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Table of Contents
PERSPECTIVE
Year : 2020  |  Volume : 2  |  Issue : 3  |  Page : 201-209

Scaling Up Interventions for Better Access to Mental Health and Epilepsy Care: A Forum with Impact


1 INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
2 Global Health Programs, Sanofi, Gentilly, France
3 INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France; Laboratory of Chronic Diseases Epidemiology (LEMACEN), Faculty of Health Sciences, School of Health Sciences, University of Abomey-Calavi (UAC) Cotonou, Benin
4 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India

Date of Submission08-Jan-2020
Date of Decision13-Apr-2020
Date of Acceptance02-Apr-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Farid Boumediene
Institute of Epidemiology and Tropical Neurology, University of Limoges, 2, rue du Dr Marcland, 87025 Limoges Cedex
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WSP.WSP_3_20

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  Abstract 


Psychiatric and neurological disorders are now considered among the first contributors to the global burden of disease. In low- and middle-income countries (LMICs), insufficient specialized human resources, inadequate training of primary care workers, traditional beliefs, stigmatization, and discrimination are the most common barriers to access to care. Availability and cost of medicines are also common problems. Although in many cases effective treatments exist, 76%–85% of patients with mental disorders or epilepsy living in LMICs are not treated. Over the last 8 years, through the Interactive Meetings Promoting Access to Care and Treatment (IMPACT) forum, the Institute of Epidemiology and Tropical Neurology UMR 1094 INSERM, the World Association of Social Psychiatry, and Sanofi Global Health Programs have convened every year a group of approximately forty people from about twenty countries (not only from Africa, Asia, and Latin America, but also from Europe), and from various backgrounds (public, private, associative, and academic sectors), who are all involved in developing access to care for people living with mental disorders or epilepsy in LMICs. The meeting held in Versailles, France, on September 13 and 14, 2018, focused on “Scaling Up Interventions for Better Access to Mental Health and Epilepsy Care.” Through didactic presentations based on the World Health Organization-ExpandNet “Nine steps for developing a scaling-up strategy” guide, as well as case studies and workshops around three pilot projects implemented in Cambodia, Guatemala, and Madagascar, this forum provided participants with an opportunity to gain in knowledge and understanding of scaling-up theories and to apply these to practical cases.

Keywords: Cambodia, epilepsy, Guatemala, low- and middle-income countries, Madagascar, mental health, scaling up


How to cite this article:
Boumediene F, Bruand PE, Luna J, Yoro-Zohoun I, Auditeau E, Vergonjeanne M, Kallivayalil RA, Preux PM. Scaling Up Interventions for Better Access to Mental Health and Epilepsy Care: A Forum with Impact. World Soc Psychiatry 2020;2:201-9

How to cite this URL:
Boumediene F, Bruand PE, Luna J, Yoro-Zohoun I, Auditeau E, Vergonjeanne M, Kallivayalil RA, Preux PM. Scaling Up Interventions for Better Access to Mental Health and Epilepsy Care: A Forum with Impact. World Soc Psychiatry [serial online] 2020 [cited 2021 May 7];2:201-9. Available from: https://www.worldsocpsychiatry.org/text.asp?2020/2/3/201/304812




  Introduction Top


The World Health Organization (WHO) estimates that approximately 450 million people worldwide are affected by mental disorders at any point in time.[1] These disorders are found in all countries across the globe, and they include diseases such as depression, bipolar disorder, anxiety disorders, addictions, schizophrenia, and other psychoses, to name a few.

Epilepsy is a chronic neurological disease characterized by recurrent epileptic seizures, which are brief episodes of involuntary movements sometimes accompanied by loss of consciousness or other symptoms related to abnormal brain activity. More than 50 million people worldwide have epilepsy.[2]

For a long time, psychiatric and neurological disorders have been neglected from the global health agenda, and their impact has been underestimated, especially in low- and middle-income countries (LMICs). Recent research has, however, demonstrated that they are among the first contributors to the global burden of disease.[3] This research suggests that their burden accounts for 32.4% of years lived with disability and 13.0% of disability-adjusted life years.[3] The impact of mental disorders and epilepsy continues to grow, and these disorders have very significant consequences on health, in all countries of the world, not to mention important repercussions at a social, human rights, and economic level.[1],[4]

