Pathways towards scaling up Problem Management Plus in Turkey: A Theory of Change Workshop

Abstract Background A considerable evidence base has been produced in recent years highlighting the effectiveness of brief scalable psychological interventions for people living in communities exposed to adversity. However, practical guidance on how to scale up these interventions to wider populations does not exist. In this paper we report on the use of Theory of Change (ToC) to plan the scale up of the World Health Organization’s flagship low intensity psychological intervention “Problem Management Plus” (PM+) for Syrian refugees in Turkey.Methods We conducted a one-day ToC workshop in Istanbul. ToC is a participatory planning process used in the development, implementation and evaluation of projects. It is similar to driver diagrams or logic models in that it offers a tool to visually present the components needed to reach a desired long-term outcome or impact. The overall aim of ToC is to understand the change process of a complex intervention and to map out causal pathways through which an intervention or strategy has an effect. Results Twenty-four stakeholders (including governmental officials, mental health providers, officials from international/national non-governmental organisations, conflict and health researchers) participated in the ToC workshop. A ToC map was produced identifying three key elements of scaling up (the resource team; the innovation and the health system; and the user organisation) which are represented in three distinct causal pathways. Context-specific barriers related to the health system and the political environment were identified, and possible strategies for overcoming these challenges were suggested. Conclusion ToC is a valuable methodology to develop an integrated framework for scaling up. The results highlight that the scaling up of PM+ for Syrian refugees in Turkey needs careful planning and investment from different stakeholders at the national level. Our paper provides a theoretical foundation of the scaling up of PM+, and exemplifies for the first time the use of ToC in planning the scaling up of an evidence-based psychological intervention in global mental health.

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Towards a more nuanced global mental health

The British Journal of Psychiatry ◽

10.1192/bjp.bp.113.139204 ◽

2014 ◽

Vol 204 (6) ◽

pp. 415-417 ◽

Cited By ~ 44

Author(s):

Ross G. White ◽

S. P. Sashidharan

Keyword(s):

Mental Health ◽

Global Mental Health ◽

Scale Up ◽

Scaling Up ◽

World Health ◽

Middle Income ◽

Middle Income Countries ◽

Health Gap ◽

Action Programme ◽

Health Organization

SummaryThe World Health Organization has made concerted efforts to scale up mental health services in low- and middle-income countries through the Mental Health Gap Action Programme (mhGAP) initiative. However, an overreliance on scaling up services based on those used in high-income countries may risk causing more harm than good.

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Scaling-up services for psychosis, depression and epilepsy in sub-Saharan Africa and South Asia: development and application of a mental health systems planning tool (OneHealth)

Epidemiology and Psychiatric Sciences ◽

10.1017/s2045796016000408 ◽

2016 ◽

Vol 26 (3) ◽

pp. 234-244 ◽

Cited By ~ 19

Author(s):

D. Chisholm ◽

M. Heslin ◽

S. Docrat ◽

S. Nanda ◽

R. Shidhaye ◽

...

Keyword(s):

Mental Health ◽

South Africa ◽

Health System ◽

Health Systems ◽

Scale Up ◽

Scaling Up ◽

Health System Strengthening ◽

Resource Needs ◽

Integrated Health ◽

Per Capita

Background.Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders.Methods.A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries.Results.Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06–0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36–1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14–1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy.Conclusions.This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.

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A systematic review of costing studies for implementing and scaling-up breastfeeding interventions: what do we know and what are the gaps?

Health Policy and Planning ◽

10.1093/heapol/czaa005 ◽

2020 ◽

Vol 35 (4) ◽

pp. 461-501 ◽

Cited By ~ 1

Author(s):

Grace Carroll ◽

Cara Safon ◽

Gabriela Buccini ◽

Mireya Vilar-Compte ◽

Graciela Teruel ◽

...

