Browsing by Author "Breuer, Erica"
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- ItemOpen AccessDeveloping a mental health care plan in a low resource setting: the theory of change approach(2015-09-28) Hailemariam, Maji; Fekadu, Abebaw; Selamu, Medhin; Alem, Atalay; Medhin, Girmay; Giorgis, Tedla W; DeSilva, Mary; Breuer, EricaAbstract Background Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health need in low-income countries. For integrated care to achieve its goal, a clear understanding of the organisational processes that can promote and hinder the integration and delivery of mental health care is essential. Theory of Change (ToC), a method employed in the planning, implementation and evaluation of complex community initiatives, is an innovative approach that has the potential to assist in the development of a comprehensive mental health care plan (MHCP), which can inform the delivery of integrated care. We used the ToC approach to develop a MHCP in a rural district in Ethiopia. The work was part of a cross-country study, the Programme for Improving Mental Health Care (PRIME) which focuses on developing evidence on the integration of mental health in to primary care. Methods An iterative ToC development process was undertaken involving multiple workshops with stakeholders from diverse backgrounds that included representatives from the community, faith and traditional healers, community associations, non-governmental organisations, Zonal, Regional and Federal level government offices, higher education institutions, social work and mental health specialists (psychiatrists and psychiatric nurses). The objective of this study is to report the process of implementing the ToC approach in developing mental health care plan. Results A total of 46 persons participated in four ToC workshops. Four critical path dimensions were identified: community, health facility, administrative and higher level care organisation. The ToC participants were actively engaged in the process and the ToC encouraged strong commitment among participants. Key opportunities and barriers to implementation and how to overcome these were suggested. During the workshops, a map incorporating the key agreed outcomes and outcome indicators was developed and finalized later. Conclusions The ToC approach was found to be an important component in the development of the MHCP and to encourage broad political support for the integration of mental health services into primary care. The method may have broader applicability in planning complex health interventions in low resource settings.
- ItemOpen AccessEvaluation of mhGAP training for primary healthcare workers in Mulanje, Malawi: a quasi-experimental and time series study(2020-01-20) Kokota, Demoubly; Lund, Crick; Ahrens, Jennifer; Breuer, Erica; Gilfillan, SheilaAbstract Background There has been a growing global movement championed by the World Health Organization (WHO) to integrate mental health into primary health care as the most effective way of reducing the mental health treatment gap. This study aimed to investigate the impact of WHO Mental Health Gap Action Programme (mhGAP) training and supervision on primary health workers’ knowledge, confidence, attitudes and detection rate of major mental disorders in Mulanje, Malawi. Method The study used a quasi-experimental method (single cohort pre- and post-measures) with an interrupted time-series design. A 2 day mhGAP training was delivered to 43 primary healthcare workers (PHWs) working in 18 primary care clinics serving the entire population of Mulanje, Malawi (population 684,107). Modules covered were psychosis, moderate-severe depression, and alcohol & substance use disorders. The PHWs completed pre and post-tests to assess knowledge, confidence and attitudes. Number of diagnosed cases was obtained from clinic registers for 5 months prior to and 7 months following training. Data was analyzed using mean scores, t-test, one-way analysis of variance and linear regression. Results The mean knowledge score increased significantly from 11.8 (SD: 0.33) before training to 15.1 (SD: 0.38) immediately after training; t (42) = 7.79, p < 0.01. Similarly, mean knowledge score was significantly higher 6 months post training at 13.9 (SD: 2.52) compared to before; t (42) = 4.57, p < 0.01. The mean confidence score also increased significantly from 39.9 (SD: 7.68) before training to 49.6 (SD: 06.14) immediately after training; t (84) = 8.43, p < 0.01. It was also significantly higher 6 months post training 46.8, (SD: 6.03) compared to before; t (84) = 6.60, p < 0.01. One-way analysis of variance showed no significant difference in mean scores on all four components of the scale used to measure attitudes. A significant positive change in the trend in mental health service utilization after the intervention was demonstrated using a segmented linear regression (β = 2.43 (95% CI 1.02; 3.83) as compared to before (β = − 0.22 (95% CI − 2.67; 2.23) and immediately after (β = 1.63 (95% CI − 7.31; 10.57). Conclusion The findings of this study add to the growing evidence for policy makers of the effectiveness of mhGAP training and supervision in a resource-constrained country.