In LMICs, the main barriers to access to mental health and epilepsy care include the scarcity of specialized human resources, the inadequate training of primary care workers, the traditional beliefs surrounding mental disorders and epilepsy which often lead to stigmatization and discrimination, as well as the issues regarding the availability and cost of medicines.[5],[6] Although in many cases, effective treatments exist, the WHO estimates that in LMICs, 76%–85% of patients with mental disorders or epilepsy do not receive suitable treatment.[1],[2],[7]


  The Interactive Meetings Promoting Access to Care and Treatment Forum: Background, Structure, and Objectives for the 2018 Edition Top


The Institute of Epidemiology and Tropical Neurology (IENT, UMR 1094 Inserm) and the World Association of Social Psychiatry (WASP) joined forces with Sanofi Global Health Programs in 2008 to promote access to health care for patients with mental disorders or epilepsy in developing countries. Through the Fight Against STigma (FAST) program and other projects, initiatives have been launched in over twenty countries in Africa, Asia, and South America.[8],[9],[10],[11],[12],[13],[14],[15],[16] Developed with local health authorities, local experts and health professionals, and patient associations or nongovernmental organizations (NGOs), these programs aim to improve access to care for patients with mental disorders or epilepsy in LMICs. They are based on training health workers, raising public awareness, and educating patients and their families. Thanks to these initiatives, thousands of patients who were previously neglected and excluded are seeking medical help and receiving treatment, so they are able to resume a normal life with their families.

Over the last 8 years, the IENT, WASP, and Sanofi Global Health programs have co-organized the Interactive Meetings Promoting Access to Care and Treatment (IMPACT) Forum. This forum convenes, on an annual basis, a group of approximately forty people from about twenty countries (not only from Africa, Asia, and Latin America, but also from Europe), and from various backgrounds (public, private, associative, and academic sectors), who are all involved in developing access to care for people living with mental disorders or epilepsy in LMICs. Participants are local project owners, representatives from ministries of health, local psychiatrists, neurologists or general practitioners (GPs), international experts, researchers, etc.

Through a mix of didactic sessions and updates on various projects and workshops, the aim of the IMPACT forum is to share outcomes and key learnings from the various initiatives that are implemented in a number of countries to develop access to care. This forum is also designed to stimulate debates and discussion, to develop capacity and ultimately to help improve access to mental health and epilepsy care in LMICs.

The focus of the IMPACT forum held in Versailles, France, on September 13 and 14, 2018, was “Scaling Up Interventions for Better Access to Mental Health and Epilepsy Care.” Scaling up is attracting a great deal of attention in the global health and international development fields. There is indeed concern that the objectives set up as part of the United Nations' Sustainable Development Goals, and other international summits, are not being achieved as fast and effectively as intended.[17] The challenge is to ensure that the benefits achieved in successful pilot or experimental projects can be expanded to serve more people, more equitably and more lastingly. Going beyond fragmented, one-off projects and ensuring that successful innovations and pilot projects can achieve sustainable impact at scale is key.

Forty participants from 19 countries [Figure 1] attended the meeting. The group included psychiatrists and neurologists directly managing people with mental disorders or epilepsy in LMICs; epidemiologists; researchers; representatives from ministries of public health; representatives of NGOs; a representative from an international organization working to develop guidelines and recommendations for the treatment of mental disorders and epilepsy; and representatives from Sanofi's Global Health programs who are developing initiatives to improve access to health care for people with mental disorders or epilepsy in LMICs. Participants represented a broad range of regions, institutions, organizations, and perspectives, majority of whom had firsthand experience in working with people with mental disorders, epilepsy, or other noncommunicable diseases (NCDs) in LMICs.
Figure 1: Participating countries

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This forum aimed to provide participants with an opportunity to gain in knowledge and understanding of scaling-up theories and to apply these to practical cases.

An introductory plenary session including a didactic presentation using the WHO-ExpandNet “Nine steps for developing a scaling-up strategy” guide,[17] provided participants with definitions so that everyone could share a common language. It also gave them a framework and a set of questions to apply to the case studies.

