Introduction
Globally, mental health accounts for a large and growing burden of disease (Whiteford et al. Reference Whiteford, Degenhardt, Rehm, Baxter, Ferrari, Erskine, Charlson, Norman, Flaxman, Johns, Burstein, Murray and Vos2013). Recent estimates from the WHO Mental Health Surveys indicate an interquartile range of lifetime DSM-IV disorder prevalence between 18.1% and 36.1% (Kessler et al. Reference Kessler, Aguilar-Gaxiola, Alonso, Chatterji, Lee, Ormel, Ustun and Wang2009). According to the Global Burden of Disease Study, between 2005 and 2013, disability-adjusted life-years attributed to mental and neurological disorders increased by 9.7% and 16.1%, respectively (Murray et al. Reference Murray, Barber, Foreman, Abbasoglu Ozgoren, Abd-Allah, Abera, Aboyans, Abraham, Abubakar, Abu-Raddad, Abu-Rmeileh, Achoki, Ackerman, Ademi, Adou, Adsuar, Afshin, Agardh, Alam, Alasfoor, Albittar, Alegretti, Alemu, Alfonso-Cristancho, Alhabib, Ali, Alla, Allebeck, Almazroa, Alsharif, Alvarez, Alvis-Guzman, Amare, Ameh, Amini, Ammar, Anderson, Anderson, Antonio, Anwari, Arnlov, Arsic Arsenijevic, Artaman, Asghar, Assadi, Atkins, Avila, Awuah, Bachman, Badawi, Bahit, Balakrishnan, Banerjee, Barker-Collo, Barquera, Barregard, Barrero, Basu, Basu, Basulaiman, Beardsley, Bedi, Beghi, Bekele, Bell, Benjet, Bennett, Bensenor, Benzian, Bernabe, Bertozzi-Villa, Beyene, Bhala, Bhalla, Bhutta, Bienhoff, Bikbov, Biryukov, Blore, Blosser, Blyth, Bohensky, Bolliger, Bora Basara, Bornstein, Bose, Boufous, Bourne, Boyers, Brainin, Brayne, Brazinova, Breitborde, Brenner, Briggs, Brooks, Brown, Brugha, Buchbinder and Buckle2015a ). Despite this burden, a study across 17 countries demonstrated that only 20% of persons with common mental disorders (CMDs) received treatment in the year prior to the survey, with only 10% receiving minimally adequate treatment (Wang et al. Reference Wang, Aguilar-Gaxiola, Alonso, Angermeyer, Borges, Bromet, Bruffaerts, De Girolamo, De Graaf, Gureje, Haro, Karam, Kessler, Kovess, Lane, Lee, Levinson, Ono, Petukhova, Posada-Villa, Seedat and Wells2007). Availability and scale-up of essential health services to achieve health system goals is often impeded by health workforce shortages (WHO, 2006). This is especially true of mental health in low- and middle-income countries (LMICs), where availability of services is not matched to population needs (Weinmann & Koesters, Reference Weinmann and Koesters2016). The World Health Organization (WHO) estimates that there is a need for 1.18 million mental health workers to move towards closing the mental health treatment gap (Fulton et al. Reference Fulton, Scheffler, Sparkes, Auh, Vujicic and Soucat2011).
In LMICs, not only are there limited mental health services available, utilization of existing services is also poor for a multitude of reasons, including geographic, cultural, and financial access barriers (Murthy, Reference Murthy2011; van Ginneken et al. Reference van Ginneken, Tharyan, Lewin, Rao Girish, Meera, Pian, Chandrashekar and Patel2013; Chowdhary et al. Reference Chowdhary, Sikander, Atif, Singh, Ahmad, Fuhr, Rahman and Patel2014; Joshi et al. Reference Joshi, Alim, Kengne, Jan, Maulik, Peiris and Patel2014; Chibanda et al. Reference Chibanda, Cowan, Healy, Abas and Lund2015; Weinmann & Koesters, Reference Weinmann and Koesters2016). Mental health service delivery is highly context-specific with culturally defined interpretations of stigma, trust, and utility affecting success and impact (Murthy, Reference Murthy2011; van Ginneken et al. Reference van Ginneken, Tharyan, Lewin, Rao Girish, Meera, Pian, Chandrashekar and Patel2013; Weinmann & Koesters, Reference Weinmann and Koesters2016). Integration of mental health services into primary care presents a strategic opportunity to overcome some of these access barriers and reach the largest number of people while minimizing stigma and discrimination (WONCA, 2008). Integration of mental health services is also in line with the essential public health function of early diagnosis and prevention; it requires primary care providers to be trained in identifying poor mental health and taking action towards treatment (WONCA, 2008). Mental and physical health are interconnected, and early detection can lead to improved health outcomes and increase cost-effectiveness for the health system (WONCA, 2008; Levin & Chisholm, Reference Levin, Chisholm, Jamison, Nugent, Gleband, Horton, Jha, Laxminarayan and Mock2015). However, effective integration requires strengthened primary care systems. The value of lay provider programmes in strengthening these systems towards universal health coverage, which includes provisions for mental health, has been recognized globally (Schneider & Lehmann, Reference Schneider and Lehmann2016). For the purposes of this paper, lay providers are defined broadly as individuals who may or may not have basic literacy skills or some form of formal post-secondary education with subsequent informal or formal pre-service training (Olaniran et al. Reference Olaniran, Smith, Unkels, Bar-Zeev and Van Den Broek2017). They are often unpaid or may receive an allowance based on the programme (Olaniran et al. Reference Olaniran, Smith, Unkels, Bar-Zeev and Van Den Broek2017).
Recognizing task shifting as a system intervention for mental health
In resource-poor settings, task shifting has been an effective approach to addressing health workforce challenges and strengthening systems for mental health (Eaton et al. Reference Eaton, Mccay, Semrau, Chatterjee, Baingana, Araya, Ntulo, Thornicroft and Saxena2011; Kakuma et al. Reference Kakuma, Minas, Van Ginneken, Dal Poz, Desiraju, Morris, Saxena and Scheffler2011). Several systematic reviews have supported the use of task shifting for mental health focused on specific populations, such as with people living with HIV/AIDS or mothers with postpartum depression (Rahman et al. Reference Rahman, Fisher, Bower, Luchters, Tran, Yasamy, Saxena and Waheed2013; van Ginneken et al. Reference van Ginneken, Tharyan, Lewin, Rao Girish, Meera, Pian, Chandrashekar and Patel2013; Chowdhary et al. Reference Chowdhary, Sikander, Atif, Singh, Ahmad, Fuhr, Rahman and Patel2014; Atif et al. Reference Atif, Lovell and Rahman2015; Chibanda et al. Reference Chibanda, Cowan, Healy, Abas and Lund2015). Task shifting includes shifting service delivery of specific tasks from professionals with higher qualifications to those with fewer qualifications or creating a new cadre with specific training (WHO, 2007b ). It is meant to alleviate the heavy workload of specialists and to ensure that those with no access to specialists have a means of accessing some level of mental health services (Patel et al. Reference Patel, Araya, Chatterjee, Chisholm, Cohen, De Silva, Hosman, Mcguire, Rojas and Van Ommeren2007). By shifting service delivery for less complex cases to lay providers, the system allows mental health specialists to focus on more complex cases with the hope that quality of care delivery will also improve (Weinmann & Koesters, Reference Weinmann and Koesters2016).
Task shifting requires various parts of the system to be working in harmony in order to be successful (GHWA, 2007; Yaya Bocoum et al. Reference Yaya Bocoum, Kouanda, Kouyate, Hounton and Adam2013). Conditions such as regular supervision, availability of resources and tools, access to medicines, quality training, and exposure to technological updates through in-service training are enabling factors in ensuring successful redistribution of tasks among health workforce teams (Yaya Bocoum et al. Reference Yaya Bocoum, Kouanda, Kouyate, Hounton and Adam2013; Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016). Buy-in and acceptance of task-shifting interventions across a wide range of stakeholders is also important in their success (Yaya Bocoum et al. Reference Yaya Bocoum, Kouanda, Kouyate, Hounton and Adam2013). For example, perceptions of a loss of hierarchal structures, shift in earnings, and burden of supervision are examples of barriers that higher professional cadres may experience regarding task shifting (Niekerk, Reference Niekerk2008; Philips et al. Reference Philips, Zachariah and Venis2008; Zachariah et al. Reference Zachariah, Ford, Philips, Lynch, Massaquoi, Janssens and Harries2009). Therefore, task shifting is a system-wide intervention that has implications beyond the players and programmes directly involved in its implementation; it reallocates resources across the health system to trigger change.
Using systems thinking to evaluate the impact of task shifting
With the recognition that task shifting for mental health is a system-wide intervention, understanding its potentially far-reaching implications and impact across the system becomes valuable for appropriate decision making, health system planning, and implementation of interventions. System-wide effects can be captured using the suite of tools available in systems thinking to collect information across a multitude of stakeholders and mechanisms involved in a given context (AHPSR, 2009; Peters, Reference Peters2014). The six building blocks of the health system – service delivery, health workforce, information technology, medical products, financing, and leadership – are made dynamic, adaptive, and interactive through a systems thinking lens as it is designed to explore how different elements are connected in a system and the impact and implications of these connections (Table 1) (Adam et al. Reference Adam, Hsu, De Savigny, Lavis, Rottingen and Bennett2012). Systems thinking also incorporates another key health systems element: communities and people (Adam et al. Reference Adam, Hsu, De Savigny, Lavis, Rottingen and Bennett2012). Therefore, in our application of the building blocks approach, we have added a seventh to account for communities and people. By enhancing understanding of different perspectives across multiple interacting agents, the changing context in which they interact, and the changes resulting from new patterns created over time, systems thinking can serve as an important policy toolkit (Adam et al. Reference Adam, Hsu, De Savigny, Lavis, Rottingen and Bennett2012; Peters, Reference Peters2014).
