Participatory mental wellness interventions in low-income and center-income countries: a realist review protocol

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  1. Cheyann J Heap1,
  2. http://orcid.org/0000-0002-8580-0327Hannah Maria Jennings2,three,4,
  3. Kaaren Mathias5,six,
  4. Himal Gairevii,
  5. Farirai Gumbonzvandaeight,
  6. Nyaradzayi Gumbonzvandaix,
  7. Garima Gupta6,
  8. Sumeet Jain10,
  9. Bidya Maharjan11,
  10. Rakchhya Maharjaneleven,
  11. Sujen Man Maharjan11,
  12. Pashupati Mahat12,
  13. Pooja Pillai6,
  14. http://orcid.org/0000-0003-3604-1376Martin Webber13,
  15. Jerome Wright2,
  16. Rochelle Burgess3
  1. 1 Department of Social Work and Social Policy, University of York, York, Uk
  2. 2 University of York, York, United kingdom
  3. iii UCL Institute for Global Health, London, United kingdom
  4. four Hull York Medical School, Hull and York, Uk
  5. 5 School of Wellness Sciences, Academy of Canterbury, Christchurch, New Zealand
  6. vi Burans, Herbertpur Christian Infirmary, Uttarakhand, India
  7. 7 Centre for Mental Health Counselling (CMC), Katmandu, Nepal
  8. 8 Rozaria Memorial Trust, Harare, Zimbabwe
  9. 9 Rozaria Memorial Trust, Harare, Uk
  10. x School of Social and Political Science, The Academy of Edinburgh, Edinburgh, UK
  11. 11 Chhahari Nepal for Mental Health (CNMH), Katmandu, Nepal
  12. 12 Centre for Mental Health and Counselling, Katmandu, Nepal
  13. 13 Department of Social Policy and Social Work, University of York, York, UK
  1. Correspondence to Dr Hannah Maria Jennings; hannah.jennings{at}york.air conditioning.uk

Abstruse

Introduction The launch of the Movement for Global Mental Wellness brought long-standing calls for improved mental health interventions in depression-and centre-income countries (LMICs) to middle stage. Inside the movement, the participation of communities and people with lived feel of mental health problems is argued as essential to successful interventions. Nevertheless, there remains a lack of conceptual clarity effectually 'participation' in mental health interventions with the specific elements of participation rarely articulated. Our review responds to this gap by exploring how 'participation' is applied, what it means and what fundamental mechanisms contribute to change in participatory interventions for mental health in LMICs.

Methods and analysis A realist review methodology will exist used to identify the different contexts that trigger mechanisms of change, and the resulting outcomes related to the development and implementation of participatory mental health interventions, that is: what makes participation piece of work in mental health interventions in LMICs and why? We augment our search with primary data drove in communities who are the targets of global mental health initiatives to inform the production of a programme theory on participation for mental health in LMICs.

Ethics and dissemination Ethical approval for focus group discussions (FGDs) was obtained in each country involved. FGDs will be conducted in line with WHO safety guidance during the COVID-xix crisis. The full review will be published in an academic journal, with further papers providing an in-depth analysis on community perspectives on participation in mental wellness. The project findings will also be shared on a website, in webinars and an online workshop.

  • MENTAL HEALTH
  • PUBLIC Wellness
  • QUALITATIVE Inquiry

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  • MENTAL Wellness
  • PUBLIC HEALTH
  • QUALITATIVE RESEARCH

Strengths and limitations of this study

  • The review is strengthened by stakeholder involvement—focus group discussions with people with mental health problems and carers in low- and middle-income countries.

  • The review is theory driven, using concepts of participation from academic literature and applied exercise as a framework.

  • The review is limited to published academic papers in English; there may be farther insights bachelor in gray literature and in other languages.

