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Taskshifting: translating theory into practice to build a community based mental health care system in rural Haiti
... After the earthquake, mental health began to find a place on the Haitian government's agenda, and during the following year the Ministry of Health held meetings with key stakeholders to move towards a national mental health policy (Boyd et al., 2015). However, despite promising efforts, there continues to remain no well-defined mental health agenda to guide service provision (Boyd et al., 2015) and mental health received just 1% of the total budget for health in the country (IESM-OMS, 2011). ...
... After the earthquake, mental health began to find a place on the Haitian government's agenda, and during the following year the Ministry of Health held meetings with key stakeholders to move towards a national mental health policy (Boyd et al., 2015). However, despite promising efforts, there continues to remain no well-defined mental health agenda to guide service provision (Boyd et al., 2015) and mental health received just 1% of the total budget for health in the country (IESM-OMS, 2011). Currently, nearly three quarters of health services in rural Haiti are provided by NGOs, comprise mainly primary health care provisionwith no mental health servicesand are often staffed by foreign workers who do not speak the language or understand key cultural cues essential for mental health treatment in Haiti (Nicolas et al., 2012). ...
... Additionally, Haiti continues to retain the lowest rate of professional psychosocial support in the Caribbean and Latin America, and one of the lowest in the worlddespite the high rate of need in the wake of one of the world's deadliest natural disasters in recent memory (Nicolas et al., 2012). Approximately ten psychiatrists and nine psychiatric nurses work in the capital Port-au-Prince, removed from rural Haiti where more than 60% of the population lives, and the country's two public psychiatric hospitals, University Hospital Center of Psychiatry Mars and Kline and Beudetwith combined total of only 180 bedsare underfinanced, understaffed, and unable to provide high quality care (Boyd et al., 2015;IESM-OMS, 2011). While estimates vary, roughly 100-200 psychologists, 50-100 social workers, up to 30 psychiatric nurses, in addition to 20-30 psychiatrists and one neurologist are addressing the mental health needs of Haitians in the whole of Haiti whereas the neighbouring Dominican Republicwith the same population as Haitihas more than 2,000 mental health professionals, and Puerto Rico has about 5,000 psychologists and psychiatrists for fewer than 4 million inhabitants (IESM-OMS, 2011;Nicolas et al., 2012). ...
Low-income countries suffer from a large gap between the burden of mental illness and access to treatment. In the Americas, no country exemplifies this disparity as much as Haiti, where services outside the capital remain virtually nonexistent. Started in 2016, the Mental Health Center at Morne Pelé (SSMMP in Krèyol) was established as the first mental health treatment facility in all of northern Haiti. With more than 3,000 patients treated since opening, SSMMP’s goal is to bring community-centered, culturally relevant, and evidence-based mental health treatment to northern Haiti for the first time. As an exclusively Haitian-led initiative that receives no outside funding, SSMMP works to combat the reputation of Haiti as the “Republic of NGOs” in which international aid organisations provide most basic services. While significant challenges exist in scaling up mental health services in northern Haiti, SSMMP uses evidence-based strategies on mental health service expansion to reach all Haitians.
... Resource constraints in LMICs, including the dearth of mental health professionals, have prompted calls for innovative approaches to expand the provision of mental health services in community settings [11]. Particularly, task shifting is a strategy for shifting tasks from specialized workers to non-specialist or lay workers in low-resource settings [5,[12][13][14]. Scholars argue that in low-resource settings, substituting specialists with lowcost community health workers provides a solution to the mental health care gap in many nations [15]. ...
Background
Children and adolescents who live in resource-limited communities in sub-Saharan Africa (SSA) experience significant mental health problems, including behavioral problems. In SSA, one of the most significant impediments to expanding services is a scarcity of mental health specialists. Task-shifting can effectively solve the mental health care gap in low-resource settings, yet it is underutilized in child and adolescent mental health. Moreover, the experiences of lay providers are understudied in global mental health, despite their potential impact on intervention effectiveness. In this study, we examined the experiences of community health workers and parent peers with the task-shifting of an evidence-based family strengthening intervention in Uganda.
Methods
As part of a larger randomized clinical trial, semi-structured in-depth interviews were conducted with 24 facilitators selected using stratified purposive sampling. Interviews explored their decision to participate in the program; experiences with the training; and experiences with intervention delivery. All interviews were conducted in Luganda (local language) and audio recorded. They were transcribed verbatim and translated into English. Thematic analysis was used to analyze the data.