Keyword(s):

Systematic Review ◽

Maternity Leave ◽

Grey Literature ◽

Scale Up ◽

Scaling Up ◽

World Health ◽

Future Research ◽

Cost Estimates ◽

Costing Study

Abstract Despite the well-established evidence that breastfeeding improves maternal and child health outcomes, global rates of exclusive breastfeeding remain low. Cost estimates can inform stakeholders about the financial resources needed to scale up interventions to ultimately improve breastfeeding outcomes in low-, middle- and high-income countries. To inform the development of comprehensive costing frameworks, this systematic review aimed to (1) identify costing studies for implementing or scaling-up breastfeeding interventions, (2) assess the quality of identified costing studies and (3) examine the availability of cost data to identify gaps that need to be addressed through future research. Peer-reviewed and grey literature were systematically searched using a combination of index terms and relevant text words related to cost and the following breastfeeding interventions: breastfeeding counselling, maternity leave, the World Health Organization International Code of Marketing of Breastmilk Substitutes, the Baby-Friendly Hospital Initiative, media promotion, workplace support and pro-breastfeeding social policies. Data were extracted after having established inter-rater reliability among the first two authors. The quality of studies was assessed using an eight-item checklist for key costing study attributes. Forty-five studies met the inclusion criteria, with the majority including costs for breastfeeding counselling and paid maternity leave. Most cost analyses included key costing study attributes; however, major weaknesses among the studies were the lack of clarity on costing perspectives and not accounting for the uncertainty of reported cost estimates. Costing methodologies varied substantially, standardized costing frameworks are needed for reliably estimating the costs of implementing and scaling-up breastfeeding interventions at local-, national- or global-levels.

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Pathways towards scaling up Problem Management Plus in Turkey: a theory of change workshop

Conflict and Health ◽

10.1186/s13031-020-00278-w ◽

2020 ◽

Vol 14 (1) ◽

Cited By ~ 3

Author(s):

Daniela C. Fuhr ◽

◽

Ceren Acarturk ◽

Ersin Uygun ◽

Michael McGrath ◽

...

Keyword(s):

Scaling Up ◽

Theory Of Change ◽

Problem Management

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A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial

Trials ◽

10.1186/s13063-019-3839-9 ◽

2020 ◽

Vol 21 (1) ◽

Cited By ~ 2

Author(s):

Matthias Knefel ◽

Viktoria Kantor ◽

Andrew A. Nicholson ◽

Jennifer Schiess-Jokanovic ◽

Dina Weindl ◽

...

Keyword(s):

Mental Health ◽

Asylum Seekers ◽

Mental Health Problems ◽

Psychological Intervention ◽

Health Problems ◽

Immigrant Integration ◽

World Health ◽

Afghan Refugees ◽

Link Type ◽

Asylum Seekers And Refugees

Abstract Background Asylum seekers and refugees are at great risk for developing mental disorders. Afghan refugees are a particularly vulnerable group with a low average education and mental health literacy level. Traumatic experiences and hardship before and during migration are predictive of mental health problems. However, post-migration living difficulties (PMLDs) also account for a large proportion of mental distress in such populations, which, critically, are not sufficiently considered in treatment protocols and research investigations. Indeed, the evidence base for the treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments, where refugees may likely suffer from other mental health problems such as depression or anxiety. Methods/design This trial is the first evaluation of a short-term, transdiagnostic treatment protocol for treatment-seeking Afghan refugees which addresses mental health problems and PMLDs while using an adapted version of the Problem Management Plus (PM+) protocol. Here, we will investigate the efficacy of an intervention manual with a prospective, single-center, randomized, assessor-blind, two-group trial among refugees who are on a waiting list for professional mental health treatment. Furthermore, we will investigate participants’ subjective experiences with the intervention manual via in-depth interviews. One hundred twenty people will be assessed and randomly allocated to either the intervention arm or a treatment-as-usual arm. Clinical psychologists will conduct the treatment, and the sessions will take place with a Dari interpreter. The protocol consists of six 90-min sessions. The primary endpoint is the general symptom distress measure, assessed with the General Health Questionnaire 28 (GHQ-28). Secondary endpoints are the Post-Migration Living Difficulties Checklist (PMLDC), the International Trauma Questionnaire (ITQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), the Psychological Outcome Profile (PSYCHLOPS), service and health care use (assessed with several items), and the Immigrant Integration Index (IPL-12). Discussion This trial may provide substantial evidence for a brief transdiagnostic psychological intervention. Here, we intend to contribute to the treatment of mental health problems among Afghan refugees. The assessment of subjective experience with this treatment manual, as well as the evaluation of its clinical applicability, may optimize treatment acceptance and outcomes across a wide range of mental health problems among refugees. Trial registration German Clinical Trials Register (DRKS) registration number: DRKS00016538. Universal Trial Number: U1111-1226-3285. Registered on January 7, 2019. https://www.drks.de/drks_web/setLocale_EN.do

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Mental health system costs, resources and constraints in South Africa: a national survey

Health Policy and Planning ◽

10.1093/heapol/czz085 ◽

2019 ◽

Vol 34 (9) ◽

pp. 706-719 ◽

Cited By ~ 14

Author(s):

Sumaiyah Docrat ◽

Donela Besada ◽

Susan Cleary ◽

Emmanuelle Daviaud ◽

Crick Lund

Keyword(s):

Public Health ◽

Mental Health ◽

South Africa ◽

Health System ◽

National Survey ◽

Mental Health System ◽

Scale Up ◽

Health Spending ◽

Mental Healthcare ◽

Mental Health Expenditure

Abstract The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa’s public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1–7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country’s progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.

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Development and piloting of a plan for integrating mental health in primary care in Sehore district, Madhya Pradesh, India

The British Journal of Psychiatry ◽

10.1192/bjp.bp.114.153700 ◽

2016 ◽

Vol 208 (s56) ◽

pp. s13-s20 ◽

Cited By ~ 32

Author(s):

Rahul Shidhaye ◽

Sanjay Shrivastava ◽

Vaibhav Murhar ◽

Sandesh Samudre ◽

Shalini Ahuja ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Mental Disorders ◽

Action Plan ◽

Mental Healthcare ◽

Theory Of Change ◽

World Health ◽

Care Workers ◽

Care Models ◽

Health Organization

BackgroundThe large treatment gap for mental disorders in India underlines the need for integration of mental health in primary care.AimsTo operationalise the delivery of the World Health Organization Mental Health Gap Action Plan interventions for priority mental disorders and to design an integrated mental healthcare plan (MHCP) comprising packages of care for primary healthcare in one district.MethodMixed methods were used including theory of change workshops, qualitative research to develop the MHCP and piloting of specific packages of care in a single facility.ResultsThe MHCP comprises three enabling packages: programme management, capacity building and community mobilisation; and four service delivery packages: awareness for mental disorders, identification, treatment and recovery. Challenges were encountered in training primary care workers to improve identification and treatment.ConclusionsThere are a number of challenges to integrating mental health into primary care, which can be addressed through the injection of new resources and collaborative care models.

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Applications of the epidemiological modelling outputs for targeted mental health planning in conflict-affected populations: the Syria case-study

Global Mental Health ◽

10.1017/gmh.2016.4 ◽

2016 ◽

Vol 3 ◽

Author(s):

F. J. Charlson ◽

Y. Y. Lee ◽

S. Diminic ◽

H. Whiteford

Keyword(s):

