Contributions to the literature
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Task-sharing based on evidence-based practices is a promising strategy to increase the global availability of mental health care, and no literature has systematically compiled barriers and facilitators to implementation of these interventions in low- and middle-income countries.
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Barriers and facilitators to evidence-based task-sharing mental health interventions are present at multiple levels, and we provide a conceptual framework to organize them into eight domains.
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Our enumeration and organization of the implementation barriers and facilitators is an important step in helping practitioners and researchers improve the implementation of these interventions, including the development of tools to measure these implementation determinants and the need to select implementation strategies that can specifically leverage the facilitators and target the barriers across multiple levels.
Introduction
Methods
Protocol, registration, reporting guidelines
Search strategy
Study selection
Development of conceptual model and codebook
Data extraction
Quality assessment
Results
Included studies
Study characteristics
N | % | |
---|---|---|
Study characteristics | ||
Region of study | ||
Africa | 14 | 50.0% |
South Asia | 9 | 32.1% |
Latin America and the Caribbean | 3 | 10.7% |
Multi-region | 2 | 7.1% |
Mental health condition | ||
Common mental disorders (CMDs) only | 23 | 82.1% |
CMDs | 6 | 21.4% |
Depression only (non-perinatal) | 9 | 32.1% |
Perinatal depression only | 2 | 7.1% |
CMDs and comorbid conditions | 6 | 21.4% |
Serious mental illnesses (SMIs) only | 1 | 3.6% |
CMDs and SMIs | 4 | 14.3% |
Implementation characteristics | ||
Type of task-sharing provider (TSP) | ||
Community health workers (CHWs)a | 18 | 64.3% |
Primary health care providers (PHCPs)b | 4 | 14.3% |
Complementary and alternative providers (CAPs) | 1 | 3.6% |
Multiple provider types | 5 | 17.9% |
Evidence-based practice (EBP) used | ||
Mental Health Gap Action Programme (mhGAP) | 8 | 28.5% |
Cognitive Behavioral Therapy (CBT) | 6 | 21.4% |
Interpersonal Therapy (IPT) | 3 | 10.7% |
Common Elements Treatment Approach (CETA) | 2 | 7.1% |
Pharmacotherapy alone | 2 | 7.1% |
Problem-Solving Therapy (PST) | 2 | 7.1% |
Problem Management Plus (PM+) | 1 | 3.6% |
Multiple EBPs | 4 | 14.3% |
Implementation stage | ||
Exploration | 1 | 3.6% |
Preparation | 4 | 14.3% |
Implementation | 17 | 60.7% |
Sustainment | 1 | 3.6% |
Multiple Stages | 5 | 17.9% |
Barriers and facilitators reported
Author (year) | Countr(ies) | Mental health conditions | Task-sharing model (provider and intervention type) | Implementation stage | How barriers and facilitators were assessed or derived | Key barriers reported | Key facilitators reported |
---|---|---|---|---|---|---|---|
Common mental disorders (CMDs) only | |||||||
Pacichana-Quinayáz et al. (2016) [47] | Colombia | CMDs | CHWs deliver Common Elements Treatment Approach (CETA) to Afro-Colombian victims of violence | Implementation | Assessed through in-depth interviews with providers and program administrators | Organization: Structure & materials MH system: Infrastructure Societal: Historical & political context | Client: Skills & self-efficacy Intervention: Format |
Chatterjee et al. (2008) [48] | India | CMDs | Lay counselors lead collaborative stepped care intervention MANAS project (psychoeducation, antidepressants, group IPT) for CMDs in primary settings | Preparation | Assessed through interviews with providers, community members in exploration, preparation, and pilot phases | Client: Other personal attributes Intervention: Timing, duration, frequency; format | Intervention: Task-sharing provider (+peer) role; setting |
Patel et al. (2010)a [6] | India | CMDs | Lay counselors in primary care provide collaborative stepped-care intervention | Implementation | Discussed in context of study results (quantitative) | Intervention: Complexity Organization: Implementation climate | Intervention: Task-sharing provider (+peer) role Organization: Implementation climate |
Patel et al. (2011)a [49] | India | CMDs | Lay counselors in primary care provide collaborative stepped-care intervention | Implementation | Discussed in context of study results (quantitative) | N/A | Provider: Motivation/optimism |
