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Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice.

ABSTRACT: In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline a framework of questions exploring key cultural and ethical dimensions of mhGAP planning, adaptation, training, and implementation. This framework is meant to guide mhGAP activity taking place around the world. Our approach is informed by recent research on cultural formulation and adaptation, and aligned with key components of the WHO implementation research guide (Peters, D. H., Tran, N. T., & Adam, T. (2013). Implementation research in health: a practical guide. Implementation research in health: a practical guide.). The framework covers three broad domains: (1) Concepts of wellness and illness-how to examine cultural norms, knowledge, values and attitudes in relation to the "culture of the mhGAP"; (2) Systems of care-identifying formal and informal systems of care in the cultural context of practice.; and (3) Ethical space: examining issues related to power dynamics, communication, and decision-making. Systematic consideration of these issues can guide integration of cultural knowledge, structural competence, and ethics in implementation efforts.

SUBMITTER: Gomez-Carrillo A

PROVIDER: S-EPMC7513569 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice.

Gómez-Carrillo Ana A Lencucha Raphael R Faregh Neda N Veissière Samuel S Kirmayer Laurence J LJ

BMJ global health 20200901 9

In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline ...[more]

PMID: 32967978

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Project description:BackgroundMany interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.MethodsWe used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.ResultsThe CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.ConclusionThe CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

Project description:IntroductionSupporting medical students' and junior doctors' development in busy clinical settings is challenging. As opportunities for developing trainees, for example, traditional bedside teaching, are decreasing, teaching outside of clinical practice is increasing. However, evidence suggests that effective learning through practice arises via an interplay between, first, what experiences are afforded by clinical settings and, second, how trainees engage with these affordances. Many studies investigating clinician learning through practice focus on only one of these two factors. Yet, a well-recognised methodological challenge of enabling learners to articulate how and what they are learning through practice exists. We need, therefore, to understand how this relationship plays out in practice in ways that enrich learning.Methods and analysisThis protocol describes a video reflexive ethnographic approach to illuminate how learning through practice in hospital settings occurs and can be enriched. The study will be conducted in two phases. In phase I, senior clinicians from emergency medicine, medicine and surgical specialties will be interviewed about how they guide trainees' learning through practice. These forms of guidance, analysed using the framework method, will inform phase II comprising observations of practice in: (1) emergency, (2) medical and (3) surgical departments. Video recorded episodes of clinicians' guiding learning through practice will be shared and appraised in reflexive sessions with each clinical team. Relational interdependent learning theory informs the design and data analyses to elicit and evaluate strategies for guiding learning through practice.Ethics and disseminationEthical approval has been received from both healthcare and university settings. The findings should provide important insights for clinicians about workplace learning practices. Findings will be disseminated across the project phases and to diverse audiences-locally, nationally and internationally. The dissemination strategy will use seminars, grand rounds, conference presentations and academic papers to articulate practical, theoretical and methodological findings.

Project description:BackgroundAttempting to implement evidence-based practices in contexts for which they are not well suited may compromise their fidelity and effectiveness or burden users (e.g., patients, providers, healthcare organizations) with elaborate strategies intended to force implementation. To improve the fit between evidence-based practices and contexts, implementation science experts have called for methods for adapting evidence-based practices and contexts and tailoring implementation strategies; yet, methods for considering the dynamic interplay among evidence-based practices, contexts, and implementation strategies remain lacking. We argue that harmonizing the three can be facilitated by user-centered design, an iterative and highly stakeholder-engaged set of principles and methods.MethodsThis paper presents a case example in which we used a three-phase user-centered design process to design and plan to implement a care coordination intervention for young adults with cancer. Specifically, we used usability testing to redesign and augment an existing patient-reported outcome measure that served as the basis for our intervention to optimize its usability and usefulness, ethnographic contextual inquiry to prepare the context (i.e., a comprehensive cancer center) to promote receptivity to implementation, and iterative prototyping workshops with a multidisciplinary design team to design the care coordination intervention and anticipate implementation strategies needed to enhance contextual fit.ResultsOur user-centered design process resulted in the Young Adult Needs Assessment and Service Bridge (NA-SB), including a patient-reported outcome measure and a collection of referral pathways that are triggered by the needs young adults report, as well as implementation guidance. By ensuring NA-SB directly responded to features of users and context, we designed NA-SB for implementation, potentially minimizing the strategies needed to address misalignment that may have otherwise existed. Furthermore, we designed NA-SB for scale-up; by engaging users from other cancer programs across the country to identify points of contextual variation which would require flexibility in delivery, we created a tool intended to accommodate diverse contexts.ConclusionsUser-centered design can help maximize usability and usefulness when designing evidence-based practices, preparing contexts, and informing implementation strategies-in effect, harmonizing evidence-based practices, contexts, and implementation strategies to promote implementation and effectiveness.

