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

Trafficking experiences and psychological dysfunction among female trafficking survivors returning to Vietnam

Background: Studies have shown high levels of depression and post-traumatic stress disorder in female trafficking survivors and that mental disorders might be associated with factors such as pretrafficking childhood abuse, trafficking trauma, and unmet needs at post-trafficking. No study has provided comparisons of trafficking experiences and subsequent psychological dysfunction between individuals trafficked for different types of exploitation. Methods: A cross-sectional convenience sample of trafficked women and girls returning to and receiving assistance through a post-trafficking project in Vietnam's northern border region were recruited for the study. Participants who provided informed consent were interviewed about demographic characteristics, trafficking experiences including trafficking trauma, and self-reported health. Psychological dysfunction was assessed by a score on the self-reporting questionnaire-20 items. Univariate and bivariate statistics were done to examine distributions of trafficking experience and psychological dysfunction between women trafficked into sex work, marriage, and domestic servitude. Multivariate regression analyses were done to determine predictive factors of psychological status in this sample of returning trafficking survivors. Findings: 80 of 92 participants who agreed to participate in the study had complete data for the dependent variable; of whom 23 reported being trafficked into sex work, 15 into marriages, 12 into domestic servitude, and 30 in other/missing category. In the sample, age at trafficking averaged at 21·0 years (SD 5·5, range 14–45), duration of trafficking averaged at 7·9 months (SD 12·2, range 0–58), and most (n=57) were rescued by the police. Participants reported an average of 5·5 trauma items (of 18, SD 3·9, range 0–14). Individuals in domestic servitude reported the most amount of trauma (mean 8·4, SD 2·7, range 4–12), followed by those in sex work (mean 6·1, SD 3·9, range 0–14), and then those in marriages (mean 4·8, SD 2·7, range 0–10). The sample averaged a self-reporting questionnaire-20 score of 7·2 (SD 3·8, range 0–20). Regression analysis showed that individuals trafficked into marriages and domestic servitude reported significantly more psychological dysfunction than those trafficked into sex work, when adjusted for age, marital status, trafficking duration, and trafficking trauma (marriage: b=3·02, SE 1·17, p=0·012; domestic servitude: b=2·47, SE 1·21, p=0·045). Interpretation: Trafficking trauma and post-trafficking psychological dysfunction might be different between women trafficked into sex work, marriages, or domestic servitude. Provision of services for trafficking survivors should assess the types and severity of trauma and mental health status while remaining cognisant of the specific type of exploitation. Further evidence is needed to determine if these patterns are present in other samples of trafficking survivors. Funding: None

Utility of a multidimensional recovery framework in understanding lived experiences of Chilean and Brazilian mental health service users

The understanding and application of recovery, despite its potential benefits for mental health services, is still in its incipient development in Latin America. Psychiatric reform in the region has been broadly known and discussed; yet, the recovery framework requires further exploration. Whitley and Drake (2010) suggested a recovery framework including five dimensions: clinical, existential, functional, physical, and social, offering a comprehensive perspective of the recovery process. The present study aimed to explore Chilean and Brazilian users’ perspectives on recovery identifying their endorsement of these five dimensions. Twenty-four users and six peer support workers were interviewed on their experiences with the Critical Time Intervention-Task Shifting (CTI-TS) carried out in Santiago (Chile) and in Rio de Janeiro (Brazil). Using a framework analysis approach focused on the users’ recovery process, we examined the utility of Whitley & Drake’s recovery framework in Chile and Brazil. Results showed that: 1. The framework was applicable to this population; 2. For Chilean and Brazilian users, dimensions were intertwined and influenced by salient processes (i.e., continuum of care, centrality of functioning and social life); and 3. Cultural values, stigma, and social determinants (e.g., housing, welfare) were mentioned as crucial factors affecting  treatment and recovery but had not been sufficiently accounted for in the framework. A reinterpretation of the framework was proposed based on Chilean and Brazilian users’ lived experiences. Findings add to the international literature on recovery by increasing the social validity of the multidimensional framework and expanding its utility to diverse populations.La comprensión y aplicación del concepto de recuperación, a pesar de sus posibles beneficios para los servicios de salud mental, aún se encuentra en incipiente desarrollo en América Latina. Si bien la reforma psiquiátrica en la región ha tenido algunos avances, el marco de la recuperación no ha sido suficientemente explorado. Whitley y Drake (2010) sugirieron un marco conceptual integral para la recuperación que incluye cinco dimensiones: clínica, existencial, funcional, física y social. El presente estudio tuvo como objetivo explorar las perspectivas de los usuarios chilenos y brasileños sobre la recuperación identificando su adscripción y aplicabilidad de estas cinco dimensiones. Se entrevistó a treinta participantes de la Intervención en Momento Crítico-Delegación de Funciones (CTI-TS) realizada en Santiago (Chile) y en Río de Janeiro (Brasil) sobre sus experiencias de recuperación. Se exploró la aplicabilidad del marco de Whitley y Drake al contexto de Chile y de Brasil. Los resultados mostraron que: 1. El marco era aplicable a esta población; 2. Las dimensiones presentaban un tipo particular de entrelazamiento y estaban influenciadas por una serie de procesos tales como la continuidad en el proceso de atención/cuidado/autocuidado, y sobresalía la funcionalidad y la esfera social; 3. Los valores culturales, el estigma y los determinantes sociales emergieron como factores cruciales que afectan el tratamiento y la recuperación. Se propuso una reinterpretación del esquema referencial. Los hallazgos representan un aporte a la literatura internacional sobre recuperación al aumentar la validez de este marco referencial multidimensional y su aplicabilidad a diversas poblaciones

Mental health and psychosocial support in humanitarian settings: research priorities for 2021-30.

We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries