Global health reciprocal innovation to address mental health and well-being: strategies used and lessons learnt

Introduction

As people live longer with chronic conditions globally, the need to address mental health and related challenges to health and well-being has become increasingly apparent.1 With this, there is growing recognition that people everywhere need to benefit from the innovations being tested and implemented globally and work collaboratively and learn from one-another. The term global health reciprocal innovation (GHRI) was recently coined to describe bidirectional and iterative exchange of ideas, resources and innovations to address shared health challenges across diverse global settings.2

In low- and middle-income countries (LMIC), there has been a long-standing major gap between the number of people experiencing mental health conditions and the availability of quality care. Prior estimates indicate that only 1 out of 26 people with depression and 1 out of 100 people living with anxiety have access to minimally adequate care in LMIC.3 4 These major constraints have stimulated innovative strategies to deliver mental health services through non-specialists in LMIC.5 Task shifting mental health service delivery comes from the recognition that the reliance on specialists such as psychiatrists and psychologists to deliver mental healthcare will not reduce inequities in LMIC.6 Instead, continuum of care models with integration of non-specialists are being implemented with an emphasis on community-based care, collaborative care, stratified care and stepped care.7 These approaches build on public health strategies,8 rely on major contributions of community health workers and community members9 10 and are increasing availability and accessibility of mental health services in LMIC. Based on the feasibility and effectiveness of these strategies, the 2022 World Mental Health Report highlighted the use of non-specialists and continuum of care implementation as pillars of successful mental health service delivery.11

Increased usage of non-specialists for delivery of health interventions was catalysed by the HIV response in many LMIC, as working with community members and other non-specialists to reach affected populations has been a key strategy in LMIC to extend the reach of HIV services and reduce HIV stigma. There is also growing recognition that stigma has negative impacts on mental health,12 and that this is a key pathway for adverse effects on other health outcomes.13 Thus, the HIV response has included the development of a multitude of innovative community-engaged strategies to address stigma and other mental health challenges faced by people living with HIV in LMIC.14 These strategies also include other innovative community-based implementation strategies such as mHealth tools, collaboration with primary healthcare workers and multilevel approaches—that could also benefit populations in high-income countries (HIC).

At a population level, HIC have a higher availability of mental health services than LMIC: one out of five individuals living with depression receive minimally adequate care in HIC.3 However, this can mask wide inequities within high resource settings. Historically minoritised groups in many regions of the USA, for instance, have low usage rates of mental health services, with racial and ethnic inequities in mental healthcare worsening in recent decades.15 This has led mental health researchers and practitioners to explore how strategies from LMIC could be leveraged in HIC to reduce these longstanding, and in some cases, worsening inequities.

In HIC in the Americas and Europe, community-based approaches for increasing access to mental health are gaining momentum.16 For example, in the USA, the translation and adoption of innovations in mental health from LMICs is increasingly supported by policymakers. In 2023, the US White House Report on Mental Health Research Priorities17 calls for pilot programmes to train paraprofessionals to deliver mental health services as a path to reducing inequities within mental healthcare. In addition to expanding the scope of who delivers services, the White House Report calls for changing the emphasis on where services are delivered with greater investments in primary care, communities and the justice system—all strategies that have a strong evidence base in LMIC. In addition, city governments and state governments are implementing global mental health strategies such as programmes in the New York City Mayor’s Office of Community Mental Health18 and the State Government of New York.19 Insurance companies, such as Blue Cross Blue Shield of Massachusetts, are also implementing interventions in Boston that were developed for humanitarian emergencies in LMICs.20 Similarly, the Ending the HIV Epidemic Initiative in the USA has a strong focus on underserved rural areas, where HIV incidence is often highest, and embraces innovative community-centred approaches to delivering HIV prevention and treatment.21

These strategies align well with the concept of GHRI.22 23 As opposed to the dominant practice of researchers from HIC directing what and how interventions will be done in LMIC, reciprocal learning emphasises the equitable involvement of LMIC researchers in informing and shaping practices in HIC. With successful reciprocal learning, there is an array of opportunities for lessons learnt from LMIC to inform care in the USA and other HIC, and for simultaneous or subsequent experiences in HIC to feedback and inform programmes in LMIC. This can occur in an ongoing iterative fashion where advances, adaptations and improvements to interventions are facilitated over time and on an ongoing basis.

There are a growing number of examples of GHRI in which initiatives in LMIC are being adapted and implemented in the USA and other HIC,19 as well as in other LMIC. For GHRI to be effective, efficient and become standard practice, there is a need to review how initial examples of the strategy have been carried out and what successes and challenges were encountered. Our objective is to review case examples in the field of mental health and HIV stigma reduction to extract what lessons learnt should inform future GHRI for mental health and well-being. Successful reciprocal learning will contribute to a more equitable global mental health research community and greater alleviation of suffering associated with mental illness and other stigmatised conditions.

We convened a group of experts in the fields of mental health, global health and HIV stigma-reduction, mainly identified from participants in a webinar (2020) and/or a workshop (2022) on GHRI organised by the National Institutes of Health (NIH) Fogarty International Center (FIC).24 These experts, based in both LMIC and HIC settings, worked together to identify domains of interest for examining GHRI work in the mental health and stigma-reduction areas, as well as key case study examples.