The second part of the plenary session included presentations by local project owners on the outputs, outcomes, and key learnings of the three projects implemented in Madagascar, Cambodia, and Guatemala. These served as the basis for the workshops with the aim to apply the 9-step framework from WHO-ExpandNet[17] and start developing a local scaling up strategy plan for these innovations.

For the two workshop sessions (1 h 30 min of duration each), the participants were split into three groups based on language, with approximately 10–15 people in each group: one French-speaking group worked on the Madagascar case study, the other French-speaking group focused on the Cambodia program, while the English-speaking participants worked on the Guatemala project. Each group worked on the same project throughout the 2 days.

On the last day, all participants met together to present each group's outputs and to gather input and comments from the other groups. These were summarized into the following proceedings.


  Overview of the Case Studies and Workshops Top


Madagascar: building capacity and raising awareness to improve access to mental health and epilepsy care

A door-to-door survey suggests that 34% of Madagascar population (46% in the Antananarivo area) will experience at least one mental disorder during their life.[18] With only 14 psychiatrists for a total population of 24 million (0.06/100,000 population vs. 12.4 in the USA),[19] Madagascar's health-care system is underresourced to meet the country's mental health needs.

In 2013, a 5-year partnership was signed between the Ministry of Public Health in Madagascar and Sanofi to improve access to health care in the fields of epilepsy and mental health. The pilot program has been implemented in 15 districts in five regions (Analamanga, Vakinankaratra, Amoron'i Mania, Vatovavy-Fitovinany, and Sofia) in the country, representing a total population of 4.4 million.[20]

The project had two specific objectives: (1) training primary health-care professionals (HCPs) on diagnosing and treating mental disorders and (2) raising awareness among the general public about mental health disorders, through a set of Behavior-Change-Communication (BCC) interventions.[20]

In total, between 2014 and 2017, 102 GPs were trained through a series of face-to-face workshops on a range of diseases (schizophrenia, depression, anxiety disorders, addictions, epilepsy, etc.) with average improvements in knowledge ranging between + 19% and + 45%, as shown through pre- and post-training questionnaires. These training sessions were followed by 149 individualized supervision sessions with a specialist. Several BCC materials in Malagasy language have been developed and disseminated. An estimated 1,837,500 people have been reached through community awareness activities as well as local TV and radio programs.[20]

According to sectorial data collected by the Ministry of Public Health, between 2015 and 2018, it is estimated that on average, every year, each trained GP in the 15 pilot districts has diagnosed and managed 210 patients with mental disorders or epilepsy, while at the same time, the average was twenty patients/GP/year for untrained GPs.[20]

Although the innovation to scale up was initially defined as the “transfer of competencies from specialist to GPs to manage patients with mental disorders and epilepsy,” the group wondered whether it was actually possible, looking at the outcomes achieved, to dissociate the effects of the training of the GPs from those of the awareness activities which were also implemented as part of the project, and whether, in fact, the innovation was not the combination of both.

When discussing step 1, and “planning actions to increase the scalability of the innovation,” the group spent quite a bit of time reviewing the Credibility, Observability, Relevance, Relative advantage, Ease of transfer/installation, Compatibility, and Testability (CORRECT) criteria. It became obvious that although there were some data available regarding the improvement in knowledge for the trained GPs, as well as some estimation regarding the number of people diagnosed by trained GPs, there were potential improvements to increase the credibility of the innovation, and that a proper evaluation of the activities would increase the credibility of the innovation. More robust data which could be published would also assist in increasing its observability. It would provide opportunities for stakeholders to see the results and would allow to build a strong advocacy campaign. Although the relevance of the innovation appeared obvious in Madagascar, where there is such a high prevalence of mental disorders and so few trained medical personnel to manage patients with these disorders, it was felt by many that highlighting comorbidities and the impact of mental disorders not only on the prevalence but also on the severity of other NCDs such as cardiovascular diseases, diabetes, and cancer could only help with the perception of the relevance of the innovation. With regard to the ease of transfer, considering that the scaling up of the innovation would mean training 950 GPs in 115 districts in 22 regions (vs. 100 GPs in 15 districts in five regions in the pilot), there was a need to look at combining e-learning and face-to-face workshops to make the scaling up feasible and cost-effective. There were also discussions about the need to integrate mental health in other programs that are already using digital tools (maternal health, plague, etc.) to pool and share resources.

