From the Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health (Dr. Greene) and Department of Sociomedical Science (Dr. Shelton), Columbia University Mailman School of Public Health; Center for Systems and Community Design and Department of Health Policy and Management, City University of New York Graduate School of Public Health and Health Policy (Dr. Huang); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons & New York State Psychiatric Institute (Drs. Giusto, Lovero, Stockton, and Wainberg); Mental Health Department, Center for Applied Psychology and Psychometric Tests, Mozambique Ministry of Health (Dr. dos Santos); Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique (Dr. Saúte).
Harv Rev Psychiatry. 2021;29(4):262-277. doi: 10.1097/HRP.0000000000000306.
Advancements in global mental health implementation research have revealed promising strategies for improving access to evidence-based mental health care. These advancements have not translated, however, into a reduced prevalence of mental disorders. In this review we examine the relationships between determinants (i.e., barriers and facilitators) and outcomes of mental health services in low- and middle-income countries to identify opportunities for improving the population-level impact and sustainability of innovations in global mental health. We identified three key implementation and services outcomes that influenced the prevalence of mental disorders in the 56 included review articles: supply (access, implementation), demand (help seeking, utilization), and quality (effectiveness, quality of care) of mental health services. Determinants of these outcomes revealed seven themes: community stakeholder engagement; cultural relevance; stigma; human resource capacity; organization of services; governance, policy, and financing; and sociopolitical and community context. We developed a causal loop diagram to illustrate the relationships among these determinants and outcomes. The causal loop diagram revealed the central role of community stakeholder engagement in bridging implementation and patient outcomes, the importance of addressing stigma and social determinants of mental health, and the need to complement supply-side implementation strategies with approaches to equilibrate demand and improve the quality of services. Applying systems science methodologies to global mental health research presents an opportunity to examine the complex relationships among community and health system factors that influence implementation of evidence-based interventions in order to identify sustainable approaches to improve the population-level impact of mental health services in low- and middle-income countries.
全球精神卫生实施研究的进展揭示了改善获得循证精神卫生保健的有希望的策略。然而，这些进展并没有转化为精神障碍患病率的降低。在这篇综述中，我们研究了中低收入国家精神卫生服务的决定因素（即障碍和促进因素）与结果之间的关系，以确定改善全球精神卫生创新的人群水平影响和可持续性的机会。我们确定了三个关键的实施和服务结果，这些结果影响了 56 篇综述文章中精神障碍的患病率：精神卫生服务的供应（可及性、实施）、需求（寻求帮助、利用）和质量（有效性、护理质量）。这些结果的决定因素揭示了七个主题：社区利益攸关方的参与；文化相关性；耻辱感；人力资源能力；服务组织；治理、政策和融资；以及社会政治和社区背景。我们开发了一个因果关系图来表示这些决定因素和结果之间的关系。因果关系图表明，社区利益攸关方的参与在弥合实施和患者结果方面起着核心作用，解决耻辱感和精神卫生的社会决定因素的重要性，以及需要用平衡需求和提高服务质量的方法来补充供应方的实施策略。将系统科学方法应用于全球精神卫生研究提供了一个机会，可以检查影响循证干预措施实施的社区和卫生系统因素之间的复杂关系，以便确定可持续的方法来改善中低收入国家精神卫生服务的人群水平影响。