Introduction

Globally, mental sick health is a leading cause of inability.1 Sociostructural factors are increasingly recognised as causes and consequences of poor mental health.ii 3 In 2007, The Lancet'southward pivotal 'Global Mental Health' serial highlighted global inequalities in mental health provision, particularly in depression-income and centre-income countries (LMICs),4 marking the kickoff of what is at present commonly referred to as the Motility for Global Mental Health.5 The motility advocates testify-based interventions, informed by a human being rights arroyo, with the aim to scale up mental health services. However, these efforts operate primarily within an essentially biomedical framework that eschews attention to structural drivers of distress in favour of pragmatics in clinical care. The movement has faced extensive critique because of this approach, with a special department of Transcultural Psychiatry in 2012 arguing for a greater emphasis of engagement with local communities within mental wellness to overcome these limitations.6 For example, when communities actively participate in the governance, pattern or delivery of mental wellness interventions, they tin can be more than acceptable and relevant to local needs as well as more cost-upshot and higher quality.7 Furthermore, depending on the social processes involved, participation can be empowering and even transformative to communities.8 nine However, an inattention to ability dynamics when working on 'participation' run the run a risk of exacerbating existing patterns of exclusion and reinforcing inequities.8

As a group of researchers and practitioners, we are interested in the theory and awarding of participation in global mental wellness interventions in LMICs for two key reasons: start, we debate that how people in LMICs define participation in mental health interventions or more broadly matters to programmes. 2nd, we argue that participation in mental health interventions creates platforms for transformation in the lives of people it seeks to benefits if attention is paid to key processes.

Theories of participation

Debates around the active involvement of communities in localities in LMICs—referred to every bit 'participation', 'community engagement' and 'mobilisation'—are important and related principles tin be found inside the broader fields of global health and international development. The diversity of approaches relating to the term also lead to its evolution into what some argue as a benign concept, a term with wide reaching boundaries that enable its wide-ranging applications.10 At that place are different perspectives on how 'participation' is achieved and for what purposes participation is implemented.9 For example, Campbell and Jovchelovitch11 suggest that participation is a machinery for negotiating social identity, and participatory power thus emerges as 'a space of possible activity'. Others suggest that mental health 'consumer participation' must include the ability to take meaningful action through orchestrating changes in service planning, delivery and intervention.12 13 What action looks like is dependant on the specific theoretical approach applied in a sure context.

Participatory theories tin be broadly separated into typologies (categories, often prepare as 'stages') or continuums (spectrums). 'Ladder' or stage typologies are common in borough, political understandings of ability. Arnstein's14 famous (1969) ladder of denizen participation has eight rungs from manipulation to citizen control. Similarly, Goetz and Gaventa15 range from consultation (data sharing) to influence (tangible impact on policy making and service delivery), and Wilcox16 considers collaboration between citizen and state from information to initiatives. Pretty frames 'participation' every bit opportunities for the poor to gain benefits, from manipulative to self-mobilisation,17 whereas Eyben's18 rights-based, half dozen-rung ladder (instrumental participation to participatory rights) suggests that the right to participation facilitates access to other human rights. These ladders/stages have several commonalities: on lower rungs people have little power, and any inclusion of their voices is tokenistic and does not atomic number 82 to tangible change. The tiptop rungs are interventions designed and led by the community. Notwithstanding, ladders do not finer accommodate the dynamic, contextual and relational aspects of ability in participation. Additionally, a fully citizen-led approach may not ever be possible or fifty-fifty desirable.

Continuums can accommodate shifts in participation and power status. In community development, Draper et al19 created a process-based continuum of participation across five categories including external back up, leadership and women'south empowerment. Bebbington and Farrington's20 continuum focuses on participation breadth (representativeness of the full community) and depth (extent of meaningful involvement). Similar to participation ladders, Hickey and Kipping's21 mental health participation continuum ranges from information to user control, with a shift from passive 'consumerism' to 'democratisation'. Too, Rifkin and Kangere22 argue participation ranges from people as passive receivers to active decision makers, acknowledging alter over fourth dimension.

