Involving relevant stakeholders

After reviewing the literature^{Reference Broner, Franczak, Dye and McAllister3} on facilitating knowledge transfer, as well as the previous experiences of Emerald consortium members, it was decided that including the relevant implementation actors in Emerald's activities early on would facilitate the incorporation of our research results and recommendations into policy and practice in the participating LMICs. Thus, we focused on the involvement of policy planners, managers, patients and carers.

The Emerald consortium recognised that the project's future recommendations would need to be aligned with existing policy priorities and mental health programmes, whether local or national. Therefore, it was crucial to understand each partner country's mental health policy priorities, to maximise impact. We also knew that to ensure more effective knowledge transfer, we had to involve not only high-level officials, but also those who, at a lower level, actually implement mental health policies on the ground. This engagement started early in the project, with the involvement of policy planners as members of the local research teams that submitted the initial project proposal for funding. This engagement had various goals. First of all, to include their expertise and views in the initial project design. There were areas of work of particular relevance for the stakeholders, such as the activities around indicators on mental health within the health management information systems (HMIS). Their involvement facilitated the situation analysis carried out to highlight the strengths, challenges and opportunities for developing and strengthening ‘mental health components’ within routine government HMIS across the participating countries. A second goal of the involvement of policy planners was to keep them aware of the main issues addressed in the project concerning mental health systems strengthening. In addition, such involvement allows us to gather their input on the uptake feasibility of specific Emerald tools and recommendations, promotes awareness of research findings, and supports a collaborative working environment. Apart from the ongoing contact that these policy planners and managers had with the local research teams, during the annual project meetings – held at the different project sites around the world – the consortium invited policymakers to join a session with the international research group. These meetings took place in Kampala, Capetown, Kathmandu and a final one in London at the UK Parliament and they were found to be an excellent way to enhance the project's visibility at the local level, and to bolster institutional support for the work and initiatives of the local Emerald team.

Furthermore, for overall impact, we aimed to understand the global health policy environment, as well as to align our recommendations with it. By working in coordination with the relevant ministries and policymakers in all of the study countries, a sustainable impact could hopefully be made on the mental health infrastructure and systems of each country.

There is growing evidence that knowledge transfer from research into policies and patient care could be accelerated by involving patients and carers.^{Reference Thornicroft, Lempp and Tansella4} Evidence from settings in high-income countries supports the use of participatory research with patients and caregivers for studies relating to mental health interventions, services and systems, although there are limited examples from LMICs.^{Reference Lempp, Abayneh, Gurung, Kola, Abdulmalik and Evans-Lacko5–Reference Hann, Pearson, Campbell, Sesay and Eaton7} A priority across all the project phases was to establish links with existing patient groups in each of the partner countries. Most of these countries have well-established patient networks, which were involved not only as potential targets of the dissemination activities, but also as key participants in Emerald's research and capacity-building activities.

Generating evidence for local implementation of policies

The consortium's members shared the conviction that research-generated information obtained in local settings is crucial for informing recommendations to implement evidence-based mental health policies. The research activities designed, carried out and summarised in other papers in this thematic series provided new evidence to support the implementation of mental health policies and programmes in the six African and Asian LMICs involved in the Emerald programme. Using the information obtained in these countries, Emerald produced an evidence-based roadmap for decision-makers in LMICs to scale-up mental health services within the constraints of the broader health system. This has included identifying what human and budgetary resources are needed to meet local targets, health financing policy options, governance requirements and coverage/performance indicators.^{Reference Chisholm, Heslin, Docrat, Nanda, Shidhaye and Upadhaya8,Reference Jordans, Chisholm, Semrau, Gurung, Abdulmalik and Ahuja9}