The group then discussed step 2 and “how to increase the capacity of the user organization to implement scaling up.” It became quite apparent that one of the key barriers to implement a successful scaling up, was actually the low availability of psychotropic medications in rural pharmacies; the central purchasing unit will normally order medicines based on actual demand, and as demand in districts where GPs have not yet been trained is very low, there might not be any psychotropic medications available for patients newly diagnosed by trained GPs. This would result in a significant reduction in the impact of the training of GPs. It seems therefore important, prior to the training taking place, to advocate for a safety stock of psychotropic medicines to be available in rural pharmacies.

While going through step 3 and “assessing the environment, reviewing conditions and institutions external to the user organization, and planning actions to increase the potential for scaling up success,” it was felt that the implementation of the Universal Health Coverage would help address what is perhaps the single-most important issue, the lack of financial resources of the population. In the meantime, to mobilize support and reduce opposition through advocacy with influential individuals, groups, or institutions, to build a network of supporters, it was thought that alliances had to be established with the media, leveraging testimonials of patients and families, that strong collaborations with other departments of the Ministry of Public Health (e.g. communications), and other ministries (e.g. economy to highlight with data the impact of mental disorders on economic outputs), as well as partnerships with traditional healers, etc., would also help. Similarly, a better information system would improve data collection and therefore monitoring and evaluation of such programs.

Discussions for Step 4 (Increasing the capacity of the resource team to support scaling up) focused on the fact that the people who facilitated the implementation of the pilot project would become the core team of the resource team during scaling up. However, their skills in terms of people management, as well as project management, would need to be reinforced, and new team members with relevant experience would need to be recruited. Additional financial resources and equipment would also be required.

Community-based management of epilepsy in Cambodia: the Epilepsy Cambodia InteRvention

With an epilepsy prevalence of 5.8 ‰ in Cambodia,[21] and a treatment gap exceeding 90%, the primary objective of the Epilepsy Cambodia InteRvention program was to reduce the epilepsy treatment gap in the intervention area compared with the control area through the identification and home follow-up of people with epilepsy (PWEs) by Domestic Health Visitors for epilepsy (DHVes), who were volunteers living in the villages they covered. The secondary objectives were to reduce stigma as measured by the Jacoby scale, and to improve knowledge, attitudes, and practices.[9]

Alhtough the entire project was of 2 years of duration, the implementation phase went on for only 12 months. In terms of outputs, the following results were achieved during the implementation phase: 12 primary health-care center staff, 5 GPs, and 3 pharmacists, as well as 30 DHVes in the intervention area, were trained. Local BCC materials were developed in Khmer language and made available in the health-care centers of the control area, while being actively disseminated by DHVes in the intervention area. There were actually 345 educational meetings organized by DHVes in the intervention area reaching 7471 people, approximately 25% of the total population. Antiepileptic drugs (AEDs) were made available in both control and intervention areas. From an outcome point of view, data published at congresses so far show that after 6 months of intervention, the treatment gap was reduced by 31.1% (0–55 cases out of the 177 expected) in the intervention area compared to a 7.0% decrease (0–23 cases out of the 327 expected) in the control area (P < 0.0001).[9]

During the discussion of step 1 and “how to increase the scalability of the innovation,” it was underlined that the data were pretty robust, issued from a study with a valid quasi-experimental evaluation methodology, it was therefore high-level evidence. Moreover, from a credibility point of view, the results have already been communicated to the Ministry of Health and to local health authorities during a symposium. Furthermore, the data have been submitted to a top-tier peer-review journal. From an observability point of view, differences between the intervention area and control area were pretty significant, and although with the end of the DHVes activities, things might have returned to their previous status, it has been shown that 98% of the effect could actually be reached through the first 6 months of DHVes activity. This seems a particularly relevant system to put in place for epilepsy as DHV and community health workers (CHWs) are already involved in Cambodia with other public health activities such as vaccination campaigns. To further increase its relevance, and its relative advantage, translating the burden of epilepsy in economic terms might help convince some of the decision makers. The ease of transfer would also be improved by the implementation of a sustainable remuneration system for DHVes/CHWs and a smoother coordination between the Ministry of Health and rural communities.