Results
Despite concerns around lack of previous experience and time commitment, facilitators reported high relevance of the intervention to the families in their communities as well as their own as a motivation to participate. They also identified financial incentives as a motivating factor. These two factors also ensured their attendance at the training. They were satisfied with the content and skills provided during the training and felt prepared to deliver the intervention. During intervention delivery, they enjoyed seeing the families engaged and participating actively in the sessions as well as observing positive changes in the families. Some challenges with family attendance and engagement were noted. The facilitators reported an increased sense of self-efficacy and competence over time; and expressed high satisfaction with supervision.
Conclusion
Facilitators’ positive experiences point to the high acceptability and appropriateness of task-shifting this intervention in low-resource settings. As the global mental health field continues to be interested in task-shifting interventions to lay providers, successful examples should be studied so that evidence-based models can be put in place to support them through the process.
... The Shona Symptom Questionnaire in Zimbabwe was able to identify pregnant women at high risk for post-partum psychiatric disorders and was more recently used as the primary outcome measure in the high-profile RCT of the Friendship Bench psychological intervention (Chibanda et al., 2016;Patel et al., 1997;Stranix-Chibanda et al., 2005). The Zanmi Lasante Depression Symptom Inventory is routinely used by practitioners to identify and measure mental distress at Zanmi Lasante clinics in Haiti (Legha et al., 2015;Rasmussen et al., 2015). ...
Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach’s alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that “brain hot” and “heart fall down” were the most difficult idioms of distress to endorse while “things playing on the mind” was the easiest. All LDS-11 elements were associated with elevated function impairment, with “things playing on the mind,” “worry too much,” “head is hurting,” and “heart cut/beat fast” achieving statistical significance. One item in the PHQ-9L demonstrated poor model fit and was excluded from psychometric analyses. The resultant eight-item PHQ demonstrated internal consistency (α = 0.76) and Rasch analysis revealed that “moving/talking too slowly/fast” was the most difficult item to endorse, while “not happy when doing things” was the easiest. Twelve items were significantly associated with functional impairment. Exploratory analyses reveal items that demonstrate ease and appropriateness of use for assessing mental distress in this population. Implementation research is needed to incorporate idioms of distress and screeners into Liberia’s mental healthcare system.
... In recent years, researchers and implementers have made considerable progress developing and testing evidence-based interventions to detect and treat mental health conditions in low-and middle-income settings, particularly in the care of common mental disorders such as depression (Singla et al., 2017). This has included approaches such as 'task-sharing' of care by non-specialists through the mobilization of peers and community health workers (CHWs), as well as adaptation of evidencebased psychotherapies such as cognitive-behavioral therapy and interpersonal therapy for delivery in low-resource settings (Legha et al., 2015;Verdeli et al., 2016;Hoeft et al., 2018). Despite the generation of rich evidence on clinically effective task-shared interventions for common mental disorders in low-and middle-income settings in recent years, the actual implementation and evaluation of such services in routine care in low-resource health systems remains limited. ...
Background
There is a growing literature in support of the effectiveness of task-shared mental health interventions in resource-limited settings globally. However, despite evidence that effect sizes are greater in research studies than actual care, the literature is sparse on the impact of such interventions as delivered in routine care. In this paper, we examine the clinical outcomes of routine depression care in a task-shared mental health system established in rural Haiti by the international health care organization Partners In Health, in collaboration with the Haitian Ministry of Health, following the 2010 earthquake.
Methods
For patients seeking depression care betw|een January 2016 and December 2019, we conducted mixed-effects longitudinal regression to quantify the effect of depression visit dose on symptoms, incorporating interaction effects to examine the relationship between baseline severity and dose.
Results
306 patients attended 2052 visits. Each visit was associated with an average reduction of 1.11 in depression score (range 0–39), controlling for sex, age, and days in treatment (95% CI −1.478 to −0.91; p < 0.001). Patients with more severe symptoms experienced greater improvement as a function of visits ( p = 0.04). Psychotherapy was provided less frequently and medication more often than expected for patients with moderate symptoms.
Conclusions
Our findings support the potential positive impact of scaling up routine mental health services in low- and middle-income countries, despite greater than expected variability in service provision, as well as the importance of understanding potential barriers and facilitators to care as they occur in resource-limited settings.