Shinde et al. (2013)a [50] | India | CMDs | Lay counselors lead collaborative stepped care intervention MANAS project (psychoeducation, antidepressants, group interpersonal therapy) for CMDs in primary settings | Implementation | Assessed through qualitative evaluation: semi-structured interviews (SSIs) with users at two time points | Intervention: Cost (client) | Provider: Skills & self-efficacy Intervention: Task-sharing provider (+peer) role |
Spagnolo et al. (2018) [51] | Tunisia | CMDs | PHCPs trained on mhGAP-based intervention to improve mental health competencies and skills | Implementation | Assessed through case study including SSIs with providers | Provider: Skills & self-efficacy; KABI Intervention: Intervention source & rationale Societal: Historical & political context | Provider: Skills & self-efficacy Intervention: Training, supervision, integration |
Maulik et al. (2017) [52] | India | CMDs | CHWs identify CMDs, treated by PHCPs using mhGAP guidelines | Implementation | Assessed through mixed methods pre-post evaluation using quantitative service usage analytics | Client: KABI Intervention: Timing, duration, frequency | Intervention: Setting; Training, supervision, integration |
Tewari et al. (2017)a [53] | India | CMDs | CHWs identify CMDs, treated by PHCPs mhGAP guidelines | Implementation | Assessed through mixed methods pre-post evaluation using quantitative service usage analytics and in-depth interviews and focus group discussions with stakeholders | Client: Other personal attributes Societal: Economic conditions Stigma: Self-stigma | Client: Motivation/optimism; KABI Intervention: Task-sharing provider (+peer) role; setting |
Shields et al. (2016) [54] | India | CMDs | Allopathic mental health practitioners and faith-based healers cooperate to detect and treat mental health patients via pharmacotherapy | Preparation | Assessed through mixed data: quantitative user characteristics, SSIs with users, caregivers, providers | Organization: Structure & materials MH System: Human resources Stigma: Fam/Comm stigma | Client: Motivation/optimism Intervention: Task-sharing provider (+peer) role; training, supervision, integration |
Sibeko et al. (2018) [55] | South Africa | CMDs | CHWs trained on culturally adapted mhGAP program to provide chronic support including for mental illness | Preparation | Discussed in context of post-training evaluation of provider's knowledge and skills | Stigma: Provider stigma | Intervention: Engagement & reinforcements Organization: Structure & materials |
Murray et al. (2014) [56] | Iraq, Thailand | CMDs (Depression, Anxiety, Traumatic stress) | Lay counselors deliver CETA | Implementation | Discussed in context of intervention development | Intervention: Complexity Organization: Structure & materials MH System: Infrastructure | Provider: Social role & identity Intervention: Engagement & reinforcement; Packaging, adaptability, trialability |
Abas et al. (2016) [57] | Zimbabwe | CMDs (Depression, others) | Female CHWs deliver Problem-Solving Therapy (PST) during home visits (‘Friendship Bench’) | Sustainment | Assessed with focus group discussions and in-depth interviews with users, providers, program staff | Client: Other personal attributes Provider: Social role & identity Intervention: Training, supervision, integration | Provider: Social role & identity Intervention: Task-sharing provider (+peer) role; Setting |
Chibanda et al. (2011)a [58] | Zimbabwe | CMDs (depression, others) | Female CHWs deliver Problem-Solving Therapy (PST) during home visits (“Friendship Bench”) | Preparation | Assessed with mixed methods including questionnaire and for providers | N/A | Provider: Social role & identity Intervention: Task-sharing provider (+peer) role; setting |
Chibanda et al. (2017)a [59] | Zimbabwe | CMDs (depression, others) | Female CHWs deliver Problem-Solving Therapy (PST) during home visits (“Friendship Bench”) | Preparation | Assessed with SSIs with providers and clients post-intervention | Client: Other personal attributes Intervention: Setting | Provider: Social role & identity; skills & self-efficacy Intervention: Task-sharing provider (+peer) role |
Woods-Jaeger et al. (2017) [60] | Kenya, Tanzania | CMDs (PTS, grief) | Lay counselors deliver trauma-focused Cognitive Behavioral Therapy (TF-CBT) | Sustainment | Assessed through SSIs with providers | Client: Other personal attributes Intervention: Timing, duration, frequency Fam/Comm: Community | Provider: KABI; Skills & self-efficacy Intervention: Packaging, adaptability, trialability |