Some approaches emphasise the dialogical nature of participation. Campbell and Jovchelovitch11 take a Freirean approach, noting how transformative dialogue can lead to reciprocal growth and learning between 'the powerful' and 'the community'. Wallerstein also highlights the capacity for mutual learning and reciprocal relationships, with partnerships betwixt resources holders and beneficiaries leading to transformational modify for both.23 The South asia Perspective Network Clan goes further to emphasise deliberately 'pro-poor' strategies, where through a dialogical approach, sustained participatory action and new social movements lead to wider social transformation.24 Nastasi et al's25 Participatory Intervention Model applies this idea to mental health interventions, noting the importance of relationships, changing interpersonal and power dynamics, and matching knowledge and back up to the needs of the community. Indeed, communities are constantly shifting and accept their own internal power dynamics.26 White takes account of this in a relationally based typological approach, which accounts for shifting priorities and dynamics between the community and those with power.27 This typology ranges from nominal (tokenistic involvement) to transformative (empowerment).

Online supplemental file 1 shows our heed map bringing together cardinal debates in participation based effectually who it is for, how it is used and the impact (if whatever) on participatory approaches. The heed map is intended to be comprehensive just non exhaustive. It was supplemented past word on the lived experiences of practitioners in the squad and the participatory work of their organisations.28 29 We conceptualise 'participation' in mental health as the active involvement of people affected by interventions or targeted action (including wider research projects). This can include a range of actors: service users, carers, providers and wider community members. Ultimately, they all contribute to the intervention in some capacity, and no grouping are merely passive recipients of an consequence. This includes involvement and buying over various phases of concept, pattern, implementation and evaluation stages of interventions. Notably, our arroyo recognises a range of dynamics and factors that shape participation including: interests and motivations, socioeconomic context, influence, and structural and interpersonal ability.

Supplemental cloth

Realist review on participation on mental wellness in LMIC

To date, in that location have been reviews of community engagement and participatory health approaches in LMICs30 31 including an ongoing realist review on community engagement in non-catching affliction interventions and research32; nonetheless, to the authors' noesis, at that place has been no specific review that interrogates participatory approaches to mental health beyond LMICs. The current review seeks to accost this gap exploring the following questions: In LMIC settings, what is the nature of participatory approaches for mental health improvement? Who are the targets of participation in mental health inquiry and practice? What factors contribute to their success or failure?

Our investigation applies a realist methodology, which has a like involvement in 'what works for these particular people in particular contexts'.30 33 Realists reviews combine theory and empirical observation and seek to understand how and why change is facilitated.30 32–34 This review volition be used to identify mechanisms of change and their related contexts, which will support the development of theory to farther our understandings of how participation is used in the design and implementation of mental health interventions.

Aim and research questions

The aim of the review is to interrogate existing literature relating to participatory mental wellness interventions in LMICs, to consider how, for whom and under what atmospheric condition participatory approaches work. Across two stages of data extraction, we will seek to answer the following questions:

  1. Why and for whom has participation been used in mental health interventions in LMIC?

  2. How and to what extent has participation been operationalised in inquiry versus implementation?

  3. What are the mechanisms of action of participation and how are they linked to local contexts?

  4. Why, how and under what circumstances does community participation in mental health interventions lead to improved mental wellness?

Method

This review was designed adapting Saul et al's suggested 10 steps for a realist review.35 Realist reviews often involve developing an initial programme theory (IPT), which is afterward refined through the development of middle-range theories of what works.35–37 Heart-range theories are general enough to be transferred to other projects but concrete and specific enough to apply to practice.33 In generating or exploring theory, context, mechanism and outcomes (CMO) are crucial (figure one: CMO configurations). When relations between these factors are explored, they create 'CMO configurations' and are developed in response to particular research questions.37

As not all papers volition take enough item to infer theories and excerpt CMO configurations, data extraction will be in two stages. Stage 1 volition extract surface-level written report characteristics and quality. Phase 2 will complete a deeper analysis of the highest quality papers, from which CMO configurations will be extracted to build our middle-range theories. To counter the western hegemonic noesis structures that shape much of the peer-reviewed literature,38 nosotros have added specific stakeholder consultations in our review, to combine and include embodied knowledges held by people with mental wellness difficulties, carers and community members. Consulting stakeholders every bit function of the review is consequent with the realist methodology.30 32 We assess their views of participation and involvement as information technology relates to mental health, at two stages in the review . The ten steps as nosotros take practical them in our report are described in more item further (figure 2: x-footstep review process).