Building blocks of the health system (WHO, 2010)
Applying evidence for success in capacity building for mental health care
The growing burden of disease attributed to mental health calls for approaches that strengthen the capacity of the health system to equitably and appropriately address the wide range of mental and neurological disorders (Whiteford et al. Reference Whiteford, Degenhardt, Rehm, Baxter, Ferrari, Erskine, Charlson, Norman, Flaxman, Johns, Burstein, Murray and Vos2013). The mhGAP (Global Mental Health Gap Action Programme) was launched in 2008 to provide technical guidance, tools and training to help address the challenges of availability in resource-poor settings (WHO, 2008). Global mental health has seen attention in academic circles through special series in The Lancet and PLoS, which highlight integration of mental health into primary care as a key strategy (Patel et al. Reference Patel, Araya, Chatterjee, Chisholm, Cohen, De Silva, Hosman, Mcguire, Rojas and Van Ommeren2007; Patel & Thornicroft, Reference Patel and Thornicroft2009).
Integration of mental health into health systems, especially in primary care systems, is not without its challenges, particularly in resource-poor settings (Patel et al. Reference Patel, Maj, Flisher, De Silva, Koschorke and Prince2010a ; Eaton et al. Reference Eaton, Mccay, Semrau, Chatterjee, Baingana, Araya, Ntulo, Thornicroft and Saxena2011; Weinmann & Koesters, Reference Weinmann and Koesters2016). Poor policy implementation, inadequate human resource allocation to support the process, poor community engagement, and low access to medicines are among the challenges of integration (Patel et al. Reference Patel, Araya, Chatterjee, Chisholm, Cohen, De Silva, Hosman, Mcguire, Rojas and Van Ommeren2007; Eaton et al. Reference Eaton, Mccay, Semrau, Chatterjee, Baingana, Araya, Ntulo, Thornicroft and Saxena2011; van Ginneken et al. Reference van Ginneken, Tharyan, Lewin, Rao Girish, Meera, Pian, Chandrashekar and Patel2013). Systems thinking contributes to documenting the system-wide impact of a given intervention, as well as enhancing the ability to predict both intended and unintended consequences of the intervention, critical in designing successful large-scale reform.
Few studies focus on the wider impact of task shifting across the health system and, likewise, the scale-up of mental health strategies (Eaton et al. Reference Eaton, Mccay, Semrau, Chatterjee, Baingana, Araya, Ntulo, Thornicroft and Saxena2011; Yaya Bocoum et al. Reference Yaya Bocoum, Kouanda, Kouyate, Hounton and Adam2013). This weakness in the literature undermines the complexity of interactions and changes that take place in health systems, and stymies the potential scale-up and sustainable integration of promising task-shifting strategies (Adam et al. Reference Adam, Hsu, De Savigny, Lavis, Rottingen and Bennett2012; Yaya Bocoum et al. Reference Yaya Bocoum, Kouanda, Kouyate, Hounton and Adam2013). To ensure that LMICs can expand large-scale mental health strategies and achieve integration into primary care, a system-wide approach can be an effective tool in understanding, evaluating, and implementing bespoke strategies (WHO, 2007b ; AHPSR, 2009). This paper reviews the available evidence to determine whether a systems approach is employed in the implementation and evaluation of task shifting for mental health using lay providers in LMICs. It seeks to highlight system-wide effects of task-shifting strategies in order to better inform efforts to strengthen community mental health systems.
Methods
Search strategy
The electronic databases of PubMed, CINAHL, and Cochrane were searched between 5 September 2016 and 30 October 2016 (Annexure 1). The search strategy consisted of three concepts: (1) lay providers, including community health workers, health aides, local references to community health workers such as accredited social health activists, non-physician health workers, community-based practitioners, and other associated terms; (2) mental health, including the standard set of disorders under the definition of CMDs such as anxiety, depression, dementia, schizophrenia, and substance abuse, as well as strategies for treatment such as supportive counselling, cognitive behavioural therapy, and others; and (3) LMIC setting, as this study is focused on alternatives for delivery of mental health services in resource-poor settings. These concepts were expanded to include similar terms and combined using ‘and’ to build the search. Further, the references of included articles were searched to identify additional citations that were not captured in the search as a means of ensuring the robustness of the study. These were included when the full text satisfied the inclusion criteria of being set in an LMIC, focusing on mental health and evaluating a task-shifting strategy of service delivery from providers with higher or more specialized qualifications to those with lower qualification. However, all eligible references were already captured in the search. Search was limited to publications between January 1996 and September 2016.
After completing the electronic search, the titles and abstracts of all identified articles were independently reviewed by two authors, who assessed whether the article should be included or excluded according to pre-defined criteria. These criteria are included in Table 2. Articles that met any of the criteria for exclusion were eliminated. In the first round of screening, articles meeting at least four of five criteria for inclusion based on titles and abstract review, were included. In the case of inter-rater disagreement, a third reviewer was consulted on the inclusion or exclusion of the article in question. The third reviewer was blinded and has expertise in health systems research. Articles intended for inclusion were combined in a Microsoft Excel spreadsheet and any duplicates were removed. Full-text versions of identified articles were examined in order to reassess inclusion based on articles meeting all five criteria before establishing the final set to be included in the study. A two-stage approach to inclusion was employed to ensure sensitivity.
Inclusion and exclusion criteria
For inclusion in this review, the study must have: (1) evaluated the implementation and/or impact of an intervention; (2) had significant focus on mental health; (3) been set in an LMIC; (4) employed task-shifting strategies where service delivery was transformed from a professional cadre with higher qualification to lay providers with lower qualifications and minimal mental health training; and (5) involved training of lay providers was limited to fewer than 3 years. The training criteria was articulated with input from a health workforce specialist in order to keep the focus on task shifting to providers with fewer qualifications without excluding task shifting to qualified providers who lack specialized mental health training as we considered this relevant to our study. Where length of training was not specified, we used our collective judgment to determine whether task shifting was towards a provider with minimal mental health training. An expanded interpretation of evaluation was used to include both quantitative and qualitative studies that reported on randomized control trials, cohort studies with before and after measures, survey and/or observational assessments of stakeholder perceptions, acceptability and satisfaction, case studies, and analysis of qualitative data.
Data extraction and analysis
Two study authors read all included full texts and extracted the following data: setting, year of publication, aim of study, type of intervention, sample size, outcomes measured, results, health system implication(s), and barriers and facilitators of implementation. Critical Appraisal Skills Programme (CASP) tools were used to assess the quality of the studies (CASP, 2016). The initial screening questions (see Table 3) were used to ensure that included studies met minimal quality standards. Risk of bias and limitations of included studies were then assessed using more detailed items found on CASP checklists for different types of studies (see Table 4).
CASP screening questions
CASP quality checklist
To determine whether a system-wide approach was taken in the evaluation of the intervention and to identify system-wide effects when available, authors identified features of interventions relevant to the WHO building blocks framework as well as systems thinking characteristics used in the study (AHPSR, 2009). Systems thinking characteristics considered included: capturing perceptions and interactions of multiple interacting agents, network analysis, mapping of contextual factors, process mapping, describing feedback mechanisms, and other approaches that could inform system dynamics modelling (Peters, Reference Peters2014). Manuscripts were coded for identification of barriers, facilitators, and outcomes that were relevant to each of the six building blocks: (1) Service Delivery, (2) Health Workforce, (3) Information Technology, (4) Medicines & Medical Devices, (5) Financing, and (6) Leadership and Governance (WHO, 2007a ). A seventh building block for communities and people was also included in data abstraction. Authors also made note of the range of stakeholders consulted in the study. The building blocks model allowed for a systematic way to determine whether the impact of the intervention was assessed beyond the specific building blocks in which they were implemented (i.e. health workforce and service delivery in the case of task shifting for mental health). By looking at the level and range of stakeholder engagement, we were able to identify instances were roles and interactions of stakeholders not directly involved in the intervention were explored, as is customary in systems thinking. Use of system dynamics theory, causal loop diagrams, and other system modelling techniques were also included in the extraction criteria, but none were found.
Results
From the 1357 papers identified, 817 were found through PubMed, 271 from Cochrane Library, and 269 from CINAHL. Removing 249 duplicates, 1108 papers were screened based on titles and abstracts. Of these, 147 met the criteria for the first stage of inclusion (four out of five criteria for inclusion met). Upon reviewing full texts, a final set of 30 papers were included although two of these reported on the same randomized controlled trial on MANAS in India (Patel et al. Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Silva, Bhat, Araya, King, Simon, Verdeli and Kirkwood2010b , Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Bhat, Araya, King, Simon, Verdeli and Kirkwood2011), and three were based on different perspectives of the community mental health programme in Ghana (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Farren and Mcauliffe b , Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016). No studies were excluded on the basis of quality. See Fig. 1 for search outcomes.
Search results.