- ItemOpen AccessA formative study on the adaptation of mental health promotion programmes for perinatal depression in West Chitwan(2017) Subba, Prasansa; Breuer, Erica; Petersen Williams, Petal; Luitel, PrasadIntroduction: Depression in mothers can have debilitating consequences on the women themselves, their infants and their family. Thus, it is imperative to detect and treat perinatal depression early. Due to lack of awareness and stigma, help seeking, detection and treatment for perinatal depression in Nepal remains low. To counter barriers on lack of awareness, stigma and non-detection of mental health problems including depression, alcohol use disorder, psychosis and epilepsy, the PRogramme for Improving Mental Health carE (PRIME) developed and implemented a community sensitization programme and a Community Informant Detection Tool (CIDT). Neither of these programmes has focused on perinatal depression. This study aims to adapt the depression CIDT and the community sensitization programme to include perinatal depression. Methods: The CIDT and community sensitization programme were adapted using the following four steps. Firstly, a qualitative study was conducted with perinatal women with depressive symptoms visiting Meghauli and Dibyanagar health facilities or "gau-ghar clinic" (n=26) and service providers (n=34) to develop a culturally relevant content. Secondly, a draft CIDT and community sensitization manual were prepared based on the qualitative findings. Thirdly, a one-day workshop and several consultation meetings were held with mental health professionals (n=16) to ensure that the content was understandable and applicable to the context. Lastly, based on the workshop findings and consultation meetings, the manual and tools were modified and adapted for perinatal depression. Results: Due to poor awareness and stigma, none of our respondents had ever sought help for depression from the antenatal or postnatal service providers. Using local expressions for common depressive symptoms such as loss of interest, rumination, pessimistic views, extreme worries, restlessness, two separate CIDTs were developed each for antenatal and postnatal depression. Lack of support from the husband and family followed by poverty were the major contributing factors for depression. In addition, cultural factors such as the low position of women in patriarchal society and preference for son exacerbated problems in some women. The community sensitization manual was adapted to include local myths and facts about perinatal depression; causes with examples related to local beliefs; symptoms explained in local idioms; and role of the family. The heads of the families and key community members were recommended as key targets for the community sensitization programmes. Conclusion: It is important for any intervention to be responsive to local understanding and needs. The adapted CIDT and community sensitization manual has integrated the local issues and expressions of symptoms of perinatal depression for women in the Chitwan district.
- ItemOpen AccessMaternal mental health in primary care in five low- and middle-income countries: a situational analysis(BioMed Central, 2016-02-16) Baron, Emily C; Hanlon, Charlotte; Mall, Sumaya; Honikman, Simone; Breuer, Erica; Kathree, Tasneem; Luitel, Nagendra P; Nakku, Juliet; Lund, Crick; Medhin, Girmay; Patel, Vikram; Petersen, Inge; Shrivastava, Sanjay; Tomlinson, MarkBackground: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3–50 %) and alcohol consumption during pregnancy (5–51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.