We will report the results of the review according to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication standards.33

Concepts of 'participation' and developing research questions (steps one and 2)

A mind map of different concepts of 'participation' (online supplemental file 1) was created between January and March 2021. This involved reading research literature on participation, particularly on LMICs and from the academic fields of evolution, health and human rights. This was supplemented past monthly meetings between the entire inquiry group to discuss emerging themes and link the research to the applied do of squad members. Squad members, across LMICs and loftier-income countries, represent varied indigenous backgrounds and disciplinary backgrounds in mental health, medicine, social work, mental health nursing, psychology, academia and not-governmental organisations. Fundamental debates from the mindmap and group discussion were used to develop the four research questions.

Based on this initial conceptual review and discussions, project principle investigator (RB) drafted an IPT and model that was discussed and refined within the research group (figure 3: programme theory). The IPT guided the remainder of the review procedure and will be refined in lite of the findings of this review (see step 9).

Our IPT considers contexts at multiple levels and is purposefully wide. The IPT suggests, that overall, individuals who live with or are at risk of developing mental health weather condition in the global south (LMIC) (who) exercise so because of a number of daily realities across various settings with relations to mental wellness needs (contexts barriers). We postulate that these wider limiting contexts will include: poor mental wellness service infrastructure; low uptake of services due to low awareness of services and due to a poor 'fit' of services to the needs of communities; stigma and exclusion faced by people living with mental wellness issues; histories of silencing of lived experience within the mental health space; and intersecting social, political and environmental challenges that link to mental health conditions. The second level of contexts we are interested in are those that may contribute positively to the impact of interventions and mental health (enabling contexts). These include various forms of capital, agency, collective mobilisation and supportive customs partnerships.

We believe that if participatory approaches to mental wellness meet the parameters of meaningful participation (which we defined equally transformative participation outlined by White's27 framework) then this would activate a serial of mechanisms that would lead to positive outcomes on mental wellness weather, likewise as a wider impacts on societal factors linked to poor mental health (addressing hindering contexts). We believe this would be the instance across diverse population groups at risk for developing mental health weather condition (who). This is because transformative participation creates opportunities for participants to change the environments that place good mental wellness at risk, as well every bit increase access to better services through various pathways such as the production of new communities of practice and back up networks.

We imagine the potential outcomes could occur at 2 levels. At the individual level, this may include: improved mental health outcomes; improved access to services, improved mental wellness literacy and a reduction in experiences of exclusion. At wider societal levels, it could include: a reduction in harmful social, political and environmental drivers of distress (ie, reduced poverty; reduced gender discrimination; improved living conditions) and increased voice and ownership for people with lived experience in wider society. We believe that when meaningful participation (transformative) is not present, positive impacts may occur but only for individual outcomes. Ultimately, this theory helps the states to determine not but the mechanisms through which participatory interventions may piece of work, but the power for participatory interventions to be activated in the presence of enabling contexts. Too, our IPT allows us to account for the fact that transformative participatory interventions themselves may work to modify the contexts that trigger or block the mechanisms that bulldoze amend mental health. As such, nosotros exercise not imagine a hard line betwixt interventions and mechanisms but will allow our literature review and stakeholder engagement to aid illuminate these dynamics in the contexts of interventions that have transformative interests at their core.