Thirteen papers were qualitative evaluations using surveys, interviews, focus groups, action research, implementation research, or case study methodology (Ali et al. Reference Ali, Ali, Azam and Khuwaja2010; Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Thurman et al. Reference Thurman, Kidman and Taylor2014; Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Farren and Mcauliffe b , Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016; Larson-Stoa et al. Reference Larson-Stoa, Jacobs, Jonathan and Poudyal2015; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015; Magidson et al. Reference Magidson, Lejuez, Kamal, Blevins, Murray, Bass, Bolton and Pagoto2015; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Abas et al. Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016; Wright & Chiwandira, Reference Wright and Chiwandira2016). Twelve papers were randomized controlled trials (Ali et al. Reference Ali, Rahbar, Naeem, Gul, Mubeen and Iqbal2003; Baker-Henningham et al. Reference Baker-Henningham, Powell, Walker and Grantham-Mcgregor2005; Rahman et al. Reference Rahman, Malik, Sikander, Roberts and Creed2008; Kumakech et al. Reference Kumakech, Cantor-Graae, Maling and Bajunirwe2009; Patel et al. Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Silva, Bhat, Araya, King, Simon, Verdeli and Kirkwood2010b , Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Bhat, Araya, King, Simon, Verdeli and Kirkwood2011; Tomlinson et al. Reference Tomlinson, Doherty, Jackson, Lawn, Ijumba, Colvin, Nkonki, Daviaud, Goga, Sanders, Lombard, Persson, Ndaba, Snetro and Chopra2011; Chatterjee et al. Reference Chatterjee, Naik, John, Dabholkar, Balaji, Koschorke, Varghese, Thara, Weiss, Williams, Mccrone, Patel and Thornicroft2014; Pradeep et al. Reference Pradeep, Isaacs, Shanbag, Selvan and Srinivasan2014; Rotheram-Borus et al. Reference Rotheram-Borus, Tomlinson, Le Roux and Stein2015). Three papers were pre/post- or prospective cohort studies (Adam et al. Reference Adam, Hsu, De Savigny, Lavis, Rottingen and Bennett2012; Whiteford et al. Reference Whiteford, Degenhardt, Rehm, Baxter, Ferrari, Erskine, Charlson, Norman, Flaxman, Johns, Burstein, Murray and Vos2013; Yaya Bocoum et al. Reference Yaya Bocoum, Kouanda, Kouyate, Hounton and Adam2013; Hung et al. Reference Hung, Tomlinson, Le Roux, Dewing, Chopra and Tsai2014; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015). Two papers included economic evaluation (Buttorff et al. Reference Buttorff, Hock, Weiss, Naik, Araya, Kirkwood, Chisholm and Patel2012; Chatterjee et al. Reference Chatterjee, Naik, John, Dabholkar, Balaji, Koschorke, Varghese, Thara, Weiss, Williams, Mccrone, Patel and Thornicroft2014). All studies showed that task shifting for mental health was feasible and acceptable in the given contexts; however, perceptions of quality of care provided by lay providers remain uncertain (Patel et al. Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Bhat, Araya, King, Simon, Verdeli and Kirkwood2011; Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Rotheram-Borus et al. Reference Rotheram-Borus, Tomlinson, Le Roux and Stein2015; Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016). A meta-analysis of outcome measures was not done as the interventions were diverse, conducted at multiple scales, and included qualitative evaluations of stakeholder perceptions. See Table 5 for characteristics of included studies.
Characteristics of included studies
Studies were conducted in India, Ghana, Zimbabwe, Pakistan, Malawi, South Africa, Uganda, Indonesia, Iraq, Argentina, Botswana Jamaica, Ethiopia, Zambia, and Thailand, primarily at the district (includes village) level (see Table 5). Across these different contexts, community mental health programmes were variable in nature with some being more integrated into existing health systems (Patel et al. Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Silva, Bhat, Araya, King, Simon, Verdeli and Kirkwood2010b , Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Bhat, Araya, King, Simon, Verdeli and Kirkwood2011; Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014; Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Farren and Mcauliffe b ; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016; Wright & Chiwandira, Reference Wright and Chiwandira2016). Others were more programme-specific in nature and targeted specific at-risk populations, such as mothers suffering from depression, people living with HIV/AIDS, orphans, refugees and torture survivors (Baker-Henningham et al. Reference Baker-Henningham, Powell, Walker and Grantham-Mcgregor2005; Neuner et al. Reference Neuner, Onyut, Ertl, Odenwald, Schauer and Elbert2008; Kumakech et al. Reference Kumakech, Cantor-Graae, Maling and Bajunirwe2009; Ali et al. Reference Ali, Ali, Azam and Khuwaja2010; Bolton et al. Reference Bolton, Lee, Haroz, Murray, Dorsey, Robinson, Ugueto and Bass2014; Murray et al. Reference Murray, Dorsey, Haroz, Lee, Alsiary, Haydary, Weiss and Bolton2014; Larson-Stoa et al. Reference Larson-Stoa, Jacobs, Jonathan and Poudyal2015; Magidson et al. Reference Magidson, Lejuez, Kamal, Blevins, Murray, Bass, Bolton and Pagoto2015; Murray et al. Reference Murray, Skavenski, Kane, Mayeya, Dorsey, Cohen, Michalopoulos, Imasiku and Bolton2015b ). Outcome measures used included mental health assessment tools, such as the 10-item Edinburgh Postnatal Depression Scale (EPDS-10), the Center for Epidemiological Studies Depression Scale (CES-D), Psychiatric Symptom Score, UCLA Post-Traumatic Stress Disorder Reaction Index, Aga Khan University Anxiety and Depression Scale (AKUADS), and the Positive and Negative Syndrome Scale (PANSS). Qualitative measures of impact included participatory action research, implementation research, case study, and other qualitative approaches with an aim to explore broader systems components.
Intervention effects across the building blocks
Of the 30 studies, 25 (83%) included mention of the six WHO health system building blocks other than service delivery and health workforce (Table 6). All 30 studies included some aspect of the seventh additional building block (communities and people) through community engagement and/or efforts to understand community needs in order to best integrate lay providers.
System building blocks mentioned in each study
SD, Service delivery; HRH, Health workforce; IT, Information and Technology; MD, Medicines & Medical Devices; FS, Financing Systems; LG, Leadership & Governance; C, Community.
Sixteen studies of the 25 (80%), considered the role of information and technology. This building block was often mentioned in terms of use of technology for screening of mental illness (Hung et al. Reference Hung, Tomlinson, Le Roux, Dewing, Chopra and Tsai2014; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015), use of mobile technology for supervision of lay providers (Tomlinson et al. Reference Tomlinson, Doherty, Jackson, Lawn, Ijumba, Colvin, Nkonki, Daviaud, Goga, Sanders, Lombard, Persson, Ndaba, Snetro and Chopra2011; Magidson et al. Reference Magidson, Lejuez, Kamal, Blevins, Murray, Bass, Bolton and Pagoto2015; Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016), and need for improved data management tools to ensure adequate follow-up patients at-risk of poor mental health (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015b ; Abas et al. Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016). Facilitators identified to support this need were the use of step sheets for enhanced fidelity to interventions and training on documentation of patient visits on mobile phones (Bolton et al. Reference Bolton, Lee, Haroz, Murray, Dorsey, Robinson, Ugueto and Bass2014; Rotheram-Borus et al. Reference Rotheram-Borus, Tomlinson, Le Roux and Stein2015; Murray et al. Reference Murray, Skavenski, Kane, Mayeya, Dorsey, Cohen, Michalopoulos, Imasiku and Bolton2015b ).
Eleven studies (55%) considered the implications of the medicines and medical devices. The discrepancies between training and service delivery in prescribing practices were a challenge in task shifting for mental health (Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016). That is, lay providers, not trained in prescription of psychotropic medicines, found themselves prescribing them due to community needs (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a ). Shortage of medicines and the resulting limitations placed on lay providers were impediments in achieving improved health outcomes and demoralized providers who were unable to provide adequate care (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015). The bias towards medication as treatment also created challenges for prioritization of psychotherapy and behavioural interventions, affecting demand-side acceptability (Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014).
Fifteen studies (70%) raised financing issues in task shifting for mental health with most referring to lack of funds as a limitation to scale-up, pointing to the need to prove cost-effectiveness as a means of ensuring investment by policy and decision makers (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016; Murray et al. Reference Murray, Skavenski, Kane, Mayeya, Dorsey, Cohen, Michalopoulos, Imasiku and Bolton2015b ). Lack of financial incentives for lay providers and their supervisors was another challenge raised (Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014; Abas et al. Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016). Some studies mentioned demand-side financing as a barrier to improved mental health delivery, citing the ability to pay for basic mental health services from the patient's perspective (Neuner et al. Reference Neuner, Onyut, Ertl, Odenwald, Schauer and Elbert2008; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Abas et al. Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016). Ensuring that referrals were made to services covered by social protection mechanisms, was raised as an important element of providing sustainable and effective mental health service delivery by lay providers (Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015). Supporting patients through advice for socioeconomic well-being and links to income-generating projects was a means through which lay providers tried to address demand-side financial barriers (Baker-Henningham et al. Reference Baker-Henningham, Powell, Walker and Grantham-Mcgregor2005; Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015).
Finally, 10 studies (50%) mentioned leadership and governance issues with reference to task shifting for mental health. Programme-level supervision of lay providers, which was raised as a challenge across most of the studies included, was not captured as an overarching leadership and governance issue in this review as it is not sufficiently addressing system-level leadership and governance (Schneider & Lehmann, Reference Schneider and Lehmann2016). Perception surveys in Ghana directly involved policy directors, which provided an improved understanding of the gap between perceptions of lay provider programmes by policy directors and realities in the field (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Farren and Mcauliffe b , Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016). Other studies referenced the need for policy support to integrate mental health services by lay providers into existing practice, citing governance structures as facilitators in scale-up and integration of mental health services through decentralization of these services (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015). Leadership and governance structures were also barriers to integration. In larger, multi-country studies, lack of clarity in lay provider roles and confidentiality issues undermined integration of programmes from a supply-side perspective (Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014). Community-level acceptability of programmes and perceptions on who can be a lay provider were cited as demand-side challenges that need mitigation through improved transparency, accountability, and leadership that listens to the needs of the population, such as the need for transportation (Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014). One study highlighted the siloed effect of multiple vertical programmes addressing disability across different sectors with no oversight or horizontal coordination (Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015). In programmes targeted at vulnerable populations, such as refugees and orphans, continuity was a challenge as these populations are mobile. Leadership and governance issues beyond the health sector played a heavy role in the ability of lay providers to provide necessary mental health services; therefore, collaboration with other officials was raised as being important to the intervention (Neuner et al. Reference Neuner, Onyut, Ertl, Odenwald, Schauer and Elbert2008; Murray et al. Reference Murray, Skavenski, Kane, Mayeya, Dorsey, Cohen, Michalopoulos, Imasiku and Bolton2015b ).
