Community-Based Mental Health Intervention Skills: Task Shifting in Low- and Middle-Income Settings
Abstract
There is a global need to provide human resources for health in low- and middle-income countries. To increase access to care, task shifting has been implemented in community-based rehabilitation (CBR) programs where skills and responsibilities are transferred to local people with shorter and more focused training. Through realist review and synthesis, this research aimed to consolidate the literature when considering (a) what skills CBR workers are reportedly using and/or being trained in relating to mental health, (b) how different settings affect how these task shifting programs work, and (c) the evidence of effectiveness when community health workers come from within the community itself. A total of 11 databases (PubMed, ABI/Inform Global, CINAHL, Cochrane, Emerald, Google Scholar, PsycINFO, SAGE, Science Direct, Scopus, and Web of Science) were systematically searched for specific terms relating to mental health, CBR, and low- and middle-income country. A total of 27 publications were identified as fitting the criteria (4 qualitative, 20 quantitative including 10 randomized controlled trials, and 3 noninvestigatory editorials). Core skills have been identified along with themes that affect how programs work in particular contexts. The use of task shifting in this area may be a potentially viable option for increasing access to mental health care. This resulted in the development of a theory to explain the outcomes being observed. When Task-shifting mental health intervention skills collaboration, harnessing resources available within the community, and the provision of ongoing supervision interact to influence awareness gains, social bonding, the building of trust, and the development of skills and understanding within the community itself.This effects intervention buy-in, overall effectiveness and sustainability, mental health symptoms and local empowerment. These findings can be considered when developing training programs for CBR mental health workers, as well as policy and intervention program design.
Impact and Implications
Currently many lower economic status communities are dependent on external support for the provision of health care and rehabilitation services. This research investigated the options for task-shifting care into communities to increase access to care and empower the historically impoverished. It walks policy and program developers through skills being used in community-based rehabilitation and consolidates which mechanisms and contexts contribute to successful and unsuccessful outcomes. This research hopes to influence building equitable and sustainable mental health care systems that successfully support well-being.
References
(2005). Scaling up health and education workers: Community health workers: A literature review. United Kingdom: Department of International Development Health Resource Centre.
(1974). A framework for the study of access to medical care. Health Services Research, 9, 208–220.
. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
(2011). A mental health training program for community health workers in India: Impact on knowledge and attitudes. International Journal of Mental Health Systems, 5,
17 . 10.1186/1752-4458-5-17(2010). Unpacking black boxes: Mechanisms and theory building in evaluations. American Journal of Evaluation, 31, 363–381.
(2012). Provision of mental health services in resource-poor settings: A randomised trial comparing counselling with routine medical treatment in North Afghanistan (Mazar-e-Sharif). BMC Psychiatry. Advance online publication. 10.1186/1471-244X-12-1
(2003). The effectiveness of counseling on anxiety and depression by minimally trained counselors: A randomized controlled trial. American Journal of Psychotherapy, 57, 324–336.
(2005). The effect of early stimulation on maternal depression: A cluster randomised controlled trial. Archives of Disease in Childhood, 90, 1230–1234. 10.1136/adc.2005.073015
(2012). The development of lay health worker delivered collaborative community based intervention for people with schizophrenia in India. BMC Health Services Research. Advance online publication. 10.1186/1472-6963-12-42
(2013). Controlled trial of psychotherapy for congolese survivors of sexual violence. New England Journal of Medicine, 368, 2182–2219. 10.1056/NEJMoa121185
(2006). Group interpersonal psychotherapy for depression in rural Uganda: 6-month outcomes. British Journal of Psychiatry, 188, 567–573.
(2003). Group interpersonal psychotherapy for depression in rural Uganda. Journal of the American Medical Association, 289, 3117–3124.
(1974). Towards an experimental ecology of human development. American Psychologist, 32, 513–531.
(1965). Lay mental health counseling: The effects of lay group counseling. Journal of Consulting Psychology, 29, 26–31.
(2003). Evaluation of a community-based rehabilitation model for chronic schizophrenia in India. The British Journal of Psychiatry, 182, 57–62. 10.1192/bjp/182/1/57
(2004). Human resources for health: Overcoming the crisis. The Lancet, 364, 1984–1990. 10.1016/S0140-6736(04)17482-5
(2005). Towards cost-effective tuberculosis control in the western cape of South Africa: Intervention study involving lay health workers on agricultural farms. Stockholm, Sweden: Karolinska University Press.
(2004). How stigma interferes with mental health care. The American Psychologist, 59, 614–625.
(2001). Three strategies for changing attribution about severe mental illness. Schizophrenia Bulletin, 27, 187–195.