Step 2 (how to increase the capacity of the user organization to implement scaling up?) and step 4 (increasing the capacity of the resource team to support scaling up) were discussed consecutively. The user organization would be the Ministry of Health and its local representatives. During the testing of the intervention strategy, the key issue encountered, in part due to the multipartner aspect of the project, has been the high turnover of stakeholders within the various organizations involved, and therefore the difficulty to gain a long-term commitment. Another learning has been the key role played by the local representatives of the Ministry of Health, for instance, the head of the province. Furthermore, there are few associations in Cambodia advocating for PWEs: to increase the capacity of the resource team, it appears important to secure the support from as many associations as possible, in particular patient and family associations (in other countries, their role in terms of access to treatment has been key), but also from learned societies such as the Cambodian Society of Neurology and the Cambodian League Against Epilepsy. Engaging with structures in charge of medicines availability to ensure that stock of AEDs be available in rural areas seemed also essential.

While “assessing the environment and reviewing conditions and institutions external to the user organization” (step 3), it was highlighted how inextricably interwoven the various components of the intervention were: training of DHVes, training of HCPs, availability of AEDs, etc., and therefore how essential it was that they all be well executed and synchronized, for the expected outcomes to be reached. This means that the activities of the various stakeholders need to be very carefully planned and orchestrated.

Step 5 focused on the “strategic choices to make to support vertical scaling up and the institutionalization of the suggested strategy.” What policy, legal, political, regulatory, budgetary, and other health system changes would be needed to ensure the innovation could be institutionalized? Examples from nurses visiting PWEs in Morocco as well as India's Village Health Sanitation and Nutrition Committees were discussed, a key mechanism for community health governance and management of diabetes.[22] Some of the key issues emphasized regarding vertical scaling up were political commitment and sustained funding of DHVe activities. Again, the burden of epilepsy and mental disorders needs to be better understood by decision makers so that resources are better allocated.

With regard to “making strategic choices to support horizontal scaling up (expansion/replication)” (Step 6), it was highlighted that the geographical expansion would have to be progressive, province by province, with prioritization of the areas, as training capacity is limited with a small number of neurologists. Close monitoring of the outcomes of the training would also allow for continuous adjustments in terms of both the content and the format of the training. It was highlighted that a team dedicated to mental health and epilepsy within the Ministry of Health would be required for an effective scaling up, allowing for effective mobilization of resources both at the central and local level, as well as the coordination of activities.

Discussions highlighted the need to combine epilepsy with other NCDs (such as psychotic disorders, diabetes, and cardiovascular diseases) as part of the awareness and screening activities of DHVes: this would avoid duplication of systems and further increase the cost-effectiveness of such activities. Similarly, the use of digital tools and centralized eMedical records was discussed.

ALAS Pro Salud Mental: improving access to mental health care in rural Guatemala

Multiple natural disasters, poor infrastructure, high poverty rate, and the 36 years of civil war that ended in December 1996 have created deep and severe emotional consequences for thousands of families in Guatemala. There is also the everyday violence that affects almost everyone in Guatemala and keeps people in a constant state of fear and alert.[23]

As a result, the prevalence of mental disorders is high (27.8%) including substance abuse disorders (7.8%), depression (6.4%), psychotic disorders (2.2%), posttraumatic stress disorder (6.9%), and anxiety disorders (3.2%).[24]

Currently, access to mental health care is limited, mainly due to the lack of specialized human resources (0.29 psychiatrists and 0.53 psychologists per 100,000 population),[25] most of them located in Guatemala City,[26] and the lack of economic resources (1.46% of the nation's health budget is dedicated to mental health, 90% of this budget funds the national hospital in Guatemala City).[26] This is particularly true in rural areas such as the Sololà Department.