Project description:The patient-centered medical home (PCMH) model of primary care is being implemented in a wide variety of socioeconomic contexts, yet there has been little research on whether its effects differ by context. Clinical preventive service use, including cancer screening, is an important outcome to assess the effectiveness of the PCMH within and across socioeconomic contexts.To determine whether the relationship between the PCMH and cancer screening is conditional on the socioeconomic context in which a primary care physician practice operates.A longitudinal study spanning July 1, 2009, through June 30, 2012, using data from the Blue Cross Blue Shield of Michigan Physician Group Incentive Program was conducted. Michigan nonpediatric primary care physician practices that participated in the Physician Group Incentive Program (5452 practice-years) were included. Sample size and outlier exclusion criteria were applied to each outcome. We examined the interaction between practices' PCMH implementation scores and their socioeconomic context. The implementation of a PCMH was self-reported by the practice's affiliated physician organizations and was measured as a continuous score ranging from 0 to 1. Socioeconomic context was calculated using a market-based approach based on zip code characteristics of the practice's patients and by combining multiple measures using principal components analysis.Breast, cervical, and colorectal cancer screening rates for practices' Blue Cross Blue Shield of Michigan patients.The implementation of a PCMH was associated with higher breast, cervical, and colorectal cancer screening rates across most market socioeconomic contexts. In multivariable models, the PCMH was associated with a higher rate of screening for breast cancer (5.4%; 95% CI, 1.5% to 9.3%), cervical cancer (4.2%; 95% CI, 1.4% to 6.9%), and colorectal cancer (7.0%; 95% CI, 3.6% to 10.5%) in the lowest socioeconomic group but nonsignificant differences in screening for breast cancer (2.6%; 95% CI, -0.1% to 5.3%) and cervical cancer (-0.5%; 95% CI, -2.7% to 1.7%) and a higher rate of colorectal cancer (4.5%; 95% CI, 1.8% to 7.3%) screening in the highest socioeconomic group. Because PCMH implementation was associated with larger increases in screening in lower socioeconomic practice settings, models suggest reduced disparities in screening rates across these contexts. For example, the model-predicted disparity in breast cancer screening rates between the highest and lowest socioeconomic contexts was 6% (77.9% vs 72.2%) among practices with no PCMH implementation and 3% (80.3% vs. 77.0%) among practices with full PCMH implementation.In our study, the PCMH model was associated with improved cancer screening rates across contexts but may be especially relevant for practices in lower socioeconomic areas.

Project description:Background:Understanding and addressing the unmet mental health needs burden in the Northern Province of Sri Lanka is the subject of the COMGAP-S two-phase study. Phase Two involves the implementation of the World Health Organization's mental health Gap Action Programme (mhGAP) in primary healthcare settings. As part of the contextual adaptation of mhGAP, eleven of the videos provided in the mhGAP training package have been re-filmed by a local team. We investigated the challenges, barriers and good practices of this adaptation effort from the point of view of team participants. Methods:Twelve persons from the adaptation team, including students of medicine and drama, doctors, drama lecturers and professionals, consented to in-depth individual interviews following an open-ended topic guide with a member of the COMGAP-S study team. Interviews were recorded, transcribed, translated as necessary, and subjected to thematic analysis. Results:The majority of participants perceived the process positively and had pride in their involvement. Expectations, opportunities, and exposure were discussed as stemming from the video production. The main challenges derived from the analysis were lack of discussion around budgeting, logistical difficulties, struggles with team cooperation, and creative differences. Issues around exact translation into the local Tamil dialect and modelling around mental health were emphasised by the majority of participants. Potential uses for the videos were identified beyond the current study and recommendations included setting out clear guidance around available funding and role allocation, and increasing the flexibility in adapting the material. Conclusions:This study illustrated details of the adaptation of existing video materials to facilitate locally-based training for non-specialists on mhGAP curricula. With this, we have added to the knowledge base on conducting cultural and language adaptations and our findings indicate participants felt adapting the mhGAP films to local context was vital to ensuring training materials were culturally appropriate and valid. Trial registration:This project was nested within the larger COMGAP-S clinical trial. Ethics approval was granted from the Ethics Review Committee, Faculty of Medicine, University of Jaffna (J/ERC/17/81/NDR/0170) and the Faculty Research Ethics Panel, Faculty of Medical Science, Anglia Ruskin University (SC/jc/FMSFREP/16/17076). The project is registered with the Sri Lankan Clinical Trial Registry (SLCTR/2018/008) and listed on the ISRCTN registry (trial ID ISRCTN62598070).

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Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice.

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Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice.

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