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Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review.

ABSTRACT: BACKGROUND:Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions. METHODS:PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR). RESULTS:A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven. CONCLUSION:Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.

SUBMITTER: Kemp CG

PROVIDER: S-EPMC6376798 | biostudies-other | 2019 Feb

REPOSITORIES: biostudies-other

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Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review.

Kemp Christopher G CG Jarrett Brooke A BA Kwon Churl-Su CS Song Lanxin L Jetté Nathalie N Sapag Jaime C JC Bass Judith J Murray Laura L Rao Deepa D Baral Stefan S

BMC medicine 20190215 1

<h4>Background</h4>Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the ut ...[more]

PMID: 30764820

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Project description:AimsTo identify and categorise core components of effective stigma reduction interventions in the field of mental health in low- and middle-income countries (LMICs) and compare these components across cultural contexts and between intervention characteristics.MethodsSeven databases were searched with a strategy including four categories of terms ('stigma', 'mental health', 'intervention' and 'low- and middle-income countries'). Additional methods included citation chaining of all papers identified for inclusion, consultation with experts and hand searching reference lists from other related reviews. Studies on interventions in LMICs aiming to reduce stigma related to mental health with a stigma-related outcome measure were included. All relevant intervention characteristics and components were extracted and a quality assessment was undertaken. A 'best fit' framework synthesis was used to organise data, followed by a narrative synthesis.ResultsFifty-six studies were included in this review, of which four were ineffective and analysed separately. A framework was developed which presents a new categorisation of stigma intervention components based on the included studies. Most interventions utilised multiple methods and of the 52 effective studies educational methods were used most frequently (n = 83), and both social contact (n = 8) and therapeutic methods (n = 3) were used infrequently. Most interventions (n = 42) based their intervention on medical knowledge, but a variety of other themes were addressed. All regions with LMICs were represented, but every region was dominated by studies from one country. Components varied between regions for most categories indicating variation between cultures, but only a minority of studies were developed in the local setting or culturally adapted.ConclusionsOur study suggests effective mental health stigma reduction interventions in LMICs have increased in quantity and quality over the past five years, and a wide variety of components have been utilised successfully - from creative methods to emphasis on recovery and strength of people with mental illness. Yet there is minimal mention of social contact, despite existing strong evidence for it. There is also a lack of robust research designs, a high number of short-term interventions and follow-up, nominal use of local expertise and the research is limited to a small number of LMICs. More research is needed to address these issues. Some congruity exists in components between cultures, but generally they vary widely. The review gives an in-depth overview of mental health stigma reduction core components, providing researchers in varied resource-poor settings additional knowledge to help with planning mental health stigma reduction interventions.

Project description:Stigmatisation and discrimination are common worldwide, and have profound negative impacts on health and quality of life. Research, albeit limited, has focused predominantly on adults. There is a paucity of literature about stigma reduction strategies concerning children and adolescents, with evidence especially sparse for low- and middle-income countries (LMIC). This systematic review synthesised child-focused stigma reduction strategies in LMIC, and compared these to adult-focused interventions. Relevant publications were systematically searched in July and August 2018 in the following databases; Cochrane, Embase, Global Health, HMIC, Medline, PsycINFO, PubMed and WorldWideScience.org, and through Google Custom Search. Included studies and identified reviews were cross-referenced. Three categories of search terms were used: (i) stigma, (ii) intervention, and (iii) LMIC settings. Data on study design, participants and intervention details including strategies and implementation factors were extracted. Within 61 unique publications describing 79 interventions, utilising 14 unique stigma reduction strategies, 14 papers discussed 21 interventions and 10 unique strategies involving children. Most studies targeted HIV/AIDS (50% for children, 38% for adults) or mental illness (14% vs 34%) stigma. Community education (47%), individual empowerment (15%) and social contact (12%) were most employed in child-focused interventions. Most interventions were implemented at one socio-ecological level; child-focused interventions mostly employed community-level strategies (88%). Intervention duration was mostly short; between half a day and a week. Printed or movie-based material was key to deliver child-focused interventions (37%), while professionals most commonly implemented adult-focused interventions (53%). Ten unique, child-focused strategies were all evaluated positively, using a diverse set of scales. Children and adolescents are under-represented in stigma reduction in LMIC. More stigma reduction interventions in LMIC, addressing a wider variety of stigmas, with children as direct and indirect target group, are needed. This systematic review is registered under International Prospective Register of Systematic Reviews PROSPERO, reference number #CRD42018094700.