The use of systems thinking tools in evaluation of interventions
System dynamics theory or modelling tools were not directly used in any of the included studies; however, six studies took a more comprehensive approach in capturing system implications of the intervention being studied. An important element of systems thinking is understanding roles, characteristics, and interactions of the players involved. The perceptions surveys conducted in Ghana, the phenomenological approach across South Africa, Botswana and Malawi, the multi-country stakeholder perspective mapping, and the cross-country comparison of South Africa and Uganda through interviews and focus groups captured such perspectives and allowed for improved understanding of gaps to ensure successful scale-up and integration into the health system (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014; Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015). These studies demonstrated the range of actors necessary for successful integration and showed that actors may have different interpretations of challenges, and different strengths in mitigating these challenges. Systems thinking also should allow for a non-linear process of change, whereby study findings are fed back into the design of the intervention; implementation research methods facilitate this, making adjustments for context and cultural needs (Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014; Murray et al. Reference Murray, Dorsey, Haroz, Lee, Alsiary, Haydary, Weiss and Bolton2014; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015).
In community mental health, robust referral pathways are an important piece of integration and working across stakeholders is necessary to ensure appropriate follow-up and service delivery for patients, not just within the health system, but also across other social sectors (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015). Intersectoral components of included studies were captured in this review where available. Intersectoral collaboration here is based on the WHO concept of intersectoral action for health, defined as ‘a recognised relationship between part or parts of the health sector with parts of another sector which has been formed to take action on an issue to achieve health outcomes (or intermediate health outcomes) in a way that is more effective, efficient or sustainable than could be achieved by the health sector acting alone’ (WHO, 1997). Eight studies touched on efforts made beyond the health sector. These interventions focused on the education sector, where peer group support for AIDS counselling (Kumakech et al. Reference Kumakech, Cantor-Graae, Maling and Bajunirwe2009) or support for disability management (Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015) would take place; across non-governmental organizations for vulnerable populations (Bolton et al. Reference Bolton, Lee, Haroz, Murray, Dorsey, Robinson, Ugueto and Bass2014); and with the criminal and social services sectors (Murray et al. Reference Murray, Skavenski, Kane, Mayeya, Dorsey, Cohen, Michalopoulos, Imasiku and Bolton2015b ). In addressing disability challenges, social development and transport sectors were involved to make the lived environment more supportive of those living with both physical and mental disabilities (Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015). Collaboration with the judicial system was also important in cases where abuse and neglect were part of the diagnosis (Murray et al. Reference Murray, Skavenski, Kane, Mayeya, Dorsey, Cohen, Michalopoulos, Imasiku and Bolton2015b ).
Several studies raised social determinants of mental health, such as socioeconomic status, employment, lack of education, and violence as risk factors that needed to be addressed in order to enhance the positive effect of task shifting for mental health (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014; Thurman et al. Reference Thurman, Kidman and Taylor2014; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Wright & Chiwandira, Reference Wright and Chiwandira2016). One study highlighted health promotion activities through working with community resources, such as schools and churches, as an enabling factor (Wright & Chiwandira, Reference Wright and Chiwandira2016). Another mentioned the lack of such collaboration with other sectors as a barrier in seeing improved treatment outcomes (Thurman et al. Reference Thurman, Kidman and Taylor2014). Four studies had formal arrangements for embedding intersectoral practice in the task shifting (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015). The intersectoral fora created to support these programmes strengthened their ability to integrate into existing systems and provided a wider range of community referral pathways for lay providers to use in linking their patients to the resources necessary for thriving, thereby indirectly enhancing mental health (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Chatterjee et al. Reference Chatterjee, Naik, John, Dabholkar, Balaji, Koschorke, Varghese, Thara, Weiss, Williams, Mccrone, Patel and Thornicroft2014; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015). One such example is the referral of patients to income-generating programmes within the agricultural sector (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011).
Discussion
Despite the global call to action to improve scale-up and integration of lay provider programmes, the evidence base around implementation, scale-up, and integration of task-shifting strategies for mental health remains limited in both quantity and breadth (GHWA, 2013; Weinmann & Koesters, Reference Weinmann and Koesters2016). Moving from fragmentation to integration requires a move beyond issues specific to lay provider programmes, such as remuneration, training, and supervision (Schneider & Lehmann, Reference Schneider and Lehmann2016). It needs an understanding of large-scale public sector involvement, interactions across key actors, mobilization of these actors, and monitoring and evaluation tools that capture the complex adaptive parts within the system as they shift and respond to scale-up toward a true community system (Hanlon et al. Reference Hanlon, Luitel, Kathree, Murhar, Shrivasta, Medhin, Ssebunnya, Fekadu, Shidhaye, Petersen and Jordans2014; Schneider & Lehmann, Reference Schneider and Lehmann2016). A systems thinking approach can help capture these complexities and understand how to optimize community mental health systems (Peters, Reference Peters2014).
This review demonstrates that there is space for more systematic approaches to studying health systems elements that affect and/or are impacted upon by task-shifting interventions for mental health. None of the included studies systematically studied system elements; however, many touched upon the WHO building blocks of the health system other than those directly related to task shifting (i.e. service delivery and health workforce). These studies included qualitative methods that allowed them to capture some of the interactions within the system and highlight barriers, facilitators and effects that fell outside the limited scope of the task-shifting intervention (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Lorenzo et al. Reference Lorenzo, Van Pletzen and Booyens2015; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015; Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016).
Barriers and facilitators of scaling up mental health care by the building blocks
Barriers to scaling up mental health services identified across studies included: stigma around mental health in the community (Ali et al. Reference Ali, Ali, Azam and Khuwaja2010; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015); poor documentation and loss of follow-up due to lack of robust data management and patient management tools (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015b ); lack of access to psychotropic medicines and/or lack of sufficient training for rational prescribing practice (Patel et al. Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Bhat, Araya, King, Simon, Verdeli and Kirkwood2011; Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a ; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015); geographic and financial demand-side barriers to access of mental health services (Baker-Henningham et al. Reference Baker-Henningham, Powell, Walker and Grantham-Mcgregor2005; Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Mendenhall et al. Reference Mendenhall, De Silva, Hanlon, Petersen, Shidhaye, Jordans, Luitel, Ssebunnya, Fekadu, Patel, Tomlinson and Lund2014; Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a ); poor collaboration with spiritual and traditional healers (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a ); disconnect between providers and decision makers (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016; Rotheram-Borus et al. Reference Rotheram-Borus, Tomlinson, Le Roux and Stein2015); existing heavy workload of lay providers (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Hung et al. Reference Hung, Tomlinson, Le Roux, Dewing, Chopra and Tsai2014); gender differences in responding to treatment (Larson-Stoa et al. Reference Larson-Stoa, Jacobs, Jonathan and Poudyal2015); and lack of access to community resources to support social determinants of mental health (Tomlinson et al. Reference Tomlinson, Doherty, Jackson, Lawn, Ijumba, Colvin, Nkonki, Daviaud, Goga, Sanders, Lombard, Persson, Ndaba, Snetro and Chopra2011; Thurman et al. Reference Thurman, Kidman and Taylor2014; Rotheram-Borus et al. Reference Rotheram-Borus, Tomlinson, Le Roux and Stein2015).
Facilitators to scaling up mental health services identified across studies included: suitability of lay providers due to their ability to relate to the community and their patients (Baker-Henningham et al. Reference Baker-Henningham, Powell, Walker and Grantham-Mcgregor2005; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015; Abas et al. Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016); support from specialized mental health professionals (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a , Reference Agyapong, Osei, Farren and Mcauliffe b ); use of technology and telemedicine to support supervisory practice (Patel et al. Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, Bhat, Araya, King, Simon, Verdeli and Kirkwood2011; Tomlinson et al. Reference Tomlinson, Doherty, Jackson, Lawn, Ijumba, Colvin, Nkonki, Daviaud, Goga, Sanders, Lombard, Persson, Ndaba, Snetro and Chopra2011; Magidson et al. Reference Magidson, Lejuez, Kamal, Blevins, Murray, Bass, Bolton and Pagoto2015; Agyapong et al. Reference Agyapong, Osei, Mcloughlin and Mcauliffe2016); integrated interventions that include life skill building for sustainable livelihood practice, social interaction, and self-care (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Chatterjee et al. Reference Chatterjee, Naik, John, Dabholkar, Balaji, Koschorke, Varghese, Thara, Weiss, Williams, Mccrone, Patel and Thornicroft2014); and integration into existing networks with robust service delivery models that support lay providers (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015).
While information and technology tools appear to be facilitators for optimizing service delivery by lay providers, care must be taken in the selection of technology solutions. It is critical to understand how providers use technology as a part of the system. Some tools require the interpretation and training of health professionals to be appropriately and efficiently used, suggesting that not all technologies are readily transferable across health workforce cadres (Jotheeswaran et al. Reference Jotheeswaran, Dias, Philp, Beard, Patel and Prince2015; Robbins et al. Reference Robbins, Mellins, Leu, Rowe, Warne, Abrams, Witte, Stein and Remien2015). Inefficiencies in the system can also be found in poor access to medicines (WHO, 2009). Financial and procurement barriers impede access to essential psychotropic medicines, impeding the delivery of appropriate mental health care to those who require pharmacotherapy (Agyapong et al. Reference Agyapong, Osei, Farren and Mcauliffe2015a ; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015). Scaling up mental health treatment by lay providers without addressing access to medicines in parallel will prove unsuccessful by undermining the quality and impact of additional service provision (WHO, 2009).