There are no facilities for primary mental health care available at the community level in the Sololà Department. Clinical personnel at primary care level lack training in psychiatry (mental health training is <1% of the medical school curriculum), and there are no resources for primary health-care workers to provide psycho-social support. More importantly, people's lack of knowledge and false beliefs regarding mental diseases (witchcraft, curses, distrust, fear of contagion, and craziness) dissuade most of them to seek clinical attention.[23]

ALAS Pro Salud Mental was founded in 2013 in partnership with the WASP and Sanofi with the aim of providing culturally respectful care, rehabilitation, and empowerment to people with mental illness within their communities and to reduce societal stigma and discrimination in the Sololà Department. Sololà is a mountainous department in South-West Guatemala. It has a population of over 450,000 people belonging almost entirely to different Mayan ethnic groups. Sololà is the second poorest department in the country, with 75% of the population living below the poverty line and 29% below the extreme poverty line.[23],[27]

ALAS has created alliances with the state health service, community health centers, local pharmacies, community leaders, and universities and includes the following four main components:

  • ALAS provides access to care through free consultations, treatment, and support to underprivileged families
  • ALAS fights against stigma by disseminating information and educating the population to reduce discrimination
  • ALAS trains primary health-care workers (physicians and other HCPs) on mental disorders
  • Finally, ALAS helps to rehabilitate and empower patients, teaching them how to recover their independence and productivity, as well as how to manage their rights.


In 2017, the following outputs and outcomes were achieved: in terms of access to care, there were 683 clinic consultations for 309 patients and 74 home visits for 38 severely ill patients. For the FAST component, there were 9 workshops involving 326 elementary teachers, 17 workshops involving 375 children and teenagers, 21 TV programs (local and YouTube), and 10 radio programs in Maya language and 2 in Spanish. Regarding training and education, 67 GPs were trained, using the WHO mhGAP materials. For rehabilitation and empowerment, 12 self-help group sessions were held for a total of 360 participants. Collaborations with Stanford University (psychiatry residents), Universidad de San Carlos de Guatemala, and with Ecole Polytechnique's X microfinancing continued.[13]

During the discussion about the feasibility of scaling up all four components of ALAS Pro Salud Mental activities, the consensus was that there was a need to prioritize, and out of the four, the most important innovation to scale up was probably the training component and in particular, the GP training. In the context of a scaling up, the training would be based on the WHO mhGAP, with the involvement of the Pan American Health Organization (PAHO), and would need to be accredited by the Ministry of Health or the Guatemalan College of GPs so that Continuing Professional Development (CPD) points would be earned by trained GPs.

As part of step 1 (planning actions to increase the scalability of the innovation), the group discussed credibility, agreeing that it could be improved with more robust data quantifying the direct gain in knowledge as well as with regard to the number of patients diagnosed and managed by the 67 GPs who have been trained in the Sololà area. Such data would need to be published. With a > 85% treatment gap, it was felt that the relevance of the innovation was high. Its relative advantage versus training specialists stems primarily from the existing broad network of GPs, well established within rural communities, and from the cost-effectiveness of training GPs. Regarding the ease of transfer/installation, there was obviously a need for additional human resources and trainers who could deliver regional training sessions, supervise GPs in their practice, and conduct posttraining evaluation 6–8 weeks post-training, not to mention time conflicts with agendas of GPs who are already overworked. The training would need to be rolled out progressively from a geographical point of view to ensure that GPs in place are adequately trained. For medical students currently going through training at Med-school, the current curriculum would need to be updated to include adequate modules for the diagnosis and management of people with mental disorders. Regarding compatibility, it was felt that if training of GPs was possible to implement, other critical success factors, such as the availability and accessibility of psychotropic medications, were not compatible with the current values or services of the user organization. Re-allocation of budget by the local authorities is required to ensure that one from each category from the WHO Essential Medicines list for mental disorders is available.

When discussing step 2 and “how to increase the capacity of the user organization to implement scaling up,” the group felt that although real and well documented, the lack of access to treatment for people with mental disorders in Guatemala was not perceived as a priority by political decision makers. There was a need to develop an advocacy campaign based on concrete examples of what access to treatment means in terms of impact for patients with debilitating mental diseases and their families. The user organization would be the Ministry of Health. With regard to implementation capacity, it would rely on PAHO to conduct the training, although it would be driving recruitment and ensuring that GPs attend training sessions.

While addressing step 3 (assessing the environment, reviewing conditions, and institutions external to the user organization), it was discussed that there was no proper national mental health policy in Guatemala and that with the political instability and constant changes at the Ministry of Health, raising the profile of mental health would only be possible by sustaining advocacy efforts. The socioeconomic and cultural context of the local population is also particularly complex with 28 different languages and many cultural beliefs preventing patients from seeking treatment. In addition, stigma is a major problem for people living with mental illness. It has a negative influence on the economic and social opportunities of patients and their families. Stigma is present at almost every level of society, from the patient and family to the community caregivers. Collaboration with public health institutions should be strengthened and the creation of patient associations should be supported to improve the social and political environment in mental health for better care and quality of life for patients and their families.