- ItemOpen AccessNon-fatal suicidal behaviour in rural Ethiopia: a cross-sectional facility- and population-based study(BioMed Central, 2016-03-22) Fekadu, Abebaw; Medhin, Girmay; Selamu, Medhin; Shiferaw, Tsion; Hailemariam, Maji; Rathod, Sujit D; Jordans, Mark; Teferra, Solomon; Lund, Crick; Breuer, Erica; Prince, Martin; Giorgis, Tedla W; Alem, Atalay; Hanlon, CharlotteBackground: Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive mental healthcare in a rural district in Ethiopia, we determined the 12-month prevalence of non-fatal suicidal behaviour as well as factors associated with this behaviour to understand the potential burden of the behaviour in the district. Method: Population-based (n = 1485) and facility-based (n = 1014) cross-sectional surveys of adults, using standardised, interview-based measures for suicidality (items on suicide from the Composite International Diagnostic Interview), depressive symptoms (the Patient Health Questionnaire) and alcohol use disorders (Alcohol Use Disorder Investigation Test; AUDIT). Results: The overall 12-month prevalence of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt, was 7.9 % (95 % Confidence Interval (CI) = 6.8 % to 8.9 %). The prevalence was significantly higher in the facility sample (10.3 %) compared with the community sample (6.3 %). The 12-month prevalence of suicide attempt was 4.4 % (95 % CI = 3.6 % to 5.3 %), non-significantly higher among the facility sample (5.4 %) compared with the community sample (3.8 %). Over half of those with suicidal ideation (56.4 %) transitioned from suicidal ideation to suicide attempt. Younger age, harmful use of alcohol and higher depression scores were associated significantly with increased non-fatal suicidal behaviours. The only factor associated with transition from suicidal ideation to suicide attempt was high depression score. Only 10.5 % of the sample with suicidal ideation had received any treatment for their suicidal behaviour: 10.8 % of the community sample and 10.2 % of the facility sample. Although help seeking increased with progression from ideation to attempt, there was no statistically significant difference between the groups. Conclusion: Non-fatal suicidal behaviour is an important public health problem in this rural district. A more in-depth understanding of the context of the occurrence of the behaviour, improving access to care and targeting depression and alcohol use disorder are important next steps. The role of other psychosocial factors should also be explored to assist the provision of holistic care.
- ItemOpen AccessParticipant profiles and symptom responses in the initial stages of a South African Mental health managed care programme(2019) Hattingh, Leandri; Breuer, Erica; Schneider, MargueriteIntroduction Continuously rising health care and workplace costs associated with mental illness is demanding attention from health care funders in South Africa’s private health care sector. The majority of mental health care costs are generated by in-hospital care, whilst funded access to ambulatory care is limited in this sector. The Medscheme Mental Health Programme (MMHP) is a collaborative care project which aims to promote the integration of good quality mental health care into the primary care setting. In a “treatment-to-target” approach, symptom score trackers are used to systematically monitor response to treatment in order to help identify and modify suboptimal treatment plans timeously (Hattingh 2017b). Aims This study describes the MMHP participants and pathways into and through the MMHP, and its initial clinical outcomes. Methods Principal members and dependant beneficiaries of two participating medical schemes screened for enrolment on the MMHP between 1 August 2016 and 28 February 2018 were included in the study. Persons younger than 18 years were excluded. Symptoms of major depressive disorder (MDD), generalised anxiety disorder (GAD), posttraumatic stress disorder (PTSD) and alcohol abuse were screened for by using the Patient Health Questionnaire-9 (PHQ-9) (Spitzer, Williams, and Kroenke 2002-2015; Kroenke and Spitzer 2002), the Generalised Anxiety Disorder Questionnaire-7 (GAD-7) (Spitzer, Williams, and Kroenke 2002-2015; Spitzer and Kroenke 2006), the Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD) US Department of Veteran Affairs (2015); (Prins, Ouimette, and Kimerling 2003) and the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al. 2001). The Medscheme Care Manager administered these questionnaires telephonically to screen candidates for enrolment on the Programme and communicated regularly with the associated clinical practitioner regarding treatment response. A specialist psychiatrist reviewed and provided recommendations on problematic cases at set intervals. Using logistic