The barriers and facilitators outlined here showcase the complexity involved in task shifting for mental health and the need for a broader systems approach to mitigating barriers and leveraging facilitators. By being community-based and having a deep understanding of community needs and assets, lay providers have an enhanced ability to identify social determinants of mental health within a given context (Richters et al. Reference Richters, Rutayisire and Slegh2013; Padilla et al. Reference Padilla, Molina, Kamis, Calvo, Stratton, Strejilevich, Aleman, Guerrero, Bourdieu, Conesa, Escobar and De Erausquin2015). This rich knowledge, combined with appropriate training, puts them in the optimal position to refer patients to relevant social services (Paudel et al. Reference Paudel, Gilles, Hahn, Hexom, Premkumar, Arole and Katz2014). Mental health is often a comorbidity in chronic disease management; training programmes should also prepare lay providers with the knowledge and skills necessary to understand such linkages and to refer appropriately (Rotheram-Borus et al. Reference Rotheram-Borus, Tomlinson, Le Roux and Stein2015).
Establishing networks and intersectoral linkages is not easy. Despite policy support, implementation and scale-up of integrated approaches to strengthening community mental health remains a challenge (Hanlon et al. Reference Hanlon, Luitel, Kathree, Murhar, Shrivasta, Medhin, Ssebunnya, Fekadu, Shidhaye, Petersen and Jordans2014). Even where formal mechanisms are in place for intersectoral collaboration (i.e. where formal engagement of health, education and development sectors are embedded in programme design), participation was erratic and uncertain without senior officials present (Petersen et al. Reference Petersen, Ssebunnya, Bhana and Baillie2011). Existing models and formal arrangements of intersectoral collaboration require additional incentives and governmental support. In this way, partnerships move beyond platitudes and truly work as collaborative fora that support lay providers in assessing patient needs and selecting appropriate referral pathways.
Implications for future research
Mental health is rarely an isolated problem. It sometimes stems from physical, environmental, or sociocultural challenges and creates positive feedback loops that become difficult to break (Tomlinson et al. Reference Tomlinson, Doherty, Jackson, Lawn, Ijumba, Colvin, Nkonki, Daviaud, Goga, Sanders, Lombard, Persson, Ndaba, Snetro and Chopra2011; Thurman et al. Reference Thurman, Kidman and Taylor2014). Taking a systems thinking approach to unpacking task-shifting interventions for mental health will unveil extant opportunities and threats in the current system. A system-level understanding of interventions will allow for improved integration and effective engagement of important actors overlooked in the traditional model of implementation and evaluation. Such actors include caregivers, non-governmental entities that support social determinants of mental health, employers, spiritual leaders, and other social sectors (e.g., education, agriculture, transport, social development, etc.) (Schneider & Lehmann, Reference Schneider and Lehmann2016). Representing the system overall and opportunities for improvement in the implementation and evaluation of such programmes can advocate for further investment in community mental health systems strengthening.
With appropriate evidence describing the roles and contributions of diverse sectors to mental health outcomes, there is potential to facilitate strategic intersectoral investment for optimal health impact as well as cost-effectiveness. Stigma, for instance, is an often-cited barrier in mental health seeking behaviours and even in provision of mental health care (van Ginneken et al. Reference van Ginneken, Tharyan, Lewin, Rao Girish, Meera, Pian, Chandrashekar and Patel2013; Nimgaonkar & Menon, Reference Nimgaonkar and Menon2015; Iheanacho et al. Reference Iheanacho, Kapadia, Ezeanolue, Osuji, Ogidi, Ike, Patel, Stefanovics, Rosenheck, Obiefune and Ezeanolue2016; Weinmann & Koesters, Reference Weinmann and Koesters2016). A study of church-based lay providers showed that higher education was correlated with improved bio-psychosocial perspectives on mental health and fewer displays of stigma-based behaviour (Iheanacho et al. Reference Iheanacho, Kapadia, Ezeanolue, Osuji, Ogidi, Ike, Patel, Stefanovics, Rosenheck, Obiefune and Ezeanolue2016). Overcoming stigma is therefore not necessarily limited to the role of the health sector; the education sector can play an important part in addressing stigma by talking about mental health and raising awareness.
Due to the nature of the search strategy, this review highlighted interventions that were conducted primarily in the health sector. Few included studies employed task-shifting strategies across other sectors to enhance mental health promotion. More examples of such collaboration exist, especially in education and social services. Therefore, it would be worth conducting a more targeted review of the evidence on interventions happening in other sectors that have impacts on mental health. Skill-mixing interventions also warrant more emphasis as they highlight the need for a range of skills beyond the health sector to address mental health challenges. Comparing the effectiveness of mental health-related interventions housed in the health sector v. those in others would be valuable in identifying cost-effective opportunities for intersectoral collaboration and cohesive strategies for mental health.
Limitations of this review may include the wide variety of mental health interventions, populations studied, and outcome measures included, making it potentially difficult or inappropriate to apply this review's broader conclusions to unique mental health conditions. While the majority of studies did not explicitly use a systems thinking approach, some studies indicated implicit consideration of systems thinking characteristics. It is possible that studies neglecting to mention system-wide effects in final manuscripts did in fact acknowledge these effects in the design and implementation of interventions to some degree, but this data was subsequently not available for this review.
Conclusions
Task shifting for mental health has been demonstrated as an acceptable and effective approach to addressing the mental health gap in LMICs. This review shows the complexity of task-shifting interventions by exploring interactions of intervention elements and actors across the six WHO building blocks. There is a lack of systematic approaches to exploring this complexity in the evaluation of task-shifting interventions. Systems thinking tools should support evidence-informed decision making for a more complete understanding of community-based systems strengthening interventions for mental health.
Acknowledgements
Special Thanks to Ambreen Sahito and Shirley Ho for their help in the early stages of this project.
Declaration of Interest
Authors have no conflicts of interest to declare.
Ethical Standards
This review did not involve human subjects and was therefore not subject to ethical review.
Annexure 1. Search Strategy
CINAHL-Ebsco
Concept 1. Mental Health
(MH “Mental Health Personnel”) OR (MH “Mental Health”) OR (MH “Mental Health Services”) OR (MH “Community Mental Health Services+”) OR (MH “Community Mental Health Nursing”) OR (MH “Mental Health Organizations”) OR (MH “Developmental Disabilities”) OR (MH “Intellectual Disability”) OR (MH “Health Services for Persons with Disabilities”) OR (MH “Mental Disorders”) OR (MH “Support, Psychosocial”) OR (MH “Depression”) OR (MH “Bipolar Disorder”) OR (MH “Dementia”) OR (MH “Schizophrenia”) OR MH “substance use disorders” OR TI “mental health” or TI “mental healthcare” or TI “mental illness” or TI “mental disorder” or TI “mental disorders” or TI “disabled” or TI “disability” or TI “disabilities” or TI “neurologic disorder” or TI “depression” or TI “depressive” or TI “depressed” or TI “PTSD” or TI “psychosis” or TI “psychoses” or TI “psychotic” or TI “Schizophrenia” or TI “bipolar” or TI “epilepsy” or TI “seizures” or TI “Developmental Disabilities” or TI “Learning Disorders” or TI “autism” or TI “autistic” or TI “dementia” or TI “substance abuse” or TI “overuse” or TI “substance dependence” or TI “drug dependency” or TI “harmful use” or TI “hazardous use” or TI “suicide” or TI “self-harm” or TI “mental retardation” or TI “neurotic” or TI “Alcoholism” or TI “alcoholic” or TI “psychotropic” or TI “anxiolytics” or TI “depressant” or TI “epileptic” or TI “mood stabilizers” or TI “psychosocial support” or TI “psychology” or TI “psychological” or TI “psychotherapy” or TI “rehabilitation” or TI “stigma” or TI “support group” or TI “cognitive therapy” OR TI “reality therapy” OR TI “behavior therapy” or TI “behaviour therapy” or TI “self-help group” OR AB “mental health” or AB “mental healthcare” or AB “mental illness” or AB “mental disorder” or AB “mental disorders” or AB “disabled” or AB “disability” or AB “disabilities” or AB “neurologic disorder” or AB “depression” or AB “depressive” or AB “depressed” or AB “PTSD” or AB “psychosis” or AB “psychoses” or AB “psychotic” or AB “Schizophrenia” or AB “bipolar” or AB “epilepsy” or AB “seizures” or AB “Developmental Disabilities” or AB “Learning Disorders” or AB “autism” or AB “autistic” or AB “dementia” or AB “substance abuse” or AB “overuse” or AB “substance dependence” or AB “drug dependency” or AB “harmful use” or AB “hazardous use” or AB “suicide” or AB “self-harm” or AB “mental retardation” or AB “neurotic” or AB “Alcoholism” or AB “alcoholic” or AB “psychotropic” or AB “anxiolytics” or AB “depressant” or AB “epileptic” or AB “mood stabilizers” or AB “psychosocial support” or AB “psychology” or AB “psychological” or AB “psychotherapy” or AB “rehabilitation” or AB “stigma” or AB “support group” or AB “cognitive therapy” OR AB “reality therapy” OR AB “behavior therapy” or AB “behaviour therapy” or AB “self-help group”