Dawson et al. (2016) [61] | Kenya | CMDs (PTSD, psychological distress) | CHWs deliver Problem Management Plus (PM+) for adults impacted by adversity to women in the community | Implementation | Discussed in context of intervention study results | Fam/Comm: Community | Intervention: Training, supervision, integration |
O’Donnell et al. (2014) [62] | Tanzania | CMDs (PTSD) | Lay counselors deliver group-based Cognitive Behavioral Therapy (CBT) to children with symptoms of grief and/or traumatic stress | Implementation | Discussed in context of intervention study results | N/A | Provider: Other personal attributes Intervention: Training, supervision, integration |
Common mental disorders (CMDs) and comorbid conditions | |||||||
Udedi et al. (2018) [63] | Malawi | CMDs with HIV (depression) | PHCPs, nurses, and CHWs screen and detect using algorithm-based care for depression (ABC-D) and treat with PST among patients living with HIV | Implementation | Assessed through stakeholder meetings, site visits, trainings | Provider: Skills & self-efficacy MH system: Infrastructure; human resources | Intervention: Task-sharing provider (+peer) role; engagement & reinforcements Organization: Implementation climate |
Depression only | |||||||
Indu et al. (2018) [64] | India | Depression | PHCPs and health workers delivered psychosocial and pharmacological treatment to women with depression | Implementation | Discussed in context of intervention study results | Client: Other personal attributes Intervention: Engagement & reinforcements | Intervention: Setting; timing, duration, frequency; cost |
Chowdhary et al. (2016) [65] | India | Depression | Lay counselors deliver treatment to patients with severe depression with CBT and mhGAP guidelines | Preparation; implementation | Assessed as part of intervention development, through focus group discussions with providers and in-depth interviews with supervisors and users | Intervention: Setting; timing, duration, frequency; packaging, adaptability, trialability | Provider: Other personal attributes Intervention: Intervention source & rationale; Training, supervision, integration |
Adewuya et al. (2017) [66] | Nigeria | Depression | PHC workers (including doctors, nurses/midwives, community health officers, and community health extension workers) trained to detect depression among primary care patients using mhGAP guidelines | Preparation | Assessed through questionnaires administered to health workers collecting data on diagnoses and perceived challenges | Provider: KABI Organization: Clinical resources MH system: Human resources | Intervention: Intervention source & rationale Fam/Comm: Community |
Petersen et al. (2012a) [11] | South Africa | Depression | CHWs deliver community-engaged mental health care | Preparation | Assessed through focus group discussions with providers and in-depth interviews with stakeholders (users, community members, mental health professionals), post-intervention | Provider: Social role & identity Societal: Sociocultural norms; historical & political context | Intervention: Format; engagement & reinforcements |
Petersen et al. (2012b)a [67] | South Africa | Depression | CHWs deliver adapted, manualized group-based Interpersonal Therapy (IPT) for female primary care patients screened with depression | Implementation | N/A | Client: Goals, health & emotions; other personal attributes | Intervention: Task-sharing provider (+peer) role; complexity; packaging, adaptability, trialability |
Tomlinson et al. (2015) [68] | South Africa | Depression | CHWs provide a home visit, Cognitive Behavioral Therapy (CBT), and psychoeducation-based intervention to women with antenatal depression | Implementation | Discussed in context of study results | N/A | Intervention: Intervention source & rationale; timing, duration, frequency Organization: Implementation climate |
elohilwe et al. (2019) [69] | South Africa | Depression | Lay counselors provide group CBT-based mhGAP intervention to depressed patients screened at primary care clinics | Implementation | Assessed with process evaluation consisting of in-depth interviews with stakeholders | Intervention: Engagement & reinforcements | Intervention: Task-sharing provider (+peer) role; setting; training, supervision, integration |
Rahman et al. (2008) [70] | Pakistan | Depression | CHWs provide cognitive CBT-based intervention (Thinking Healthy Program) to mothers with depression | Implementation | Discussed in context of intervention development process and study results | N/A | Provider: Social role & identity Intervention: Training, supervision, integration; packaging, adaptability, trialability |