regression, the association between demographic characteristics and scheme type and the presence of moderate or severe symptoms of 1) depression, 2) generalised anxiety disorder, and 3) post-traumatic stress disorder, was assessed. Percentages of the sample with a single condition, one, two and three comorbidities were also analysed, as well as the proportions of co-occurrence per various combinations of conditions. Wilcoxon signed rank tests were used to determine the change in symptom severity between baseline and 10 weeks in those receiving intervention through the MMHP. Linear regression models were created to analyse the predictors of change in clinical scores. Results In the screened group, 48.6% were found to have moderate to severe symptoms of anxiety on the GAD-7, 53.2% of depression on the PHQ-9, and 33.2% of PTSD on the PC-PTSD. Relatively high rates of possible comorbidity were found in this study, especially between depression and anxiety: of those screening positive for any one condition, 73.8% screened positive on the combination of PHQ-9 and GAD-7. Screening positive on the PHQ-9 was found to be a very strong predictor of concomitant positive screening on the GAD-7 (OR = 36.4, CI = 25.3 - 52.2), and vice versa - screening positively on the GAD-7 strongly predicted positive screening on the PHQ-9 (OR = 36.6, CI = 25.4 - 52.6). Strong associations were demonstrated with females and potential depression (OR = 1.51, CI = 1.03 - 2.21) and/or PTSD (OR = 1.65, CI = 1.18 - 2.31), while younger age was significantly associated with higher likelihood of screening positive for potential depression (OR: 0.99, CI= 0.98 - 1.00), PTSD (OR = 0.97, CI 0.96 - 0.98) and/or generalised anxiety disorder (OR = 0.97, CI = 0.96 - 0.98). There were statistically and clinically significant improvements in clinical scores for all four conditions at Week 10 after enrolment on the MMHP, compared to baseline: 21% reduction in mean scores in the AUDIT, 43% in the GAD-7, 45% in the PHQ-9, and 36% in the PC-PTSD. Conclusion In its current form, the MMHP appears to be successful in reaching significantly symptomatic medical scheme beneficiaries, with possible scope to expand its reach. Certain key design elements such as using clinical data to determine risk and need for intervention, treatment target calculation adjusted for baseline, screening for comorbidity, and current referral sources, appear to be appropriate. Given the absence of a control group, however, further research is required to confirm the outcomes of the intervention.
- ItemOpen AccessPopulation level mental distress in rural Ethiopia(BioMed Central Ltd, 2014) Fekadu, Abebaw; Medhin, Girmay; Selamu, Medhin; Hailemariam, Maji; Alem, Atalay; Giorgis, Tedla; Breuer, Erica; Lund, Crick; Prince, Martin; Hanlon, CharlotteBACKGROUND:As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME), we conducted a baseline study aimed at determining the broad indicators of the population level of psychosocial distress in a predominantly rural community in Ethiopia. METHODS: The study was a population-based cross-sectional survey of 1497 adults selected through a multi-stage random sampling process. Population level psychosocial distress was evaluated by estimating the magnitude of common mental disorder symptoms (CMD; depressive, anxiety and somatic symptoms reaching the level of probable clinical significance), harmful use of alcohol, suicidality and psychosocial stressors experienced by the population. RESULTS: The one-month prevalence of CMD at the mild, moderate and severe threshold levels was 13.8%, 9.0% and 5.1% respectively. The respective one-month prevalence of any suicidal ideation, persistent suicidal ideation and suicide attempt was 13.5%, 3.8% and 1.8%. Hazardous use of alcohol was identified in 22.4%, significantly higher among men (33.4%) compared to women (11.3%). Stressful life events were widespread, with 41.4% reporting at least one threatening life event in the preceding six months. A similar proportion reported poor social support (40.8%). Stressful life events, increasing age, marital loss and hazardous use of alcohol were associated with CMD while stressful life events, marital loss and lower educational status, and CMD were associated with suicidality. CMD was the strongest factor associated with suicidality [e.g., OR (95% CI) for severe CMD=60.91 (28.01, 132.48)] and the strength of association increased with increase in the severity of the CMD. CONCLUSION: Indicators of psychosocial distress are prevalent in this rural community. Contrary to former assumptions in the literature, social support systems seem relatively weak and stressful life events common. Interventions geared towards modifying general risk factors and broader strategies to promote mental wellbeing are required.
