles were included if they: focused on mental disorders as the main outcome(s); included a task-sharing intervention using or based on an evidence-based practice; were implemented in an LMIC setting; and included assessment or data-supported analysis of barriers and facilitators. An initial conceptual model and coding framework derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework was developed and iteratively refined to create an integrated conceptual framework, the Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH), which specifies 37 constructs across eight domains: (I) client characteristics, (II) provider characteristics, (III) family and community factors, (IV) organizational characteristics, (V) societal factors, (VI) mental health system factors, (VII) intervention characteristics, and (VIII) stigma. Results Of the 26,935 articles screened (title and abstract), 192 articles underwent full-text review, yielding 37 articles representing 28 unique intervention studies that met the inclusion criteria. The most prevalent facilitators occur in domains that are more amenable to adaptation (i.e., the intervention and provider characteristics domains), while salient barriers occur in domains that are more challenging to modulate or intervene on—these include constructs in the client characteristics as well as the broader societal and structural levels of influence (i.e., the organizational, mental health system domains). Other notable trends include constructs in the family and community domains occurring as barriers and as facilitators roughly equally, and stigma constructs acting exclusively as barriers. Conclusions Using the BeFITS-MH model we developed based on implementation science frameworks, this systematic review provides a comprehensive identification and organization of barriers and facilitators to evidence-based task-sharing mental health interventions in LMICs. These findings have important implications for ongoing and future implementation of this critically needed intervention strategy, including the promise of leveraging task-sharing intervention characteristics as sites of continued innovation, the importance of but relative lack of engagement with constructs in macro-level domains (e.g., organizational characteristics, stigma), and the need for more delineation of strategies for task-sharing mental health interventions that researchers and implementers can employ to enhance implementation in and across levels. Trial registration PROSPERO CRD4202016135

A pilot pragmatic trial of a “what matters most”-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana

We conducted a pilot trial of an intervention targeting intersectional stigma related to being pregnant and living with HIV while promoting capabilities for achieving ‘respected motherhood’ (‘what matters most’) in Botswana. A pragmatic design allocated participants to the intervention (N = 44) group and the treatment-as-usual (N = 15) group. An intent-to-treat, difference-in-difference analysis found the intervention group had significant decreases in HIV stigma (d = − 1.20; 95% CI − 1.99, − 0.39) and depressive symptoms (d = − 1.96; 95% CI − 2.89, − 1.02) from baseline to 4-months postpartum. Some, albeit less pronounced, changes in intersectional stigma were observed, suggesting the importance of structural-level intervention components to reduce intersectional stigma

Toward a relational conceptualization of structural stigma: A scoping review of the concept and two supporting studies on structural stigma toward opioid use and injection drug use

Stigma is a fundamental cause of health disparities, and its structural forms are garnering increased attention in public health research. However, there are limitations in how the concept of “structural stigma” has been conceptualized and operationalized to date, and public health research could benefit from a more relational understanding of the concept. A relational conceptualization of structural stigma positions it as the most macro level of an entrenched and wide-reaching system of intersectional stratification that influences one’s relationships with self, others, and structures across one’s lifecourse and the locations in which one lives. Further, the known negative effects of stigma related to opioid use and injection drug use underscore an urgent need to address stigma at all levels, including the structural level, to improve the health and well-being of people who use opioids and people who inject drugs. This dissertation first presents a scoping review of the “structural stigma” concept to elucidate trends in the term’s conceptualization and operationalization in empirical health-related research. A total of 233 articles were identified across five databases, over half of which were published since the beginning of 2020. One third of the articles (n = 77; 33%) quantitatively operationalized structural stigma, while nearly a quarter (n = 53; 23%) operationalized it qualitatively; the remainder (n = 106; 46%) mentioned but did not operationalize the concept. Moreover, over one-third (n = 86, 37%) of articles focused solely on stigma related to sexual minority people’s health. These and additional findings point to not only the promise of applying the concept across more populations, settings, and stigmatized statuses of interest, but also a need for more rigorous methods that account for individuals’ agency and intersectional lived experiences across the lifecourse and within different structural contexts. The remaining two studies of this dissertation focus on people who use opioids and people with a history of injection drug use. The second study used natural language processing methods to identify an analytic sample of 273 posts and comments from the social media platform Reddit related to structural stigma toward opioid use. This content was then qualitatively analyzed using a prominent conceptualization of stigma. This analysis revealed how Redditors described how structures—including governmental programs and policies, the pharmaceutical industry, and healthcare systems—stigmatize people who use opioids. Redditors reported structures stigmatizing people who use opioids through medical labeling, assigning negative stereotypes, separating people who use opioids (e.g., as either “legitimate” or “illegitimate” patients), and engendering status loss and discrimination (e.g., loss of employment, denial of healthcare). Redditors also posted robust formulations of structural stigma, mostly around how historic and ongoing structural stigma manifests in the criminalization of substance use, is often driven by profit motive, and leads to the pervasiveness of fentanyl in the drug supply and the current state of the overdose crisis. Some posts and comments highlighted interpersonal and structural resources (e.g., other people who use opioids, harm reduction programs, telemedicine) that Redditors leverage to navigate structural stigma. The third study is a longitudinal secondary data analysis that used data from the AIDS Linked to the IntraVenous Experience (ALIVE) prospective cohort study collected from January 2014 to March 2020. This analysis examined whether the reported experience of structural stigma toward drug use in healthcare settings is associated with prospective emergency department utilization among people with a history of injection drug use who report a clinic or doctor’s office visit in the prior six months (N = 1,342, contributing 7,289 study visits). Logistic and negative binomial regressions with generalized estimating equations were used to estimate these associations, and the same models were fit for the same sample stratified by race, sex, HIV status, and housing status. These analyses found that after adjusting for relevant covariates, reporting an experience of structural stigma toward drug use in healthcare settings was associated with 1.28 (95% CI: 1.04-1.59) times the odds of reporting any emergency room use and 1.16 (95% CI: 0.99-1.37) times the number of reported emergency room visits at the next study visit. Stratified models revealed nuances in how certain sociodemographic characteristics may intersectionally shape the experience of structural stigma toward drug use in healthcare settings and its relationship with emergency department utilization. Altogether, these studies advance public health inquiry into structural stigma, contribute knowledge about the lived experience of structural stigma toward people who use opioids, and provide evidence of how structural stigma shapes the healthcare utilization of people with a history of injection drug use. In so doing, this dissertation argues for a more relational conceptualization of structural stigma that can not only advance scientific inquiry into the intricate interrelationships between structures and individuals’ health, but also help public health urge and enact structural transformation to improve health and well-being for all