Inclusion criteria for the case examples were: (1) a defined intervention specifically addressing mental health and well-being, including stigma reduction; (2) evidence of reciprocal implementation in at least one LMIC and one HIC setting; and (3) evidence of interaction and multidirectional learning between the different country sites. The team reviewed 14 potentially relevant case examples before selecting the 12 examples examined in detail in this paper. Domains examined in included studies were: countries involved; conceptual and other frameworks used; type of GHRI design and directionality; core intervention name and type; research/project team composition and modes of collaboration; health system contexts; intervention adaptation methods used; intervention delivery modalities; funding sources and mechanisms; barriers/challenges encountered; benefits of the GHRI collaboration; special resources needed; outcomes measured; involvement of people with lived experience; unintended (positive or negative) consequences; and other lessons learnt.

Members of the expert group used a standard form to extract information on each of the identified domains from peer reviewed and grey literature, scientific presentations and media articles on the GHRI case studies. When not present in the expert group team, investigators directly involved in the GHRI case implementation and evaluation were consulted to obtain information on domains that were not fully elucidated in the available sources. Information across cases for each domain was then summarised and synthesised.

Case examples of global health reciprocal innovation

Case examples included in this review are presented in table 1. Illustrative case examples are presented in further detail in boxes 1–3.

Conclusion

Our review of these examples of GHRI around mental health and well-being—including HIV-related stigma reduction examples—has revealed an emerging body of work that has the potential to benefit diverse populations in both LMIC and HIC. The examples of GHRI analysed in this review highlight the implementation benefits of a bidirectional, iterative process and the importance of communication and collaboration among project teams in different settings. This work also presents an opportunity to reflect on colonial legacies in global mental health research and to strive for more balance and partnership.29 30

In many cases the transfer of an intervention from one setting to another was not envisioned in the initial project; many such transfers were stimulated the COVID-19 pandemic, which increased the need for widely accessible mental health interventions within the USA.31 In these examples of GHRI ‘sequential designs’, we observed fewer opportunities for the LMIC and HIC teams to interact and learn from one another, as compared with ‘simultaneous designs’ when the different settings intentionally began the GHRI together around the same time. The fact that most examples did not have an a priori focus on GHRI probably reflects the lack of comprehensive targeted funding mechanisms to support long-term multinational interactive, iterative work in the field of mental health and well-being. In the few examples of true ‘simultaneous designs’, mechanisms for interaction, shared leadership and multidirectional learning could be built in from the beginning and continue over time, yielding immense benefits. As such programmes require larger budgets over a multiyear time horizon and require the availability of funds for international travel, we advocate for future funding opportunities specifically tailored for GHRI that can help the global community to continue this work that has high potential to improve mental health and well-being globally.

Many of our case examples emphasised task-sharing and intervention delivery by health workers who are not mental health specialists, including primary care and community health workers and other non-specialist providers such as peer coaches, peer facilitators, religious leaders and non-health staff of CBOs. This approach, which has been a necessity for years in LMIC,32 is now being adopted in many high-income settings to address shortages of formally trained mental health and psychosocial support staff and increased mental healthcare need, especially in lower-resource areas.33 Across multiple task-sharing cases, technology served as an important facilitator to training non-specialists, ensuring fidelity of intervention delivery and expanding reach to under-resourced populations. Our examples also revealed some of the challenges with task-sharing approaches, including already overburdened health workers, shortages of experts for effective supervision and different country regulations about what cadre of workers can deliver certain types of healthcare.

Culturally and contextually relevant adaptation is paramount to successful GHRI. On one hand, inclusion of the intervention developers and/or implementors from the prior setting(s) on the team in the new setting in a meaningful collaboration can ensure that the core components necessary for the effectiveness of the intervention are not lost in translation. On the other hand, interventions themselves may need to change in major ways to effectively respond to the needs of new target populations and new contexts. To navigate this balance, careful and rigorous usage of theories, methods and frameworks from IS can be particularly useful to adapt and scale up interventions in new contexts once they have been shown to be effective in one setting. By encouraging communication between stakeholders across multiple settings, GHRI approaches fit well within IS to improve the process of implementation, to enhance equity and shared leadership and to work towards the decolonisation of global health.34

We consider reducing stigma as an important part of promoting mental health and well-being related to a variety of health conditions and identified many examples of GHRI in HIV-related stigma reduction. Many mental health interventions we examined involved reducing the stigma around mental health disorders and seeking mental health treatment, although stigma was not usually measured in these cases and effects of these interventions on mental illness-related stigma are largely underexplored. Future work should assess and carefully consider both anticipated and unanticipated effects of interventions on stigma in the community.

Our analysis had both limitations and strengths. Limitations include that our analysis was not a systematic review of the literature, and that the HIC implementation examples were limited to the USA. We also acknowledge that some of the case examples included in this analysis were based on projects conducted by members of our authorship team (seven of the case examples), and while that brought a strength in terms of in-depth knowledge project, it could also be considered a source of bias. We partly mitigate this by the joint authorship of multiple authors and the reflexive discussions among the author-team. Strengths include the synthesis of key findings from LMIC and US researchers who have been intimately involved in projects involving GHRI, as well as the timely sharing of insights in a relatively new and actively developing field of work.

The current analysis suggests that there are important research questions to be addressed to further understand the processes and outcomes of GHRI in mental health and well-being. These include research to: (1) document processes and identify best practices for co-led LMIC-HIC teams for GHRI projects, (2) test the effects of different cultural and contextual adaptation frameworks on implementation and effectiveness outcomes, (3) compare the implementation strategies and outcomes of specific mental health and well-being interventions in different settings globally and (4) examine how mental health interventions impact community-level and healthcare setting stigma around mental illness and other stigmatised identities in different global settings.