(2015). What’s in a mechanism? Development of a key concept in Realist Evaluation. Implementation Science. Advance online publication. 10.1186/s13012-015-0237-x
(2014). Programmatice response to malnutrition in India: Room for more than one elephant. Indian Pediatrics, 51, 863–868.
(2011). Community-based rehabilitation programme as a model for task shifting. Disability and Rehabilitation, 33, 21–22.
(2011). CBR matrix and perceived training needs of CBR workers: A multi-country study. Disability, CBR and Inclusive Development. Advance online publication. 10.5463/dcid.v22i1.16
(2014). Policy actions to achieve integrated community-based mental health services. Health Affairs, 33, 1595–1602. 10.1377/hlthaff.2014.0365
(2008). The effectiveness of home care program for supporting caregivers of persons with dementia in developing countries: A randomised controlled trial from Gao, India. PLoS ONE, 3,
e2333 . 10.1371/journal.pone.0002333(2011). The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development, 82, 405–432.
(2006). The ISTSS/Rand guidelines on mental health trainging of primary healthcare providers for trauma-exposed populations in conflict-affected countries. Journal of Traumatic Stress, 19, 5–17. 10.1002/jts.20094
(2005). Workers for priorities in health. Amsterdam, the Netherlands: K. P. Joint Learning Initiative.
(2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda. Journal of the American Medical Association, 306, 503–512.
(1992). Stigma and mental illness. Washington, DC: A. P. Press.
(2014). Unmet health and rehabilitation needs of people with long-term neurological conditions in Queensland, Australia. Disability and Rehabilitation, 17, 1–7.
(2005). Contextual factors influencing research use in nursing. Worldviews Evidence Based Nursing, 2, 172–183.
(2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376, 1923–1958.
(2004). Why love matters: How affection shapes a baby’s brain. Hove, United Kingdom: Brunner-Routledge.
(2017). A study of human resource competencies required to implement community rehabilitation in less resourced settings. Human Resources for Health. Advance online publication. 10.1186/s12960-017-0240-1
(2003). The legend and lessons of Geel, Belgium: A 1500-year-old legend, a 21st-century model. Community Mental Health Journal, 39, 441–458.
(2016). Expert consensus on best evaluative practices in community-based rehabilitation. Disability and Rehabilitation, 38, 499–510. 10.3109/09638288.2015.1044030
(2004). “More of the same and try something new” Evaluation of the community based rehabilitation programme in Eritrea. Trondheim, Norway: SINTEF. Retrieved from https://www.norad.no/globalassets/import-2162015-80434-am/www.norad.no-ny/filarkiv/ngo-evaluations/more-of-the-same-and-try-something-new_---evaluation-of-the-community-based-rehabilitation-programm.pdf
(2006). Teaching psychiatry in Ethiopia. Bulletin of the Board of International Affairs of the Royal College of Psychiatrists, 3, 43–46.
(2014). Reflecting on the tensions faced by a community-based multicultural health navigator service. Australian Health Review, 38, 584–588.
(2010). Testing a community derived intervention to promote women’s health: Preliminary results of a 3-arm randomized controlled trial in Karachi, Pakistan. Southern Online Journal of Nursing Research, 10, 1–10.
(2012). Challenges of postdisaster intervention in cultural context: The implementation of a lay mental health worker project in post earthquake Haiti. International Perspectives in Psychology: Research, Practice, Consultation, 1, 110–126. 10.1037/a0028321
(2014). A mixed-methods assessment of the experiences of lay mental health workers in postearthquake Haiti. American Journal of Orthopsychiatry, 84, 152–163. 10.1037/h0099387
(2004). The Sonagachi project: A sustainable community intervention program. AIDS Education and Prevention, 16, 405–414.
(2015). Mental health services in Cambodia, challenges and opportunities in a post-conflict setting. Asian Journal of Psychiatry, 13,
13, 75–80 .(2010). Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: A cluster randomized controlled trial. Journal of Child Psychology and Psychiatry, 51, 818–826. 10.1111/j.1469-7610.2010.02209.x
(2011). Human resources for mental health care: Current situation and strategies for action. The Lancet, 378, 1654–1663. 10.1016/S0140-6736(11)61093-3
(2013). Making sense of complex data: A mapping process for analyzing findings of a realist review on guideline implementability. BMC Medical Research Methodology, 13,
112 . 10.1186/1471-2288-13-112(2013). Community-based mental health counseling for children orphaned by AIDS in China. AIDS Care, 25, 430–437. 10.1080/09540121.2012.712661
(2015). The concept of mechanism from a realist approach: A scoping review to facilitate its operationalization in public health program evaluation. Implementation Science, 10, 153. 10.1186/s13012-015-0345-7
(2004). Review of the utilisation and effectiveness of community-based health workers in Africa. Global Health Trust, Joint Learning Initiative on Human Resources for Health and Development (JLI), JLI Working Paper, 4-1.