Furthermore, the Emerald programme has mapped and articulated a pathway that can be used in the six countries' local health systems to integrate mental healthcare within existing services.^{Reference Abdulmalik, Kola and Gureje10–Reference Hanlon, Eshetu, Alemayehu, Fekadu, Semrau and Thornicroft16} It has also documented the impact of this integration on service inputs, processes and outputs.^{Reference Jordans, Chisholm, Semrau, Upadhaya, Abdulmalik and Ahuja17,Reference Upadhaya, Jordans, Pokhrel, Gurung, Adhikari and Petersen18} In doing so, Emerald has produced evidence-based strategies, and developed new tools and instruments – such as the OneHealth tool module on mental, neurological and substance use disorders, and a new set of indicators for routine monitoring of effective mental healthcare coverage–for the sustainable integration of mental health programmes into general health services, in the six partner countries and beyond.^{Reference Jordans, Chisholm, Semrau, Gurung, Abdulmalik and Ahuja9}

Capacity-building initiatives

Details of the wide range of capacity-building activities that were implemented by our multicountry research consortium and its evaluation are described elsewhere in this thematic series.^{Reference Evans-Lacko, Hanlon, Alem, Ayuso-Mateos, Chisholm and Gureje6} They specifically targeted patients and caregivers, service planners and researchers. These activities are also very effective knowledge transfer tools, both for those directly involved and for those who can later benefit from using the training materials. The shortage of technical know-how at the planning level has been previously identified as a major barrier to scaling-up mental health services in LMICs.^{Reference Thornicroft, Cooper, Bortel, Kakuma and Lund19} Emerald has addressed this by developing capacity-building activities within the sites involved, as well as teaching materials specifically targeting service planners. The materials were customised to meet different countries' specific needs and priorities.^{Reference Evans-Lacko, Hanlon, Alem, Ayuso-Mateos, Chisholm and Gureje6}

As mentioned, there is growing recognition of the advantages of partnerships with patients and caregivers for effective implementation of evidence-based mental health policies; it has been argued that they may offer one solution to the slow translation of research evidence into meaningful treatment and service development.^{Reference Semrau, Alem, Abdulmalik, Docrat, Evans-Lacko and Gureje20} Emerald has developed workshop materials for patients and caregivers to raise awareness and mobilise for greater advocacy and involvement, and also designed workshops for primary care workers and managers to support greater involvement of patients.^{Reference Lempp, Abayneh, Gurung, Kola, Abdulmalik and Evans-Lacko5,Reference Gurung, Upadhyaya, Magar, Giri, Hanlon and Jordans21,Reference Abayneh, Lempp, Alem, Alemayehu, Eshetu and Lund22} We implemented and evaluated a total of 24 short courses across the six Emerald countries. Our evaluation of them found that they led to improvements in knowledge across all the target groups and that the participants found it particularly useful to tailor the course to the country-specific context.

Mental health research is an essential component to support mental health system strengthening in LMICs, and a main driver for effective translation of evidence into policy and practice. A unique characteristic of the research capacity-building elements incorporated into Emerald is that they were intended to equip mental health researchers with general health service and system research skills that are also applicable to other health conditions. This approach maximised researchers' understanding of the overall public health context and the relevance of mental health in LMICs, fostering the implementation of mental health initiatives within the general health services of their countries and settings.

Targeted dissemination strategy

The literature on knowledge transfer recognises that academic papers are not necessarily the most effective method for disseminating research results, and emphasises the need for multiple dissemination strategies.^{Reference Thornicroft, Cooper, Bortel, Kakuma and Lund19} Bearing all of this in mind, the Emerald consortium formulated a strategy early in the project to disseminate its activities and results in a manner aligned with the overall project objectives. The specific objectives for the dissemination strategy can be summarised as follows: (a) raising awareness about the challenges and potential solutions provided by the project; (b) informing and educating the target audience appropriately about Emerald's aims and results; (c) engaging a significant number of representatives within the target audience groups to get input/feedback to address some of the project's research questions;^{Reference Jordans, Chisholm, Semrau, Upadhaya, Abdulmalik and Ahuja17,Reference Upadhaya, Jordans, Pokhrel, Gurung, Adhikari and Petersen18,Reference Gurung, Upadhyaya, Magar, Giri, Hanlon and Jordans21,Reference Upadhaya, Jordans, Gurung, Pokhrel, Adhikari and Komproe23} and (d) promoting the use of the project's findings and tools.