Search terms and identifying papers (steps 3 and 4)

Search terms and databases searched were discussed in team meetings in early 2021. Searches are beingness carried out in the databases: Scopus, Medline/PsychINFO, ASSIA, CINAHL, Embase and JSTOR. If additional studies are identified in the references or through the team, they will exist considered for screening. Tabular array i shows our search terms. Online supplemental file 2 gives details for the total search strategy.

Supplemental material

View this table:

  • View inline

Tabular array 1

Literature search terms

Screening and report choice

Instead of limiting to a particular definition of 'participation', this review will take a pragmatic approach. It volition include all papers which either: (A) claim to be participatory or (B) clearly include participation (the active involvement of people with mental health bug and their supporters). We will include studies located in LMICs (as according the Globe Bank definition) that are related to a mental health intervention. We employ a wide definition of mental health every bit defined by the WHO and draw on their listing of mental and neurological disorders.39 We define interventions as programmes or policies that are implemented with the aim to change outcome/s. Table 2 shows our inclusion and exclusion criteria.

View this table:

  • View inline

Table 2

Inclusion and exclusion criteria

Possible relevant papers identified during the searches volition be uploaded onto the software Ryaan for championship and abstruse screening. Title and abstract screening will be conducted blinded by members of the inquiry team to ensure consistency 10% of studies screened by 2 members of the inquiry team. Full-text screening will exist completed by the whole research team with members working in pairs and the papers divided amidst the team. Any uncertainties throughout the process will be discussed within the team at regular squad meetings.

Data extraction and quality appraisal (steps v and 6)

There volition be two stages of data extraction. The first phase will answer the outset two research questions of the review.:

  1. Why and for whom has participation been used in mental health interventions in LMIC?

  2. How and to what extent has participation been operationalised in enquiry versus implementation?

At the end of the first phase, the highest quality papers with the most detail about theories of participation and CMOs will be identified and taken frontwards to the second phase. This more in-depth assay and CMO configuration extraction volition answer the final two questions:

  1. What are the mechanisms of action of participation and how are they linked to local contexts?

  2. Why, how and under what circumstances does customs participation in mental health interventions lead to improved mental health?

Stage 1

Every bit with the full-text screening, data extraction volition be completed in pairs by the research team. A information extraction tool will exist developed and refined as relevant data are extracted. Extracted data will likely include: written report aims, methods, why participation is used; concept and theory of 'participation'; target population and stakeholders; how participation is 'done'; outcomes of intervention; level of participation; and analysis of power. For quality, a realist review asks whether papers are relevant (to the research question) and rigorous (of skilful-enough quality to make a meaningful contribution).33 The data extraction tool will include whether papers are depression, medium or high relevance. For 'rigour', equally we are including all methods (example studies, qualitative and quantitative), specific quality checklists will be selected based on the nature of the papers, primarily cartoon from the Joanna Briggs Institute Critical Appraisal tools.40 Uncertainties equally to the data extraction, relevance and rigour will be discussed in the team meetings and enquiry associate (CJH) and principle investigators (RB and HMJ) will practice final quality checks.

Stage 2

Papers of 'high quality'—rigorous, relevant and with sufficient information to extract CMO configurations—volition exist taken forward for the second phase of review. Potential studies for this stage of data extraction will be identified by the enquiry squad during stage one. All studies identified and those marked as 'loftier' for relevance volition exist considered. Three members of the research team (CJH, RB and HMJ) will read the shortlisted papers and agree through consensus whether they should become through to the side by side round of the review. They volition tape and report back to the wider team the reasoning for the decisions. The criteria for studies to go through to the next round of review include: data and discussion about participation, enough detail to extract information on CMO configurations.

Data synthesis and CMO configurations (footstep 7)

Phase one

The get-go phase of data synthesis based on the first round of information collection will be narrative, based effectually the first two research questions. It will report on the breadth and scope of participation as used in mental health settings in LMICs. Comparisons will be fabricated with the FGDs and their understanding of participation.