When discussing “the capacity of the resource team to support scaling up” (Step 4), it was felt that there was a strong group of supporters and champions surrounding the ALAS core Team, with strong leadership and credibility, and good skills. Although of limited size, this team had been very stable and would be key as a resource team for the scaling up.

Horizontal and vertical scaling ups were also briefly discussed. Horizontal scaling up would be possible at various sites that have already heard about the program, so the “innovation” can be replicated in different geographically close areas. With regard to vertical scaling up, the first step is to seek a real political commitment in order to institutionalize the innovation.


  Results of the Survey on Knowledge and Understanding of Scaling Up Theories Top


An online survey, in both English and French languages, was conducted right at the start of the Forum, to evaluate the baseline knowledge and understanding of the participants toward scaling up. The same questionnaire was used again at the end of the IMPACT Forum to assess changes in the knowledge and understanding of scaling up.

Thirty-seven out of the forty IMPACT Forum participants (92.5%) completed the online survey on their laptop computer, tablet, or smartphone at the start of the forum and 32 (80%) completed it at the end of the forum. Twenty-nine questionnaires could be paired and six pairs had to be excluded as these people were involved in preparing for the workshops and therefore had been exposed to the WHO-ExpandNet literature prior to the Forum, which left 23 paired questionnaires for the analysis.

The majority of participants who completed the survey were physicians (69.5%) [Table 1], while there was broader representation with regard to their place of work [Table 2].
Table 1: Professional status of the participants

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Table 2: Place of work of the participants

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When asked at baseline about their level of knowledge on scaling up methodology, the vast majority (16 participants, 69.6%) indicated that they had very limited knowledge and no experience with it [Figure 2].
Figure 2: Level of knowledge of the scaling up methodology at the start of the Interactive Meetings Promoting Access to Care and Treatment forum (n = 23)

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With regard to their level of comfort with scaling-up theories, out of a maximum score of 5, the average score for participants went from 2.5 ± 1.3 at the start of the forum, to 4.0 ± 0.6 (P = 0.001) at the end of it, suggesting a positive impact of the various plenary and workshop sessions [Table 3].
Table 3: Evolution of the level of comfort with scaling-up theories and overall knowledge score, between pre- and postsessions

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Similarly, there were improvements in the overall knowledge score: out of a maximum of 10, the score at baseline was 4.4 ± 2.6, versus 6.8 ± 2.5 at the end of the forum, P < 0.001 [Table 3].

Out of the nine knowledge questions, a positive trend was shown for all of them, although statistical significance was only reached for four of them [Table 4].
Table 4: Individual knowledge questions - evolution of responses between pre- and post-sessions

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When looking at the overall score for each participant [Figure 3], there was an improvement at the end of the forum for all but three participants who actually maintained their initial score.
Figure 3: Evolution of individual knowledge scores (pre-sessions vs postsessions)

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  Conclusion Top


Overall, the level of satisfaction of the participants at the 2018 edition of the IMPACT Forum, was very high (mean of 4.7 – out of a maximum score of 5).

In terms of usefulness of the scaling-up sessions (plenary and workshops), the average score was 4.5, with 58% of participants giving it the maximum score of 5, and 33% rating them at 4.

The 2018 IMPACT Forum achieved positive outcomes with regard to the participants' knowledge and understanding of scaling-up principles. It also allowed participants to review the outputs and outcomes of three pilot projects, discuss these, and apply the WHO-ExpandNet 9-step scaling-up conceptual framework to help stakeholders from these three countries to start planning for scaling up.

Acknowledgments

We are very grateful for the contributions made by all the IMPACT Forum participants that enriched the discussions and allowed to write the proceedings of this meeting.

Financial support and sponsorship

The IMPACT Forum was fully funded by Sanofi.

Conflicts of interest

PEB is an employee of Sanofi and owns Sanofi stocks. All other authors declare that there is no conflict of interest related to the writing and publication of this article.



 
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    Figures

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