Concept 2. Community health workers
(MH “Community Health Workers”) OR (MH “Rural Health Personnel”) OR MH “Allied Health Personnel” (MH “Community Health Services”) OR TI “health extension worker” or TI “health extension workers” or TI “community health worker” or TI “community health workers” or TI “community health aide” or TI “home health aide” or TI “community health representative” or TI “community health representatives” or TI “community networks” or TI “peer group” or TI “lay volunteer” or TI “lay worker” or TI “lay health worker” or TI “lay health workers” or TI “lay health advisor” or TI “lay health advisors” or TI “barefoot doctor” or TI “barefoot doctors” or TI “peer to peer” or TI “community based practitioner” or TI “community based practitioners” or TI “community-based practitioner” or TI “community-based practitioners” or TI “Accredited social health activist” or TI “Accredited social health activists” or TI “village health worker” or TI “village health workers” or TI “village health guide” or TI “village health guides” or TI “village health support guide” or TI “village health support guides” or TI “health auxiliary worker” or TI “health auxiliary workers” or TI “front-line health worker” or TI “front-line health workers” or TI “Shasthyo Sebikas” or TI “Community Outreach Worker” or TI “Community Outreach Workers” or TI “Peer Counsellor” or TI “Peer Counsellors” or TI “Peer Counselour” or TI “Peer Counselours” or TI Promotora or TI “peer educator” or TI “peer educators” OR TI “non-physician healthcare worker” OR TI “non-physician healthcare workers” or TI “task-shifting” or TI “task shifting” or TI “task-sharing” OR AB “health extension worker” or AB “health extension workers” or AB “community health worker” or AB “community health workers” or AB “community health aide” or AB “home health aide” or AB “community health representative” or AB “community health representatives” or AB “community networks” or AB “peer group” or AB “lay volunteer” or AB “lay worker” or AB “lay health worker” or AB “lay health workers” or AB “lay health advisor” or AB “lay health advisors” or AB “barefoot doctor” or AB “barefoot doctors” or AB “peer to peer” or AB “community based practitioner” or AB “community based practitioners” or AB “community-based practitioner” or AB “community-based practitioners” or AB “Accredited social health activist” or AB “Accredited social health activists” or AB “village health worker” or AB “village health workers” or AB “village health guide” or AB “village health guides” or AB “village health support guide” or AB “village health support guides” or AB “health auxiliary worker” or AB “health auxiliary workers” or AB “front-line health worker” or AB “front-line health workers” or AB “Shasthyo Sebikas” or AB “Community Outreach Worker” or AB “Community Outreach Workers” or AB “Peer Counsellor” or AB “Peer Counsellors” or AB “Peer Counselor” or AB “Peer Counselors” or AB “Peer Counselour” or AB “Peer Counselours” or AB Promotora or AB “peer educator” or AB “peer educators” OR AB “non-physician healthcare worker” OR AB “non-physician healthcare workers” or AB “task-shifting” or AB “task shifting” or AB “task-sharing”
Concept 3. LMICs
(MH “Developing Countries”) OR (MH “Africa, Central”) OR (MH “Africa, Northern”) OR (MH “Africa, Western”) OR (MH “Africa, Eastern”) OR (MH “Africa, Southern”) OR Africa OR Afghanistan OR Albania OR Algeria OR Angola OR Antigua OR Barbuda OR Argentina OR Armenia OR Armenian OR Aruba OR Azerbaijan OR Bahrain OR Bangladesh OR Barbados OR Benin OR Byelarus OR Byelorussian OR Belarus OR Belorussian OR Belorussia OR Belize OR Bhutan OR Bolivia OR Bosnia OR Herzegovina OR Hercegovina OR Botswana OR Brazil OR Bulgaria OR “Burkina Faso” OR “Burkina Fasso” OR “Upper Volta” OR Burundi OR Urundi OR Cambodia OR “Khmer Republic” OR Kampuchea OR Cameroon OR Cameroons OR Cameron OR Camerons OR “Cape Verde” OR “Central African Republic” OR Chad OR Chile OR China OR Colombia OR Comoros OR “Comoro Islands” OR Comores OR Mayotte OR Congo OR Zaire OR “Costa Rica” OR “Cote d'Ivoire” OR “Ivory Coast” OR Croatia OR Cuba OR Cyprus OR Czechoslovakia OR “Czech Republic” OR Slovakia OR “Slovak Republic” OR Djibouti OR “French Somaliland” OR Dominica OR “Dominican Republic” OR “East Timor” OR “East Timur” OR “Timor Leste” OR Ecuador OR Egypt OR “United Arab Republic” OR “El Salvador” OR Eritrea OR Estonia OR Ethiopia OR Fiji OR Gabon OR “Gabonese Republic” OR Gambia OR Gaza OR “Georgia Republic” OR “Georgian Republic” OR Ghana OR “Gold Coast” OR Greece OR Grenada OR Guatemala OR Guinea OR Guam OR Guiana OR Guyana OR Haiti OR Honduras OR Hungary OR India OR Maldives OR Indonesia OR Iran OR Iraq OR Jamaica OR Jordan OR Kazakhstan OR Kazakh OR Kenya OR Kiribati OR Korea OR Kosovo OR Kyrgyzstan OR Kirghizia OR Kyrgyz OR Kirghiz OR Kirgizstan OR “Lao PDR” OR Laos OR Latvia OR Lebanon OR Lesotho OR Basutoland OR Liberia OR Libya OR Lithuania OR Macedonia OR Madagascar OR Malagasy OR Malaysia OR Malaya OR Malay OR Sabah OR Sarawak OR Malawi OR Nyasaland OR Mali OR Malta OR “Marshall Islands” OR Mauritania OR Mauritius OR “Agalega Islands” OR Mexico OR Micronesia OR “Middle East” OR Moldova OR Moldovia OR Moldovian OR Mongolia OR Montenegro OR Morocco OR Ifni OR Mozambique OR Myanmar OR Myanma OR Burma OR Namibia OR Nepal OR “Netherlands Antilles” OR “New Caledonia” OR Nicaragua OR Niger OR Nigeria OR “Mariana Islands” OR Oman OR Muscat OR Pakistan OR Palau OR Palestine OR Panama OR Paraguay OR Peru OR Philippines OR Philipines OR Phillipines OR Phillippines OR Poland OR Portugal OR “Puerto Rico” OR Romania OR Rumania OR Roumania OR Russia OR Russian OR Rwanda OR Ruanda OR “Saint Kitts” OR “St Kitts” OR Nevis OR “Saint Lucia” OR “St Lucia” OR “Saint Vincent” OR “St Vincent” OR Grenadines OR Samoa OR “Samoan Islands” OR “Navigator Island” OR “Navigator Islands” OR “Sao Tome” OR “Saudi Arabia” OR Senegal OR Serbia OR Montenegro OR Seychelles OR “Sierra Leone” OR Slovenia OR “Sri Lanka” OR Ceylon OR “Solomon Islands” OR Somalia OR Sudan OR Suriname OR Surinam OR Swaziland OR Syria OR Tajikistan OR Tadzhikistan OR Tadjikistan OR Tadzhik OR Tanzania OR Thailand OR Togo OR Togolese OR Tonga OR Trinidad OR Tobago OR Tunisia OR Turkey OR Turkmenistan OR Turkmen OR Uganda OR Ukraine OR Uruguay OR USSR OR “Soviet Union” OR “Union of Soviet Socialist Republics” OR Uzbekistan OR Uzbek OR Vanuatu OR “New Hebrides” OR Venezuela OR Vietnam OR “Viet Nam” OR “West Bank” OR Yemen OR Yugoslavia OR Zambia OR Zimbabwe OR Rhodesia OR TI “low- and middle- income” OR TI “low income” OR TI “low resource” OR AB “low resource” OR AB “low income” OR AB “low- and middle- income”
Cochrane Library
Concept 1. Mental Health