(2007). Lay health workers in primary and community health care. The Cochrane Database of Systematic Reviews, 25,
CD004015 .(2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. 10.1146/annurev.soc.27.1.363
(2006). The impact of structured activities among Palestinian children in a time of conflict. Journal of Child Psychology and Psychiatry, 47, 1211–1218. 10.1111/j.1469-7610.2006.01656.x
(2016). Supporting successful implementation of public health interventions: Protocol for realist synthesis. Systematic Reviews, 5, 54. 10.1186/s13643-016-0229-1
(2010). The aid triangle: Recognizing the human dynamics or dominance, justice and identity. New York, NY: Z. Books.
(2011). Staff skills not staff types for community-based rehabilitation. The Lancet, 377, 1988–1989.
(2012). A systematic review of the effectiveness of alternative cadres in community based rehabilitation. Human Resources for Health, 10, 20.
(2007). Understanding the implementation of complex interventions in health care: The normalization process model. Biomedical Central Health Services, 7, 148.
(2012). Participatory public health systems research: Value of community involvement in a study-series in mental health emergency preparedness. American Journal of Disaster Medicine, 7, 303–312.
(2014). Psychological first aid: A concensus-derived, empirically supported, competency-based training model. American Journal of Public Health, 104, 621–628.
(2013). Guided preparedness planning with lay communities: A systems-based model for enhancing capacity of rural emergency response. Prehospital Disaster Medicine, 28, 1–8.
(2011). Psychological first-aid training for paraprofessional: A systems-based model for enhancing capacity of rural emergency response. Prehospital Disaster Medicine, 26, 251–258.
(2016). Promoting good policy for leadership and governance of health related rehabilitation: A realist synthesis. Globalization and Health, 12, 49.
(2003). The reluctance to seek treatment for neurotic disorders. International Review of Psychiatry, 15, 123–128.
(2014). Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science and Medicine, 118, 33–42. 10.1016/j.socscimed.2014.07.057
(2012). What is a clinical skill? Searching for order in chaos through the modified delphi process. Medical Teacher, 34, e573–e581. 10.3109/0142159X.2012.669218
(2015). Maternal experiences of caring for an infant with neurological impairment after neonatal encephalopathy in uganda: A qualitative study. Disability and Rehabilitation, 37, 1470–1476.
(2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 686–694. 10.1037/0022-006X.76.4.686
(2005). Evaluation of the CBR program in Palestine: From the perspectives of persons with disabilities themselves. Retrieved from https://www.norad.no/globalassets/import-2162015-80434-am/www.norad.no-ny/filarkiv/ngo-evaluations/evaluation-of-the-cbr-program-in-palestine-_-from-the-perspective-of-persons-with-disabilities-the.pdf
(2011). Understanding the conditions for improvement: Research to discover which context influences affect improvement success. British Medical Journal Quality and Safety, 20, 18–23. 10.1136/bmjqs.2010.045955
(2001). Depression in developing countries: Lessons from Zimbabwe. British Medical Journal, 322, 482–484.
(2015). Factors influencing intercultural doctor-patient communication: A realist review. Patient Education and Counseling, 98, 420–445.
(2014). Impact of mental health training on village health workers regarding clinical depression in rural India. Community Mental Health Journal, 50, 480–486. 10.1007/s10597-013-9630-
(1989). A measure for measures: A manifesto for empirical sociology. New York, NY: Routledge.
(2006). Evidence-based policy: A realist perspective. London, United Kingdom: S. Publications.
(2005). Realist review - a new method of systematic review for complex policy interventions. Journal of Health Services Research and Policy, 10, 21–34. 10.1258/1355819054308530
(1997). Realistic evaluation. London, United Kingdom: Sage.
(2004). Realist evaluation. Saga. Retrieved from http://www.communitymatters.com.au/RE_chapter.pdf
(1998). The stigma of severe mental illness: Some potential solutions for a recalcitrant problem. The Psychiatric Quarterly, 69, 235–247.
(2012). The feasibility of adapted group-based interpersonal therapy (IPT) for the reatment of depression by community health workers within the context of task shifting in South Africa. Community Mental Health, 48, 336–341. 10.1007/s10597-011-9429-2
(2015). Context and implementation: A concept analysis towards conceptual maturity. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, 109, 103–114. 10.1016/j.zefq.2015.01.004
(2007). Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan - a multi-method study. Archives of Women’s Mental Health, 10, 211–219. 10.1007/s00737-007-0193-9
(2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised controlled trial. The Lancet, 372, 902–909. 10.1016/s0140-6736(08)61400-2
(1982). The effect of traditional birth attendants and tetanus toxoid in reduction of neo-natal mortality. Journal of Tropical Pediatrics, 28, 163–165.