Mental Health ◽

Major Depression ◽

Disease Burden ◽

Health Planning ◽

Scale Up ◽

Health Benefit ◽

World Health ◽

Steady Increase ◽

Linear Scale ◽

Post Traumatic Stress

BackgroundEpidemiological models are frequently utilised to ascertain disease prevalence in a population; however, these estimates can have wider practical applications for informing targeted scale-up and optimisation of mental health services. We explore potential applications for a conflict-affected population, Syria.MethodsWe use prevalence estimates of major depression and post-traumatic stress disorder (PTSD) in conflict-affected populations as inputs for subsequent estimations. We use Global Burden of Disease (GBD) methodology to estimate years lived with a disability (YLDs) for depression and PTSD in Syrian populations. Human resource (HR) requirements to scale-up recommended packages of care for PTSD and depression in Syria over a 15-year period were modelled using the World Health Organisation mhGAP costing tool. Associated avertable burden was estimated using health benefit analyses.ResultsThe total number of cases of PTSD in Syria was estimated at approximately 2.2 million, and approximately 1.1 million for depression. An age-standardised major depression rate of 13.4 (95% UI 9.8–17.5) YLDs per 1000 Syrian population is estimated compared with the GBD 2010 global age-standardised YLD rate of 9.2 (95% UI 7.0–11.8). HR requirements to support a linear scale-up of services in Syria using the mhGAP costing tool demonstrates a steady increase from 0.3 FTE in at baseline to 7.6 FTE per 100 000 population after scale-up. Linear scale-up over 15 years could see 7–9% of disease burden being averted.ConclusionEpidemiological estimates of mental disorders are key inputs into determining disease burden and guiding optimal mental health service delivery and can be used in target populations such as conflict-affected populations.

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Syrian Refugees in Canada: Clinical Experience in Mental Health Care

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.996 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S620-S620

Author(s):

K. Bazaid

Keyword(s):

Mental Health ◽

Health Care ◽

Mental Health Care ◽

Well Being ◽

World Health ◽

Idioms Of Distress ◽

Syrian Refugees ◽

Competing Interest ◽

And Migration ◽

Health Organization

War is the most serious of all threats to health (World Health Organization, 1982) and can have severe and lasting impacts on mental health. Forced displacement and migration generate risks to mental well-being, which can result in psychiatric illness. Yet, the majority of refugees do not develop psychopathology. Rather, they demonstrate resilience in the face of tremendous adversity. The influx of Syrian refugees to Canada poses challenges to the health care system. We will present our experience to date in the Ottawa region, including a multisector collaborative effort to provide settlement and health services to newly arriving refugees from the Middle East and elsewhere. The workshop will be brought to life by engaging with clinical cases and public health scenarios that present real world clinical challenges to the provision of mental health care for refugees.Objectives(1) Understand the predicament of refugees including risks to mental health, coping strategies and mental health consequences, (2) know the evidence for the emergence of mental illness in refugees and the effectiveness of multi-level interventions, (3) become familiar with published guidelines and gain a working knowledge of assessment and management of psychiatric conditions in refugee populations and cultural idioms of distress.How will the participants receive feedback about their learning? Participants will have direct feedback through answers to questions. The authors welcome subsequent communication by email. Presenters can give attendants handouts on pertinent and concise information linked to the workshop.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Is scaling-up COVID-19 testing cost-saving?

10.1101/2020.03.22.20041137 ◽

2020 ◽

Author(s):

Bernardo Sousa-Pinto ◽

João Almeida Fonseca ◽

Altamiro Costa-Pereira ◽

Francisco Nuno Rocha-Gonçalves

Keyword(s):

Cost Saving ◽

Large Scale ◽

Scale Up ◽

Scaling Up ◽

World Health ◽

Hospitalization Costs ◽

Testing Cost ◽

Additional Costs ◽

Economic Analyses ◽

Health Organization

The World Health Organization currently recommends that governments scale up testing for COVID-19 infection. We performed health economic analyses projecting whether the additional costs from screening would be offset by the avoided costs with hospitalizations. We analysed Portuguese COVID-19 data up until the 22nd March 2020, and estimated the additional number of cases that would be detected if different testing rates and frequencies of positive results would have been observed. We projected that, in most scenarios, the costs with scaling up COVID-19 tests would be lower than savings with hospitalization costs, rendering large scale testing cost-saving.

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