... For example, the organization's Partner in Health and Zanmi Lasante, in collaboration with the Haitian government, developed a comprehensive community mental health intervention after the 2010 earthquake offering mental health services in underserved and rural communities (Raviola et al., 2020). Another study developed a community based medical care system, which provided medical and mental health treatments for people suffering mental health problems with lack of access to care (Rupinder et al., 2015). However, interventions targeting women living with HIV who experienced sexual trauma have not been developed. ...
Childhood abuse has been linked to problematic drinking in adulthood. It is also documented that people living with HIV have higher rates of alcohol use than the general population. In Haiti, a total of 25% of women living with HIV have experienced childhood sexual abuse (CSA), which puts them at an increased risk for alcohol abuse. CSA has also been associated with anxiety disorders in adulthood. Therefore, it is critical to understand the relationship between CSA, anxiety, and alcohol use among women living with HIV. A total of 244 women living with HIV participated in this study, with 35% reporting CSA. Alcohol abuse was measured with the AUDIT, anxiety with the State-Trait Anxiety Inventory test, and sexual abuse with the Childhood Trauma Questionnaire. Compared to participants who did not experience childhood sexual abuse, participants who experienced childhood sexual abuse reported greater levels of alcohol use [(17.0, SD = 9.1) (11.9, SD = 8.6) p =.001] and anxiety [(55.8, SD = 9.8) (48.9 SD = 8.3) p =.001] respectively. The indirect effect of anxiety on the association between CSA and alcohol use was significant [(ß =.19 p =.05) 95% bootstrap CI.019 –.13] Thus, women who reported being sexually abused as children reported anxiety, which in turn, was associated with an increased risk for alcohol abuse. Results demonstrate that alcohol may be used as a negative coping mechanism to alleviate anxiety symptoms triggered by CSA. These findings elucidate the need for further research examining the impact that sexual trauma has on mental health.
... While recently "en vogue" in the field of Global Mental Health (GMH), task shifting is the process of training primary care and community health workers to assume health care responsibilities traditionally reserved for specialists (Boyd et al., 2015). GMH advocates argue that replacing specialists with low cost community health workers in low resource environments provides a solution to the mental health treatment gap in many countries (Kohrt & Mendenhall, 2016). ...
Despite an increasing demand for mental health services in sub-Saharan Africa, few professionals are available to meet these needs. In the last few decades, task shifting using non-specialist workers has been increasingly employed to deliver physical and mental health treatment services. While evidence suggests task shifting is effective for mental health service provision, few studies have examined the literature in sub-Saharan Africa. This systematic review includes 14 intervention studies utilizing task shifting for mental health interventions in sub-Saharan Africa. Researchers conducted a rigorous systematic search using four databases: Academic Search Complete, MEDLINE, Global Health, and PsychINFO. In addition to PRISMA guidelines, this review also developed a Methodological Quality Rating Scale and an Outcome Attainment Index to analyze the data. Our systematic search generated 2,071 articles with 14 included in the review. Methodological rigor scores ranged from 7 to 12 on a 12-point scale (mean = 9.9, median = 10), with nearly half of studies (43%) not using a control group in their intervention study. Individual interventions were found to have slightly higher rigor compared with group interventions, while multisite interventions were found to have significantly higher rigor compared with single site studies. Initial evidence suggests that task shifting interventions are a valuable tool for implementing mental health services in settings with limited professionals. However, current studies are faced with methodological challenges, particularly by lacking comparison groups and detailed fidelity guidelines. Additionally, studies can be strengthened by including multiple sites in the intervention and ensuring appropriate cultural adaptation of services.
... psychotic illness) and common (i.e. depression, anxiety, and stress-related conditions) mental disorders, as well as untreated epilepsy, the collaborative team focused increasingly on establishing the operational, human resource, and content building blocks needed to actualize the 5 × 5 framework, and extend commitments made to develop a functional, model mental health system Legha et al., 2015;Fils-Aime et al., 2018). In 2012 this led to the development of a Theory of Change (ToC), building on the principles embodied in the 5 × 5 framework (Fig. 1). ...