Stage 2

The second round of information synthesis will be a theory focused iterative process based on the 'high quality papers'. Data synthesis will take the post-obit process:

  • Taking our 'loftier quality' papers, we volition extract CMO configurations related to participation from each paper. This volition exist an iterative process where researchers will work in groups to discuss and excerpt the configurations. They will consider the evidence for the relationships between CMO relating to participation before finalising the CMO configurations.

  • CMO configurations will be combined and refined to identify 'enabling contexts', the types of 'enabling mechanisms' they trigger and their possible outcomes (midrange theories). Once more, this volition be an iterative process involving the whole network.

  • Based on these findings and the FGD assay, we will revise our IPT.

We plan to undertake this process equally a team, involving workshops led by KM (who has experience in realist methodology).41 One workshop will develop our initial CMO configurations based on the 'high quality papers'. Subsequent team meetings will allow refining of CMO configurations, comparing them against a thematic analysis of FGDs. Equally theories and CMO configurations are gradually refined, the process will be carefully documented to justify changes and ensure a rigorous and transparent process. Overall, the synthesis should be such that the weaknesses (or omissions) in ane particular paper from the review are accommodated for by the strengths of other papers. In one case the review has been completed, nosotros will take a set of centre-range theories, informed by the embodied knowledge of everyday citizens who are often the targets of mental health interventions in LMICs. The theories explain how participatory mental wellness interventions create changes in local context (C), to trigger sociopsychological mechanisms (Yard) that lead to new behaviour outcomes (O) in communities of interest. Terminal CMO configurations volition be used to refine the IPT by RB and HMJ, which will be fedback and refined by the wider group.

Focus grouping discussions (stride 8)

There will be two rounds of stakeholder consultations through focus group discussions, across four sites in 3 countries (Nepal, Republic of india and Zimbabwe), organised by members of the network who work in participation and mental health (BM, RM, SMM, PM, PP, NG, FG and GG). The groups will include people affected by mental health difficulties, carers and community members.

The first round of FGDs will explore understandings of participation and contribute to the IPT. In the second round of FGDs, a summary of data so far from the literature review will be presented in order to get feedback and reflections from the participants and will further contribute to the refinement of the programme theory. Findings of the FGDs will be compared and integrated with findings from the data extraction to help theorise 'what works and how' in the style that is considered nigh participatory in the context. Findings from the FGDs will be reported in our last write-upwards, dissemination and revision of our IPT (steps 9 and 10).

Broadcasting and workshop (steps ix and 10)

Information technology is anticipated that the current realist review volition create a potent theoretical and practice-based foundation for time to come work in participatory enquiry and do for mental wellness in LMIC settings and other environments of adversity. It will likewise directly shape the efforts of our network for participatory mental wellness in LMICs. We volition disseminate our findings inside a workshop series; this volition allow us to aggrandize our network by welcoming a range of interested stakeholders including people with mental health issues, paid and unpaid carers, practitioners, academics and policymakers. We also plan to disseminate our findings though peer-review papers and blogs written in accessible and local languages in each of our country settings.

Patient and public interest

As office of the review, nosotros will take planned stakeholder consultations with people with mental health difficulties, carers and community members in three LMICs (Nepal, India and Zimbabwe). The consultations are an of import part of the review and volition contribute to our refined programme theory. Every bit part of our dissemination, nosotros will organise workshops with people with mental wellness difficulties, carers, practitioners and community members in LMICs.

Ethics and dissemination

Ethical approval for the written report received from the University of York Health Scientific discipline and Research Governance committee (HSRGC/2021/438) and nosotros take received ethical approval from the relevant bodies of the countries involved (Nepal Wellness Research Council, 3026; Emmanuel Hospital Association Institutional Ethics Commission, 254; UCL Ethics Board 127/002 and The Women's University in Africa 02/2020). The review has been registered with PROSPERO (ID number CRD42021241787). The full review is intended to be published in an bookish journal, with further papers providing an in-depth assay on community perspectives on participation. The project findings will also be shared on a website, in webinars and an online workshop.

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Supplementary materials

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