A dissemination plan was formulated as a basic structure and template to be used in all six partner countries where the Emerald project was to be implemented. This was a framework for designing the actions systematically, monitoring their progress and recording all the activities. Based on a consultation process within the consortium, the following key target groups were identified: patient groups, service providers, policymakers, the Ministries of Health and Ministries of Finance in the six partner countries, national and international development agencies, non-governmental organisation funders of health research in LMICs, researchers and the media (national and international). With the help of the local teams, we identified audiences for a given country, taking into account the local context in relation to mental healthcare delivery and policy priorities. A discussion within the consortium was carried out for further analysis of these target groups. Members of the consortium helped to prioritise the implementation of dissemination strategies, with the initial working assumption that if Emerald included all relevant actors from the beginning, this would facilitate knowledge transfer and the eventual implementation of the project's findings and recommendations.

Dissemination materials were developed, including a website, leaflets, posters, folders, newsletters, result summaries, publications, policy briefs, annual reports, videos, press releases, newsletters, direct mail and presentation materials to reach Emerald's target audiences and promote its objectives. To ensure clear branding, an Emerald logo was designed and used in all outputs and deliverables. Moreover, standard texts to introduce the programme were prepared for use in official communications with external agencies.

Different events, ranging from small workshops at the local level to presentations at large-scale conferences, were hosted by the Emerald consortium members and planned well in advance. These events were marketed widely, by distributing leaflets and using websites, email lists, social media channels and professional groups to spread the word.

The Emerald webpage was established within the first 6 months of the project (https://www.centreforglobalmentalhealth.org/emerald-emerging-mental-health-systems-in-low-and-middle-income-countries), and designed to include information for the public, patients, policymakers, clinical staff and practitioners, and research specialists. Updates on the Emerald partners' activities related to the project, such as publications and workshops, have been posted on the website and disseminated through social media channels. Links to all Emerald social media channels are included on the website header, along with a sign-in button to register for the Emerald newsletter and RSS newsfeeds provided by the European Commission.

Emerald has accounts on Facebook, Twitter, LinkedIn, Google Plus and YouTube. Dissemination activities have been conducted through all of these social media channels, including materials related to the Emerald project and initiatives linked to its objectives. Content was posted daily or weekly on social media profiles, as well as videos uploaded to the YouTube channel. The videos included interviews with junior and senior researchers of the consortium, as well as with policymakers, along with short stories describing the local sites where the studies were conducted. Of all the social media accounts created, Twitter was found to be the one with the most activity (over 2500 tweets posted) and followers. The messages that were best received and most retweeted were the ones related to links to the Emerald's videos and scientific papers.

Research findings were presented at scientific events for communities of researchers and mental health professionals. In addition to high-profile research conferences, we targeted broader multistakeholder assemblies, such as the Union World Conference on Lung Health. A resource list of the most relevant conferences was developed early in the project, and regularly updated and prioritised to optimise dissemination efforts. The consortium aimed to reach a heterogeneous audience in terms of geographical coverage and different stakeholders. Presentations in a total of 50 different congresses and workshops were given, covering audiences ranging from the World Psychiatric Association, the European Parliament, African Association of Psychiatrists and Allied Professions and the Global Mental Health Forum, to the congresses of local national associations such as the Ethiopian psychiatric association.

The consortium developed a publication protocol concerning any research stemming from Emerald. An internal review process for manuscripts was established early on, and included in the grant agreement and the consortium agreement. To date, 46 scientific papers have been published reporting Emerald-related results, and as many as 50 are in progress. They have covered all of the project's objectives, and report results collected in all the participating countries.

Scientific seminars were organised for key stakeholders, such as policymakers and funding agencies. Timely national and international policy briefs were released, both pre-planned and in response to policy windows, such as World Health Day and World Mental Health Day. In addition, workshops and public talks were organised to discuss the use of systems approaches in scaling-up mental health services and reducing the treatment gap for mental health disorders. Participants included health providers, policymakers, funding agencies and, most importantly, patients.