Between 2010 and 2019 the international health care organization Partners In Health (PIH) and its sister organization Zanmi Lasante (ZL) mounted a long-term response to the 2010 Haiti earthquake, focused on mental health. Over that time, implementing a Theory of Change developed in 2012, the organization successfully developed a comprehensive, sustained community mental health system in Haiti's Central Plateau and Artibonite departments, directly serving a catchment area of 1.5 million people through multiple diagnosis-specific care pathways. The resulting ZL mental health system delivered 28 184 patient visits and served 6305 discrete patients at ZL facilities between January 2016 and September 2019. The experience of developing a system of mental health services in Haiti that currently provides ongoing care to thousands of people serves as a case study in major challenges involved in global mental health delivery. The essential components of the effort to develop and sustain this community mental health system are summarized.
... To broaden access to mental health support and address many of the aforementioned logistical and stigma-related barriers to mental health care, C2C implements a model of service delivery known as "task shifting" or "task sharing." 2 In the context of mental health, task shifting is a way of expanding the mental health workforce by training lay staff to deliver basic mental health screening and evidence-informed psychosocial intervention strategies (Chibanda et al., 2011;Govindarajan and Ramamurti, 2018;Huang et al., 2014;Legha et al., 2015). Under this model, mental health specialists (e.g., psychiatrists, psychologists, social workers) provide training, supervision, and fidelity monitoring for nonspecialists (e.g., community outreach and early childhood workers, teachers, employment specialists, shelter staff) over the course of the intervention. ...
... All counsellors require oversight and supervision of their work by certi¢ed and credentialed professionals. However, carefully selected and trained IDPs o¡er the advantage of their ¢rst-hand understanding of the forced migration experience useful for creating rapport.This 'task-shifting' approach has proven to be highly e¡ective for applications of evidence based therapies for a variety of con£ict exposed populations worldwide (Legha et al., 2015). ...
The signing of the truce on 23 June 2016 and the finalisation of peace negotiations on 24 August 2016 marked the end of more than 50 years of continuous armed conflict in Colombia, South America and the transition to 'post conflict' status. According to annual reports from the Internal Displacement Monitoring Centre based in Geneva, Switzerland, Colombia has ranked first or second in numbers of internally displaced persons every year for the past 12 years, making forced migration a defining characteristic of the country. This is based on the personal reflections of a mother and daughter (ER and AdPGR) who were displaced from rural Colombia and resettled in the nation's urban capital of Bogota. They survived the rigors and hardships of displacement and became capable counsellors on a global mental health project, bringing evidence based interventions to a highly traumatised population of internally displaced women in Bogota. Their account speaks to the lived experiences of more than six million Colombian internally displaced 'victims of the armed conflict'. Particularly notable is the description of myriad trauma exposures prior to the moment of displacement. This field report demonstrates how personal accounts are a useful tool for educating clinicians working with these populations.
(C) 2016 War Trauma Foundation, Diemen, The Netherlands
Supervision of nonspecialist clinicians by trained mental health professionals is integral to developing capacity for providing mental health care in low-resource settings. Current supervision efforts in low-resource settings, however, are often variable in quality. Scant published literature addresses how supervision practices affect treatment outcomes; only a few studies have been published on evidence-based supervision methods. Additionally, in low-resource settings many systems-level obstacles exist in providing adequate mental health supervision to nonspecialist clinicians. This article seeks to address psychiatrists' role in providing supervision and promoting quality of care in low-resource settings. We review the literature on evidence-based supervision practices, address obstacles and current practices of providing high-quality mental health supervision in low-resource settings, and weave this knowledge with our experiences learning from the clinicians at Partners in Health in Haiti. We also discuss feasible strategies and provide recommendations for strengthening the supervision process in resource-limited settings.
Quantitative data serve key purposes in global mental health. They tell us who is in need of care, how well that care is working, and what risk and protective factors are associated with mental health outcomes. It is therefore vital to ensure that our quantitative data are collected in ethical ways. A key concern is how we decide what to measure. In particular, whose goals and priorities are we attempting to meet – funders, other researchers, or the individuals and communities we hope to serve through our interventions? Additionally, we must consider how our measures are designed. Simple translation of screening tools is often insufficient for capturing mental health needs and experiences in a new setting. Mixed-method approaches to cultural adaptation can ensure that our tools are comprehensible, acceptable, and relevant and that they reflect what matters most. Although screening tools should ideally be validated, there are trade-offs to consider in validation studies. Finally, it is vital that epidemiologic data only be collected if procedures are in place for referring individuals identified as in need of care. Drawing on case studies from Haiti and Nigeria, I demonstrate some of the complexities of ensuring ethical measurement procedures in global mental health.
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