- ItemOpen AccessPrevalence of moderate and high risk substance use and service needs among psychiatric inpatients at Zomba Mental Hospital in Malawi(2015) Mafuta, Chitsanzo; Breuer, Erica; Lund, CrickBackground: Mental illness increases risk for substance use and the presence of substance use in people living with mental illness makes diagnosis and treatment of both disorders more complicated. For treatment of either disorder to be successful, both must be identified and treated individually. The substance use burden and service needs of psychiatric inpatients in Malawi are unknown. Objectives: The study aimed to determine prevalence of risky substance use and service needs among psychiatric inpatients. Methods: A cross-sectional study was conducted examining subjective substance use using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) version 3.1 in 323 new inpatients aged ≥18 years. The prevalence of risky and lifetime substance use was calculated in addition to bivariate analysis and linear regression. The kappa statistic was calculated to compare diagnosis of substance use during routine clinical assessment on admission with screening using the ASSIST. Results: ASSIST-linked lifetime prevalence for each substance were alcohol 54.8 %, (95 % CI: 49.3-60.1 %), followed by tobacco 43.7 %, (95 % CI: 38.4-49.1 %), and cannabis 39.0 %, (95 % CI: 33.9-44.4 %). No-one reported any use of amphetamine-type stimulants, hallucinogens, or opioids. The prevalence of moderate risk use, requiring brief intervention were tobacco 19.2 %, (95 % CI: 15.3-23.9 %), cannabis 9.9 %, (95 % CI: 7.1-13.7 %), alcohol 7.1 %, (95 % CI: 4.8-10.5 %), sedatives 1.2 %, (95 % CI: 0.4-3.3 %) and cocaine 0.6 %, (95 % CI: 0-2.4 %). High risk use requiring specialist care was identified for alcohol 18.6 %, (95 % CI: 14.7-23.2 %), cannabis 16.7 %, (95 % CI: 13.0-21.2 %), tobacco 10.8 %, (95 % CI: 7.9 -14.7 %) and inhalants 0.3 %, (95 % CI: -0.1-2.0 %). Interrater agreement for diagnosis of substance use disorder between routine clinical assessment compared to ASSIST questionnaire was Kappa = 0.530 (p < 0.001) which is moderate but statistically significant. The multivariate linear regression to determine the risk factors associated with tobacco, alcohol and cannabis. Males are more likely to use all these substances and have a higher ASSIST score than female patients (p < 0.001). The model indicated that risky alcohol use is significantly higher in Christians than other religions or no religious affiliation (p =.044) while risky cannabis use is significantly higher in rural residents compared to urban residents (p =.042). Conclusions: Results suggest that tobacco, alcohol and cannabis are commonly used among psychiatric inpatients in this population. Most patients use substances at risky levels requiring both brief intervention and specialist care. Although substance use is common, the detection of substance use disorders in admission assessments is moderate and could be improved. The ASSIST questionnaire is useful in screening for substance use in psychiatric inpatient populations and is likely to improve detection and management.
- ItemOpen AccessTheory of Change: a theory-driven approach to enhance the Medical Research Council's framework for complex interventions(2014-07-05) De Silva, Mary J; Breuer, Erica; Lee, Lucy; Asher, Laura; Chowdhary, Neerja; Lund, Crick; Patel, VikramAbstract Background The Medical Research Councils’ framework for complex interventions has been criticized for not including theory-driven approaches to evaluation. Although the framework does include broad guidance on the use of theory, it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach. A prospective, theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective, sustainable and scalable. Methods We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool, Theory of Change (ToC), into the MRC framework for complex interventions. We provide a guide to what ToC is, how to construct one, and how to integrate its use into research projects seeking to design, implement and evaluate complex interventions using the MRC framework. We test this approach by using ToC within two randomized controlled trials and one non-randomized evaluation of complex interventions. Results Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework. It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly designing an intervention that is embedded in the local context. For the feasibility and piloting stage, ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design. ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all stages of the causal pathway through which an intervention achieves impact, combining evaluations of intervention effectiveness with detailed process evaluations into one theoretical framework. Conclusions Incorporating a ToC approach into the MRC framework holds promise for improving the design and evaluation of complex interventions, thereby increasing the likelihood that the intervention will be ultimately effective, sustainable and scalable. We urge researchers developing and evaluating complex interventions to consider using this approach, to evaluate its usefulness and to build an evidence base to further refine the methodology. Trial registration Clinical trials.gov: NCT02160249
- ItemOpen AccessTreatment Contact Coverage for Probable Depressive and Probable Alcohol Use Disorders in Four Low- and Middle-Income Country Districts: The PRIME Cross-Sectional Community Surveys(Public Library of Science, 2016) Rathod, Sujit D; De Silva, Mary J; Ssebunnya, Joshua; Breuer, Erica; Murhar, Vaibhav; Luitel, Nagendra P; Medhin, Girmay; Kigozi, Fred; Shidhaye, Rahul; Fekadu, Abebaw; Jordans, Mark; Patel, Vikram; Tomlinson, Mark; Lund, CrickContext A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown. Objective To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage. METHODS: Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months. Setting Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda Participants 8036 adults residing in these districts between May 2013 and May 2014 Main Outcome Measures Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD. RESULTS: The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%. CONCLUSIONS: Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans.