(2004). Needs assessment of programmes integrating community based rehabilitation into health activities. Asia Pacific Disability Rehabilitation Journal, 15, 69–74.
(1991). Mental health services in India. Journal of Sociology and Social Welfare, 18, 41–56.
(1965). The indigenous nonprofessional: A strategy of change in community action and community mental health programs. Lexington, MA: Community Mental Health Journal.
(1959).
A theory of therapy, personality and interpersonal relationships as developed in the client-centered framework . In S. Koch (Ed.), Psychology: A study of science: Formulations of the person and the social context (Vol. 3, pp. 184–256). New York, NY: McGraw Hill.(2004). The PARHIS framework: A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19, 297–304.
(2012). Realist synthesis: Illustrating the method for implementation research. implementation science. Implementation Science, 7, 33.
(2007). Resources for mental health: Scarcity, inequity and inefficiency. The Lancet, 370, 878–889.
(2011). The effect on mental health of a large scale psychosocial intervention for survivors of mass violence: A quasi-experimental study in Rwanda. PloS ONE, 6,
8 . 10.1371/journal.pone.0021819(1994). Training indigenous workers in mental-health care. Taylor and Francis, 4, 112–122.
(2000). Mental health economic studies from developing countries reviewed in the context of those from developed countries. Acta Psychiatrica Scandinacica, 101, 87–103.
(2015). Identifying the domains of context important to implementation science: A study protocol. Implementation Science, 10, 135. 10.1186/s13012-015-0325-y
. (2012/2013). The Kintampo Trust, Southern Health NHS Foundation Trust, Ministry of Health. Retrieved from http://static1.1.sqspcdn.com/static/f/288575/23071455/1373324728663/Kintampo_Project_Report+2012_13.pdf?token=YSqcyouFMzYrT4FSsjjKaYz%2FD3I%3D
(2000). Realistic evaluation: An overview. Presented at the founding conference of the Danish Evaluation Society. København, Denmark: Dansk EvalueringsSelskab.
(2009). Dementia in low and middle income countries: The need for research and advocacy. Dementia, 8, 451–454.
(2003). Adapting group interpersonal psychotherapy for a developing country: Experiece in rural uganda. World Psychiatry, 2, 114–120.
(1997). Theory-based evaluation: Past, present, and future. New Directions for Evaluation, 1997, 41–55. 10.1002/ev.1086
(2006). Evaluations of community mental health care in low- and middle income countries: A 10-year review of the literature. Social Science and Medicine, 64, 1231–1241.
(1995). Community health workers: Integral members of the health care work force. American Journal of Public Health, 85, 1055–1058.
(2014).
Guidelines for snowballing in systematic literature studies and a replication in softward engineering . EASE Proceedings of the 18th International Conference on Evaluation and Assessment in Software Engineering. London, United Kingdom: ACM. 10.1145/2601248.2601268(2013). RAMSES publication standards: Realist synthesis. Journal of Advanced Nursing, 69, 1005–1022. 10.1111/jan.12095
(2012). Realist methods in medical education research: What are they and what can they contribute? Medical Education, 46, 90–96.
. (2015). Country income group. Retrieved from http://chartsbin.com/view/243
. (2001). International classification of functioning, disability and health. Geneva, Switzerland: World Health Organization. Retrieved from http://apps.who.int/gb/archive/pdf_files/WHA54/ea54r21.pdf?ua=1
. (1978). Declaration of Alma-Ata. International Conference on Primary Health Care. Retrieved from http://www.who.int/publications/almaata_declaration_en.pdf
. (1981). Disability prevention and rehabilitation. Report of the WHO expert committee on disability and rehabilitation. Geneva, Switzerland: Author. Retrieved from http://www.who.int/iris/handle/10665/40896
. (2003). Community contribution to TB care: Practice and policy. Review of experience of community contribution to TB care and recommendations to national TB programmes. Geneva, Switzerland: Author.
. (2005). Mental health policy and service guidance package: Human resources and training in mental health. Geneva, Switzerland: Author.
. (2010). Community-based rehabilitation: CBR guidelines. Geneva, Switzerland: Author.
. (2013). Mental health action plan 2013–2020 (WHO Document Production Services, Ed.). Geneva, Switzerland: Author.
. (2008). Task shifting: Rational redistribution of tasks amoung health workforce teams. Geneva, Switzerland: Author.
. (2009). An assessment of interactions between global health initiatives and country health systems. The Lancet, 373, 2137–2169. 10.1016/S0140-6736(09)60919-3