Project description:Low- and middle-income countries (LMICs) bear the brunt of communicable and non-communicable diseases and experience higher mortality and poor health outcomes compared to resource-rich countries. Chronic resource deficits in LMICs impede their ability to successfully address vexing health issues. Implementation science provides researchers with an approach to develop specific interventions that can generate and/or maximize resources to facilitate the implementation of other public health interventions, in resource-constrained LMIC settings. Resources generated from these interventions could be in the form of increased health workers' skills, task shifting to free up higher-skilled health workers, increasing laboratory capacity, and using supply chain innovations to make medications available. Pivotal to the success of such interventions is ensuring feasibility in the LMIC context. We selected and appraised three case studies of evidence-based resource-generating health interventions based in LMICs (Zambia, Zimbabwe, and Madagascar), which generated or maximized resources to facilitate ongoing health services. We used a determinant implementation framework-Consolidated Framework for Implementation Research (CFIR) to identify and map contextual factors that are reported to influence implementation feasibility in an LMIC setting. Contextual factors influencing the feasibility of these interventions included leadership engagement, local capacity building and readiness for research and implementing evidence-based practices (EBPs), infrastructural support for multilevel scale-up, and cultural and contextual adaptations. These factors highlight the importance of utilizing implementation science frameworks to evaluate, guide, and execute feasible public health interventions and projects in resource-limited settings. Within LMICs, we recommend EBPs incorporate feasible resource-generating components in health interventions to ensure improved and sustained optimal health outcomes.

Project description:Background:We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage. Methods:PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019. Results:A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3). Conclusions:Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.

Project description:Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.

Project description:BackgroundTask-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.MethodsPubMed, 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.ResultsOf 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.ConclusionsUsing 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 registrationPROSPERO CRD42020161357.

Project description:ObjectiveAs environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.Design and methodsWe conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.ResultsFour-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.ConclusionsIS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Project description:BackgroundSeveral interventions for tuberculosis (TB) control have been recommended by the World Health Organization (WHO) over the past decade. These include isoniazid preventive therapy (IPT) for HIV-infected individuals and household contacts of infectious TB patients, diagnostic algorithms for rule-in or rule-out of smear-negative pulmonary TB, and programmatic treatment for multidrug-resistant TB. There is no systematically collected data on the type of evidence that is publicly available to guide the scale-up of these interventions in low- and middle-income countries. We investigated the availability of published evidence on their effectiveness, delivery, and cost-effectiveness that policy makers need for scaling-up these interventions at country level.Methods and findingsPubMed, Web of Science, EMBASE, and several regional databases were searched for studies published from 1 January 1990 through 31 March 2012 that assessed health outcomes, delivery aspects, or cost-effectiveness for any of these interventions in low- or middle-income countries. Selected studies were evaluated for their objective(s), design, geographical and institutional setting, and generalizability. Studies reporting health outcomes were categorized as primarily addressing efficacy or effectiveness of the intervention. These criteria were used to draw landscapes of published research. We identified 59 studies on IPT in HIV infection, 14 on IPT in household contacts, 44 on rule-in diagnosis, 19 on rule-out diagnosis, and 72 on second-line treatment. Comparative effectiveness studies were relatively few (n = 9) and limited to South America and sub-Saharan Africa for IPT in HIV-infection, absent for IPT in household contacts, and rare for second-line treatment (n = 3). Evaluations of diagnostic and screening algorithms were more frequent (n = 19) but geographically clustered and mainly of non-comparative design. Fifty-four studies evaluated ways of delivering these interventions, and nine addressed their cost-effectiveness.ConclusionsThere are substantial gaps in published evidence for scale-up for five WHO-recommended TB interventions settings at country level, which for many countries possibly precludes program-wide implementation of these interventions. There is a strong need for rigorous operational research studies to be carried out in programmatic settings to inform on best use of existing and new interventions in TB control.

Project description:ObjectiveA review of the implementation outcomes of clean cookstove use, and its effects on blood pressure (BP) in low-income and middle-income countries (LMICs).DesignSystematic review of studies that reported the effect of clean cookstove use on BP among women, and implementation science outcomes in LMICs.Data sourcesWe searched PubMed, Embase, INSPEC, Scielo, Cochrane Library, Global Health and Web of Science PLUS. We conducted searches in November 2017 with a repeat in May 2018. We did not restrict article publication date.Eligibility criteria for selecting studiesWe included only studies conducted in LMICs, published in English, regardless of publication year and studies that examined the use of improved or clean cookstove intervention on BP. Two authors independently screened journal article titles, abstracts and full-text articles to identify those that included the following search terms: high BP, hypertension and or household air pollution, LMICs, cookstove and implementation outcomes.ResultsOf the 461 non-duplicate articles identified, three randomised controlled trials (RCTs) (in Nigeria, Guatemala and Ghana) and two studies of pre-post design (in Bolivia and Nicaragua) met eligibility criteria. These articles evaluated the effect of cookstove use on BP in women. Two of the three RCTs reported a mean reduction in diastolic BP of -2.8 mm Hg (-5.0, -0.6; p=0.01) for the Nigerian study; -3.0 mm Hg; (-5.7, -0.4; p=0.02) for the Guatemalan study; while the study conducted in Ghana reported a non-significant change in BP. The pre-post studies reported a significant reduction in mean systolic BP of -5.5 mm Hg; (p=0.01) for the Bolivian study, and -5.9 mm Hg (-11.3, -0.4; p=0.05) for the Nicaraguan study. Implementation science outcomes were reported in all five studies (three reported feasibility, one reported adoption and one reported feasibility and adoption of cookstove interventions).ConclusionAlthough this review demonstrated that there is limited evidence on the implementation of clean cookstove use in LMICs, the effects of clean cookstove on BP were significant for both systolic and diastolic BP among women. Future studies should consider standardised reporting of implementation outcomes.

Dataset Information

Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review.

Publications

Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review.

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