- ItemOpen AccessUsing theory of change to design and evaluate public health interventions: a systematic review(BioMed Central, 2016-05-06) Breuer, Erica; Lee, Lucy; De Silva, Mary; Lund, CrickBackground: Despite the increasing popularity of the theory of change (ToC) approach, little is known about the extent to which ToC has been used in the design and evaluation of public health interventions. This review aims to determine how ToCs have been developed and used in the development and evaluation of public health interventions globally. Methods: We searched for papers reporting the use of “theory of change” in the development or evaluation of public health interventions in databases of peer-reviewed journal articles such as Scopus, Pubmed, PsychInfo, grey literature databases, Google and websites of development funders. We included papers of any date, language or study design. Both abstracts and full text papers were double screened. Data were extracted and narratively and quantitatively summarised. Results: A total of 62 papers were included in the review. Forty-nine (79 %) described the development of ToC, 18 (29 %) described the use of ToC in the development of the intervention and 49 (79 %) described the use of ToC in the evaluation of the intervention. Although a large number of papers were included in the review, their descriptions of the ToC development and use in intervention design and evaluation lacked detail. Conclusions: The use of the ToC approach is widespread in the public health literature. Clear reporting of the ToC process and outputs is important to strengthen the body of literature on practical application of ToC in order to develop our understanding of the benefits and advantages of using ToC. We also propose a checklist for reporting on the use of ToC to ensure transparent reporting and recommend that our checklist is used and refined by authors reporting the ToC approach.
- ItemOpen AccessUsing workshops to develop theories of change in five low and middle income countries: lessons from the programme for improving mental health care (PRIME)(2014-04-30) Breuer, Erica; De Silva, Mary J; Fekadu, Abebaw; Luitel, Nagendra P; Murhar, Vaibhav; Nakku, Juliet; Petersen, Inge; Lund, CrickAbstract Background The Theory of Change (ToC) approach has been used to develop and evaluate complex health initiatives in a participatory way in high income countries. Little is known about its use to develop mental health care plans in low and middle income countries where mental health services remain inadequate. Aims ToC workshops were held as part of formative phase of the Programme for Improving Mental Health Care (PRIME) in order 1) to develop a structured logical and evidence-based ToC map as a basis for a mental health care plan in each district; (2) to contextualise the plans; and (3) to obtain stakeholder buy-in in Ethiopia, India, Nepal, South Africa and Uganda. This study describes the structure and facilitator’s experiences of ToC workshops. Methods The facilitators of the ToC workshops were interviewed and the interviews were recorded, transcribed and analysed together with process documentation from the workshops using a framework analysis approach. Results Thirteen workshops were held in the five PRIME countries at different levels of the health system. The ToC workshops achieved their stated goals with the contributions of different stakeholders. District health planners, mental health specialists, and researchers contributed the most to the development of the ToC while service providers provided detailed contextual information. Buy-in was achieved from all stakeholders but valued more from those in control of resources. Conclusions ToC workshops are a useful approach for developing ToCs as a basis for mental health care plans because they facilitate logical, evidence based and contextualised plans, while promoting stakeholder buy in. Because of the existing hierarchies within some health systems, strategies such as limiting the types of participants and stratifying the workshops can be used to ensure productive workshops.