Everitt-Penhale et al. (2019) [71] | South Africa | Depression | Nurses deliver an adapted CBT treatment for medication adherence and depression to individuals with HIV | Implementation | Assessed through SSIs with users post-intervention | N/A | Client: KABI Provider: Skills & self-efficacy Intervention: Task-sharing provider (+peer) role |
Matsuzaka et al. (2017) [72] | Brazil | Depression | CHWs provide Interpersonal Counseling (IPC; based on IPT) to treat depression | Implementation | Discussed in context of study results | Fam/Comm: Community Societal: Religion/spirituality Stigma: Fam/Comm stigma | Provider: Goals, health & emotions; KABI Intervention: Training, supervision, integration |
Munodawafa et al. (2017) [73] | South Africa | Depression: Perinatal | CHWs deliver psychosocial program (based on CBT, IPT, PST principles) for perinatal depression, part of AFFIRM in South Africa | Preparation | Assessed through SSIs with providers post-intervention | Client: Other personal attributes Provider: Skills & self-efficacy Fam/Comm: Community | Intervention: Timing, duration, frequency; cost Organization: Structure & materials |
Nyatsanza et al. (2016)a [74] | South Africa | Depression: Perinatal | CHWs deliver psychosocial program (based on CBT, IPT, PST principles) for perinatal depression, part of AFFIRM in South Africa | Exploration | N/A | Client: KABI Provider: Skills & self-efficacy Organization: Clinical Resources | Intervention: Intervention source & rationale; Training, supervision, integration; Engagement & reinforcements |
Zafar et al. (2014) [75] | Pakistan | Depression: Perinatal | CHWs deliver CBT-based maternal psychosocial wellbeing intervention (Five Pillars Approach) | Implementation | Assessed through qualitative data collected in three phases (adaptation, formative, implementation) including focus group discussions and in-depth interviews with various stakeholders | Client: Other personal attributes Fam/Comm: Family Societal: Sociocultural norms | Intervention: Timing, duration, frequency; format; design quality & packaging |
Serious mental illnesses (SMIs) | |||||||
Jordans et al. (2017) [76] | Nepal | SMI: Psychosis, epilepsy | PHCPs deliver mhGAP treatment | Implementation | Discussed in context of study results (quantitative) | N/A | Intervention: Intervention source & rationale; task-sharing provider (+peer) role; training, supervision, integration |
Serious mental illnesses (SMIs) and common mental disorders (CMDs) | |||||||
Fils-Aimé et al. (2018) [77] | Haiti | MNS | Team including B-level psychologists, PHCPs, and CHWs treat patients with MNS disorders via mobile clinics using mhGAP guidelines and IPT | Exploration | Assessed through mixed quantitative data (quality improvement questionnaire) and qualitative (interview with implementer) | Intervention: Timing, duration, frequency Stigma: Fam/Comm stigma | Intervention: Setting; training, supervision, integration |
Hanlon et al. (2014) [78] | Ethiopia, India, Nepal, South Africa, Uganda | MNS | CHWs help deliver mhGAP-informed interventions in their communities | Preparation | Assessed through qualitative ad-hoc “situation analysis tool” filled out by experts | Client: Other personal attributes Organization: Implementation climate MH System: Infrastructure | N/A |
Mendenhall et al. (2014)a [79] | Ethiopia, India, Nepal, South Africa, Uganda | MNS | CHWs help deliver mhGAP-informed interventions in their communities | Preparation | Assessed through focus group discussions and in-depth interviews with stakeholders | Provider: Skills & self-efficacy Intervention: Training, supervision, integration MH system: Infrastructure | Intervention: Intervention source & rationale; cost |
Gureje et al. (2015) [80] | Nigeria | MNS: Depression, psychosis, alcohol use, epilepsy | PHCPs detect and manage MNS using the mhGAP model | Implementation | Discussed in context of post-training quantitative and qualitative data (observations) | MH System: Infrastructure; human resources Stigma: Fam/Comm stigma | Intervention: Engagement & reinforcements; packaging, adaptability, trialability; training, supervision, integration |
Khoja et al. (2016) [81] | Afghanistan | MNS: Depression, psychosis, PTSD, and substance use | CHWs deliver mhGAP-based intervention to provide mental health consultation and referral to remote communities | Implementation | Discussed in context of intervention implementation and study results | N/A | Intervention: Cost; complexity Organization: Implementation climate |