[mh “Depression”] or [mh “Bipolar disorder”] or [mh “Depressive disorder”] or [mh “mental health”] or [mh “community mental health services”] or [mh “mental health services”] or [mh “psychiatric rehabilitation”] or [mh “psychiatric nursing”] or [mh “mental disorders”] or [mh “dementia”] or [mh “schizophrenia”] or [mh “developmental disabilities”] or “mental health”:ti,ab,kw or “mental healthcare”:ti,ab,kw or “mental illness”:ti,ab,kw or “mental disorder”:ti,ab,kw or “mental disorders”:ti,ab,kw or “disabled”:ti,ab,kw or “disability”:ti,ab,kw or “disabilities”:ti,ab,kw OR “neurologic disorder”:ti,ab,kw or “depression”:ti,ab,kw or “depressive” :ti,ab,kw or “depressed”:ti,ab,kw or “PTSD”:ti,ab,kw or “psychosis”:ti,ab,kw or “psychoses”:ti,ab,kw or “psychotic”:ti,ab,kw or “schizophrenia”:ti,ab,kw or “bipolar”:ti,ab,kw or “epilepsy”:ti,ab,kw or “seizures”:ti,ab,kw or “autism” :ti,ab,kw or “autistic” :ti,ab,kw or “dementia”:ti,ab,kw or “substance abuse”:ti,ab,kw or “drug abuse”:ti,ab,kw or “overuse”:ti,ab,kw or “substance dependence”:ti,ab,kw or “drug dependence”:ti,ab,kw or “harmful use”:ti,ab,kw or “hazardous use”:ti,ab,kw or “suicide”:ti,ab,kw or “self-harm”:ti,ab,kw or “mental retardation”:ti,ab,kw or “neurotic”:ti,ab,kw or “psychotropic” :ti,ab,kw or “anxiolytics”:ti,ab,kw or “depressant”:ti,ab,kw or “epileptic”:ti,ab,kw or “mood stabilizers”:ti,ab,kw or “psychosocial support”:ti,ab,kw or “psychology”:ti,ab,kw or “psychological”:ti,ab,kw or “psychotherapy”:ti,ab,kw or “rehabilitation”:ti,ab,kw or “stigma”:ti,ab,kw or “support group”:ti,ab,kw or “cognitive therapy”:ti,ab,kw OR “reality therapy”:ti,ab,kw OR “behavior therapy”:ti,ab,kw OR “behaviour therapy”:ti,ab,kw or “self-help group”:ti,ab,kw or “alcoholism”:ti,ab,kw or “alcoholic”:ti,ab,kw
Concept 2. Community health workers
[mh “community health workers”] or [mh “allied health personnel”] or “health extension worker”:ti,ab,kw or “health extension workers”:ti,ab,kw or “community health worker”:ti,ab,kw or “community health workers”:ti,ab,kw or “community health aide”:ti,ab,kw or “home health aide”:ti,ab,kw or “community health representative”:ti,ab,kw or “community health representatives”:ti,ab,kw or “community networks”:ti,ab,kw or “peer group”:ti,ab,kw or “lay volunteer”:ti,ab,kw or “lay worker”:ti,ab,kw or “lay health worker”:ti,ab,kw or “lay health workers”:ti,ab,kw or “lay health advisor”:ti,ab,kw or “lay health advisors”:ti,ab,kw or “barefoot doctor”:ti,ab,kw or “barefoot doctors”:ti,ab,kw or “peer to peer”:ti,ab,kw or “community based practitioner”:ti,ab,kw or “community based practitioners”:ti,ab,kw or “community-based practitioner”:ti,ab,kw or “community-based practitioners”:ti,ab,kw or “Accredited social health activist”:ti,ab,kw or “Accredited social health activists”:ti,ab,kw or “village health worker”:ti,ab,kw or “village health workers”:ti,ab,kw or “village health guide”:ti,ab,kw or “village health guides”:ti,ab,kw or “village health support guide”:ti,ab,kw or “village health support guides”:ti,ab,kw or “health auxiliary worker”:ti,ab,kw or “health auxiliary workers”:ti,ab,kw or “front-line health worker”:ti,ab,kw or “front-line health workers”:ti,ab,kw or “Shasthyo Sebikas”:ti,ab,kw or “Community Outreach Worker”:ti,ab,kw or “Community Outreach Workers”:ti,ab,kw or “Peer counsellor”:ti,ab,kw or “Peer counsellors”:ti,ab,kw or “Peer counselor”:ti,ab,kw or “Peer counselors”:ti,ab,kw or “Peer Counselour”:ti,ab,kw or “Peer Counselours”:ti,ab,kw or Promotora:ti,ab,kw or “peer educator”:ti,ab,kw or “peer educators”:ti,ab,kw OR “non-physician healthcare worker”:ti,ab,kw OR “non-physician healthcare workers”:ti,ab,kw or “task-shifting”:ti,ab,kw or “task shifting”:ti,ab,kw or “task-sharing”:ti,ab,kw
Concept 3. LMICs
[mh “Developing Countries”] OR [mh “Africa, Central”] OR [mh “Africa, Northern”] OR [mh “Africa, Western”] OR [mh “Africa, Eastern”] OR [mh “Africa, Southern”] OR Africa OR Afghanistan OR Albania OR Algeria OR Angola OR Antigua OR Barbuda OR Argentina OR Armenia OR Armenian OR Aruba OR Azerbaijan OR Bahrain OR Bangladesh OR Barbados OR Benin OR Byelarus OR Byelorussian OR Belarus OR Belorussian OR Belorussia OR Belize OR Bhutan OR Bolivia OR Bosnia OR Herzegovina OR Hercegovina OR Botswana OR Brazil OR Bulgaria OR “Burkina Faso” OR “Burkina Fasso” OR “Upper Volta” OR Burundi OR Urundi OR Cambodia OR “Khmer Republic” OR Kampuchea OR Cameroon OR Cameroons OR Cameron OR Camerons OR “Cape Verde” OR “Central African Republic” OR Chad OR Chile OR China OR Colombia OR Comoros OR “Comoro Islands” OR Comores OR Mayotte OR Congo OR Zaire OR “Costa Rica” OR “Cote d'Ivoire” OR “Ivory Coast” OR Croatia OR Cuba OR Cyprus OR Czechoslovakia OR “Czech Republic” OR Slovakia OR “Slovak Republic” OR Djibouti OR “French Somaliland” OR Dominica OR “Dominican Republic” OR “East Timor” OR “East Timur” OR “Timor Leste” OR Ecuador OR Egypt OR “United Arab Republic” OR “El Salvador” OR Eritrea OR Estonia OR Ethiopia OR Fiji OR Gabon OR “Gabonese Republic” OR Gambia OR Gaza OR “Georgia Republic” OR “Georgian Republic” OR Ghana OR “Gold Coast” OR Greece OR Grenada OR Guatemala OR Guinea OR Guam OR Guiana OR Guyana OR Haiti OR Honduras OR Hungary OR India OR Maldives OR Indonesia OR Iran OR Iraq OR Jamaica OR Jordan OR Kazakhstan OR Kazakh OR Kenya OR Kiribati OR Korea OR Kosovo OR Kyrgyzstan OR Kirghizia OR Kyrgyz OR Kirghiz OR Kirgizstan OR “Lao PDR” OR Laos OR Latvia OR Lebanon OR Lesotho OR Basutoland OR Liberia OR Libya OR Lithuania OR Macedonia OR Madagascar OR Malagasy OR Malaysia OR Malaya OR Malay OR Sabah OR Sarawak OR Malawi OR Nyasaland OR Mali OR Malta OR “Marshall Islands” OR Mauritania OR Mauritius OR “Agalega Islands” OR Mexico OR Micronesia OR “Middle East” OR Moldova OR Moldovia OR Moldovian OR Mongolia OR Montenegro OR Morocco OR Ifni OR Mozambique OR Myanmar OR Myanma OR Burma OR Namibia OR Nepal OR “Netherlands Antilles” OR “New Caledonia” OR Nicaragua OR Niger OR Nigeria OR “Mariana Islands” OR Oman OR Muscat OR Pakistan OR Palau OR Palestine OR Panama OR Paraguay OR Peru OR Philippines OR Philipines OR Phillipines OR Phillippines OR Poland OR Portugal OR “Puerto Rico” OR Romania OR Rumania OR Roumania OR Russia OR Russian OR Rwanda OR Ruanda OR “Saint Kitts” OR “St Kitts” OR Nevis OR “Saint Lucia” OR “St Lucia” OR “Saint Vincent” OR “St Vincent” OR Grenadines OR Samoa OR “Samoan Islands” OR “Navigator Island” OR “Navigator Islands” OR “Sao Tome” OR “Saudi Arabia” OR Senegal OR Serbia OR Montenegro OR Seychelles OR “Sierra Leone” OR Slovenia OR “Sri Lanka” OR Ceylon OR “Solomon Islands” OR Somalia OR Sudan OR Suriname OR Surinam OR Swaziland OR Syria OR Tajikistan OR Tadzhikistan OR Tadjikistan OR Tadzhik OR Tanzania OR Thailand OR Togo OR Togolese OR Tonga OR Trinidad OR Tobago OR Tunisia OR Turkey OR Turkmenistan OR Turkmen OR Uganda OR Ukraine OR Uruguay OR USSR OR “Soviet Union” OR “Union of Soviet Socialist Republics” OR Uzbekistan OR Uzbek OR Vanuatu OR “New Hebrides” OR Venezuela OR Vietnam OR “Viet Nam” OR “West Bank” OR Yemen OR Yugoslavia OR Zambia OR Zimbabwe OR Rhodesia OR “low- and middle- income”:ti,ab,kw OR “low income”:ti,ab,kw OR “low resource”:ti,ab,kw
Pubmed
Concept 1. Mental Health
(“Mental Health”[Mesh] or “mental health”[tiab]or “mental healthcare”[tiab] or “Mental Disorders”[Mesh] or “mental illness”[tiab] or “mental disorder”[tiab] or “mental disorders”[tiab] or “disabled”[tiab] or “disability”[tiab] or “disabilities”[tiab] or “Disabled Children”[Mesh] or “Disabled Persons”[Mesh] or “Mentally Disabled Persons”[Mesh] or “neurologic disorder”[tiab] or “Depression”[Mesh] or “depression”[tiab] or “Depressive Disorder”[Mesh] or “depressive”[tiab] or “depressed”[tiab] or “Stress Disorder, Post-Traumatic”[Mesh] or “PTSD”[tiab] or “Psychotic Disorder”[Mesh] or “psychosis”[tiab] or “psychoses”[tiab] or “psychotic”[tiab] or “Schizophrenia”[Mesh] or “schizophrenia”[tiab] or “Bipolar Disorder”[Mesh] or “bipolar”[tiab] or “Epilepsy”[Mesh] or “epilepsy”[tiab] or “Seizures”[Mesh] or “seizures”[tiab] or “Developmental Disabilities”[Mesh] or “Learning Disorders”[Mesh] or “Intellectual Disability”[Mesh] or “Autistic disorder” [Mesh] or “autism” [tiab] or “autistic” [tiab] or “Dementia”[Mesh] or “dementia”[tiab] or “Substance-Related Disorders”[Mesh] or “Substance Abuse, Intravenous”[Mesh] or “Marijuana Abuse”[Mesh] or “Cocaine-Related Disorders”[Mesh] or “Amphetamine-Related Disorders”[Mesh] or “substance abuse”[tiab] or “drug abuse”[tiab] or “overuse”[tiab] or “substance dependence”[tiab] or “drug dependence”[tiab] or “harmful use”[tiab] or “hazardous use”[tiab] or “Suicide”[Mesh] or “suicide”[tiab] or “self-harm”[tiab] or “mental retardation”[tiab] or “neurotic”[tiab] or “Alcoholism”[Mesh] or “Adjustment Disorders”[Mesh] OR “Affective Disorders, Psychotic”[Mesh] or “psychotropic” [tiab] or “anxiolytics”[tiab] or “depressant”[tiab] or “epileptic”[tiab] or “mood stabilizers”[tiab] or “psychosocial support”[tiab] or “psychology”[tiab] or “psychological”[tiab] or “psychotherapy”[tiab] or “rehabilitation”[tiab] or “stigma”[tiab] or “support group”[tiab] or “cognitive therapy”[tiab] OR “reality therapy”[tiab] OR “behavior therapy”[tiab] OR “behaviour therapy”[tiab] or “self-help group”[tiab] or “Self-Help Groups”[Mesh] or “Psychology”[Mesh] or “Psychotherapy”[Mesh] or “Counseling”[Mesh] or “Rehabilitation”[Mesh] or “Social Stigma”[Mesh] or “Resilience, Psychological”[Mesh] or “Discrimination (Psychology)”[Mesh]).
Concept 2. Community health workers
(“health extension worker”[tiab] or “health extension workers”[tiab] or “Community Health Workers”[Mesh] or “community health worker”[tiab] or “community health workers”[tiab] or “community health aide”[tiab] or “home health aide”[tiab] or “community health representative”[tiab] or “community health representatives”[tiab] or “community networks”[tiab] or “peer group”[tiab] or “lay volunteer”[tiab] or “lay worker”[tiab] or “lay health worker”[tiab] or “lay health workers”[tiab] or “lay health advisor”[tiab] or “lay health advisors”[tiab] or “barefoot doctor”[tiab] or “barefoot doctors”[tiab] or “peer to peer”[tiab] or “community based practitioner”[tiab] or “community based practitioners”[tiab] or “community-based practitioner”[tiab] or “community-based practitioners”[tiab] or “Accredited social health activist”[tiab] or “Accredited social health activists”[tiab] or “village health worker”[tiab] or “village health workers”[tiab] or “village health guide”[tiab] or “village health guides”[tiab] or “village health support guide”[tiab] or “village health support guides”[tiab] or “health auxiliary worker”[tiab] or “health auxiliary workers”[tiab] or “front-line health worker”[tiab] or “front-line health workers”[tiab] or “Shasthyo Sebikas”[tiab] or “Community Outreach Worker”[tiab] or “Community Outreach Workers”[tiab] or “Peer counsellor”[tiab] or “Peer counsellors”[tiab] or “Peer counselor”[tiab] or “Peer counselors”[tiab] or “Peer Counselour”[tiab] or “Peer Counselours”[tiab] or Promotora[tiab] or “peer educator”[tiab] or “peer educators”[tiab] OR “non-physician healthcare worker”[tiab] OR “non-physician healthcare workers”[tiab] or “task-shifting”[tiab] or “task shifting”[tiab] or “task-sharing”[tiab] or “lay counselor”[tiab] or “lay counselors”[tiab])
Concept 3. LMICs
(Africa[tw] OR Afghanistan [tw] OR Albania [tw] OR Algeria [tw] OR Angola [tw] OR Antigua [tw] OR Barbuda [tw] OR Argentina [tw] OR Armenia [tw] OR Armenian [tw] OR Aruba [tw] OR Azerbaijan [tw] OR Bahrain [tw] OR Bangladesh [tw] OR Barbados [tw] OR Benin [tw] OR Byelarus [tw] OR Byelorussian [tw] OR Belarus [tw] OR Belorussian [tw] OR Belorussia [tw] OR Belize [tw] OR Bhutan [tw] OR Bolivia [tw] OR Bosnia [tw] OR Herzegovina [tw] OR Hercegovina [tw] OR Botswana [tw] OR Brazil [tw] OR Bulgaria [tw] OR “Burkina Faso” [tw] OR “Burkina Fasso” [tw] OR “Upper Volta” [tw] OR Burundi [tw] OR Urundi [tw] OR Cambodia [tw] OR “Khmer Republic” [tw] OR Kampuchea [tw] OR Cameroon [tw] OR Cameroons [tw] OR Cameron [tw] OR Camerons [tw] OR “Cape Verde” [tw] OR “Central African Republic” [tw] OR Chad [tw] OR Chile [tw] OR China [tw] OR Colombia [tw] OR Comoros [tw] OR “Comoro Islands” [tw] OR Comores [tw] OR Mayotte [tw] OR Congo [tw] OR Zaire [tw] OR “Costa Rica” [tw] OR “Cote d'Ivoire” [tw] OR “Ivory Coast” [tw] OR Croatia [tw] OR Cuba [tw] OR Cyprus [tw] OR Czechoslovakia [tw] OR “Czech Republic” [tw] OR Slovakia [tw] OR “Slovak Republic” [tw] OR Djibouti [tw] OR “French Somaliland” [tw] OR Dominica [tw] OR “Dominican Republic” [tw] OR “East Timor” [tw] OR “East Timur” [tw] OR “Timor Leste” [tw] OR Ecuador [tw] OR Egypt [tw] OR “United Arab Republic” [tw] OR “El Salvador” [tw] OR Eritrea [tw] OR Estonia [tw] OR Ethiopia [tw] OR Fiji [tw] OR Gabon [tw] OR “Gabonese Republic” [tw] OR Gambia [tw] OR Gaza [tw] OR “Georgia Republic” [tw] OR “Georgian Republic” [tw] OR Ghana [tw] OR “Gold Coast” [tw] OR Greece [tw] OR Grenada [tw] OR Guatemala [tw] OR Guinea [tw] OR Guam [tw] OR Guiana [tw] OR Guyana [tw] OR Haiti [tw] OR Honduras [tw] OR Hungary [tw] OR India [tw] OR Maldives [tw] OR Indonesia [tw] OR Iran [tw] OR Iraq [tw] OR Jamaica [tw] OR Jordan [tw] OR Kazakhstan [tw] OR Kazakh [tw] OR Kenya [tw] OR Kiribati [tw] OR Korea [tw] OR Kosovo [tw] OR Kyrgyzstan [tw] OR Kirghizia [tw] OR Kyrgyz [tw] OR Kirghiz [tw] OR Kirgizstan [tw] OR “Lao PDR” [tw] OR Laos [tw] OR Latvia [tw] OR Lebanon [tw] OR Lesotho [tw] OR Basutoland [tw] OR Liberia [tw] OR Libya [tw] OR Lithuania [tw] OR Macedonia [tw] OR Madagascar [tw] OR Malagasy [tw] OR Malaysia [tw] OR Malaya [tw] OR Malay [tw] OR Sabah [tw] OR Sarawak [tw] OR Malawi [tw] OR Nyasaland [tw] OR Mali [tw] OR Malta [tw] OR “Marshall Islands” [tw] OR Mauritania [tw] OR Mauritius [tw] OR “Agalega Islands” [tw] OR Mexico [tw] OR Micronesia [tw] OR “Middle East” [tw] OR Moldova [tw] OR Moldovia [tw] OR Moldovian [tw] OR Mongolia [tw] OR Montenegro [tw] OR Morocco [tw] OR Ifni [tw] OR Mozambique [tw] OR Myanmar [tw] OR Myanma [tw] OR Burma [tw] OR Namibia [tw] OR Nepal [tw] OR “Netherlands Antilles” [tw] OR “New Caledonia” [tw] OR Nicaragua [tw] OR Niger [tw] OR Nigeria [tw] OR “Mariana Islands” [tw] OR Oman [tw] OR Muscat [tw] OR Pakistan [tw] OR Palau [tw] OR Palestine [tw] OR Panama [tw] OR Paraguay [tw] OR Peru [tw] OR Philippines [tw] OR Philipines [tw] OR Phillipines [tw] OR Phillippines [tw] OR Poland [tw] OR Portugal [tw] OR “Puerto Rico” [tw] OR Romania [tw] OR Rumania [tw] OR Roumania [tw] OR Russia [tw] OR Russian [tw] OR Rwanda [tw] OR Ruanda [tw] OR “Saint Kitts” [tw] OR “St Kitts” [tw] OR Nevis [tw] OR “Saint Lucia” [tw] OR “St Lucia” [tw] OR “Saint Vincent” [tw] OR “St Vincent” [tw] OR Grenadines [tw] OR Samoa [tw] OR “Samoan Islands” [tw] OR “Navigator Island” [tw] OR “Navigator Islands” [tw] OR “Sao Tome” [tw] OR “Saudi Arabia” [tw] OR Senegal [tw] OR Serbia [tw] OR Montenegro [tw] OR Seychelles [tw] OR “Sierra Leone” [tw] OR Slovenia [tw] OR “Sri Lanka” [tw] OR Ceylon [tw] OR “Solomon Islands” [tw] OR Somalia [tw] OR Sudan [tw] OR Suriname [tw] OR Surinam [tw] OR Swaziland [tw] OR Syria [tw] OR Tajikistan [tw] OR Tadzhikistan [tw] OR Tadjikistan [tw] OR Tadzhik [tw] OR Tanzania [tw] OR Thailand [tw] OR Togo [tw] OR Togolese [tw] OR Tonga [tw] OR Trinidad [tw] OR Tobago [tw] OR Tunisia [tw] OR Turkey [tw] OR Turkmenistan [tw] OR Turkmen [tw] OR Uganda [tw] OR Ukraine [tw] OR Uruguay [tw] OR USSR [tw] OR “Soviet Union” [tw] OR “Union of Soviet Socialist Republics” [tw] OR Uzbekistan [tw] OR Uzbek [tw] OR Vanuatu [tw] OR “New Hebrides” [tw] OR Venezuela [tw] OR Vietnam OR “Viet Nam” [tw] OR “West Bank” [tw] OR Yemen [tw] OR Yugoslavia [tw] OR Zambia [tw] OR Zimbabwe [tw] OR Rhodesia [tw] OR ((developing [TiAB] OR “less developed” [TiAB] OR “under developed” [TiAB] OR underdeveloped [TiAB] OR “middle income” [TiAB] OR “low income” [TiAB] OR “lower income” [TiAB] OR underserved [TiAB] OR “under served” [TiAB] OR deprived [TiAB] OR poor* [TiAB]) AND (countr* [TiAB] OR nation* [TiAB] OR population* [TiAB] OR world [TiAB])) OR ((transitional [TiAB] OR developing [TiAB] OR “less developed” [TiAB] OR “lesser developed” [TiAB] OR “under developed” [TiAB] OR underdeveloped [TiAB] OR middle income [TiAB] OR “lower income” [TiAB] OR “lower income” [TiAB]) AND (economy [TiAB] OR economies [TiAB])) OR “low resource”[tiab] OR “low-resource”[tiab])
Open access
