Evaluation of collaborative mental health services in Latin America: Theoretical and methodological basis.

OBJECTIVES: Approaches to collaborative mental health care (CMHC) have been implemented in many countries to strengthen the accessibility and delivery of mental health services in primary care. However, there are not well-defined frameworks to evaluate CMHC models. The purpose of this article is to identify, contextualize and discuss relevant health services research approaches, theory, and evaluation models for the development of an appropriate evaluation framework in order to foster effective CMHC in Latin America. METHODS: A comprehensive literature review informed a critical analysis of relevant theories and alternative methods to be considered in the development of the framework. RESULTS: Specific health services research frameworks are discussed in the context of evaluating CMHC. Two theoretical perspectives - collaboration theory and systems theory - and three evaluation models- realistic, developmental and collaborative - are analyzed in terms of their relevance. Methodological implications are identified. CONCLUSION: An appropriate evaluation framework for CMHC in Latin America needs to reflect theoretical and contextual considerations and relevant evaluation approaches and methods, including key dimensions and attributes/variables, core indicators, and recommendations for implementation.

Developing and Testing an Evaluation Framework for Collaborative Mental Health Services in Primary Care Systems in Latin America.

To develop and pilot-test a feasible and meaningful evaluation framework to support the ongoing improvement and performance measurement of services and systems in Latin America regarding Collaborative Mental health Care (CMHC). This mixed methods study, guided by a developmental evaluation approach, included: (1) a critical review of the literature; (2) an environmental scan at three selected health networks in Mexico, Nicaragua and Chile; (3) a Delphi group with experts; (4) a final consultation in the three sites; and (5) a pilot-test of the framework. A comprehensive evaluation framework was developed and successfully piloted. It considers five levels, 28 dimensions and 40 domains, as well as examples of indicators and an implementation plan. This evaluation framework represents an important effort to foster accountability and quality regarding CMHC in Latin America. Recommendations to build upon current capacity and to effectively address the existing implementation challenges are further discussed.

Perceived importance and interest in research by Chilean primary care providers.

BACKGROUND: Primary care providers (PCPs) are relevant stakeholders for primary care research (PCR). OBJECTIVE: We report the perceived importance and interest in PCR of a national sample of Chilean PCPs. METHODS: We conducted a cross-sectional study targeting Chilean PCPs. An electronic survey assessing perceived relevance of PCR, research training and experience, training interests, and demographics was disseminated through emails and WhatsApp messages. Descriptive statistics were used to summarize data. Logistic regression models were used to estimate adjusted probabilities and 95% confidence intervals for high interest in PCR, high interest in using research methods, and high interest in receiving research training, and predictors of these outcomes. RESULTS: A total of 387 providers completed the online survey. Only 26.4% of PCPs had research experience as a principal or co-investigator. However, most clinicians perceived PCR as very important (92.5%) and were interested in using research methods (90.7%) and receiving training (94.3%). There were no statistically significant differences in these perceptions between provider's discipline, role, sex, age, and geographical location after adjusting for covariates. CONCLUSIONS: Despite few Chilean PCPs have research training, a large majority perceive it as important, are interested in using it in their practice and would like to receive training.

Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare.

Background & objectives: Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation. Methods: Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training. Results: Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State. Interpretation & conclusions: The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Evaluation of patients´ perspective on a multimorbidity patient-centered care model piloted in the chilean public health system.

BACKGROUND: The progressive multimorbidity explosion has challenged Chile's health systems and worldwide. The Centro de Innovación en Salud ANCORA UC implemented a new Multimorbidity Patient-Centered Care Model in Chile. OBJECTIVE: Evaluate the perspective of high-risk patients about the core elements of the model. METHODOLOGY: We conducted a cross sectional telephone-based survey that considered the application of a 13 items questionnaire. Of them, nine were Likert scale questions with scores from 1 to 7, one dichotomic question, and three open-ended questions. 231 high-risk patients who received care through the model at primary care centers participated in the study. Quantitative data were encoded, consolidated, and analyzed with the SPSS software. We performed descriptive and analytic statistics techniques to assess different variables and their potential associations. Thematic analysis was conducted for qualitative data. RESULTS: The overall score was 5.84 (range: 1 to 7), with a standard deviation of 1.25. Questions with the best scores were those related with personalized care and the primary care teams. The lowest scored was for the item regarding the continuity of care between primary nurses and inpatient care at the hospital. There was a difference in patient outcomes depending on their health center. Regarding sociodemographic characteristics, age did not significantly affect the results. CONCLUSIONS: The study reveals the perceptions about a complex multimorbidity intervention from the patient's perspective. It complements the impact on health services utilization evaluation that supports decision-makers currently scaling up a similar strategy in our country and could be considered in other countries dealing with non-communicable diseases.

Evaluation of the implementation progress through key performance indicators in a new multimorbidity patient-centered care model in Chile.

BACKGROUND: Complex health interventions involve deep organizational, structural, and cultural changes that challenge health teams and decision-makers. The explosion of chronic diseases has made the multimorbidity approach a global priority. The Centro de Innovación en Salud ANCORA UC implemented a Multimorbidity Patient-Centered Care Model in the Chilean public health system. OBJECTIVE: This study aims to evaluate the progress of the implementation of the Multimorbidity Patient-Centered Care Model in seven primary care centers through key performance indicators. METHODS: a set of indicators was designed to evaluate change management, operations, installation of new roles, and services and activities of the intervention strategy of the model. Key performance indicators were identified to monitor the implementation progress on minimal components for the model's sustainability. Each item was assigned against an expected minimum score of 67% of progress from the overall score. They were monitored twice in seven primary health centers in 2019 and 2020, which intervened 22,642 patients with the intervention. RESULTS: The results showed that six of the seven primary care centers reached the minimum implementation threshold. The main advances were in operational conditions, and those with minor progress in implementation were the clinical services. Population size, organization, coordination of the health care teams, additional training, and decision-makers support were key factors that determined the degree of progress in a complex intervention. CONCLUSION: It was possible to measure the progression of the implementation of a complex intervention through key performance indicators delivering relevant information for decision-makers that pursue a successful and faithful implementation. This study provides a valuable tool for the national scale-up of a similar model started in Chile by the Ministry of Health and other countries.

Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries.

BACKGROUND: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. METHODS: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. FINDINGS: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. CONCLUSIONS: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

[Contribution of a multimorbidity person-centered care strategy to the Comprehensive Family and Community Healthcare Model in Chile]. / Contribución de una estrategia de atención centrada en la persona con multimorbilidad al Modelo de Atención Integral de Salud Familiar y Comunitario en Chile.

BACKGROUND: The Multimorbidity Person-Centered Care Model allows to customize care according the needs of each person. AIM: To characterize the perception of health teams about the contribution of the Multimorbidity Person-Centered Care Model (MACEP) to the development of the key principles of the Comprehensive Family and Community Health Care Model (MAIS). MATERIAL AND METHODS: A qualitative collaborative study with 35 interviews and the participation of 67 professionals from the primary healthcare network. Content analysis using mixed code system with MAXQDA2020 program. RESULTS: The innovations and complex interventions that positively affect the development and implementation of the essential principles of MAIS were recognized by participants as a contribution of the central elements of MACEP. CONCLUSIONS: This contribution is an opportunity for the expeditious implementation of Family Health principles in the health network. Incorporating the vision of implementers and users, who are part of these changes, is essential. It is necessary to establish, project and evaluate innovations to identify, implement and promote learning at Health Services throughout the country.

Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India.

BACKGROUND: Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level. AIMS: To describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India. METHOD: This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention. RESULTS: Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50-0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15). CONCLUSIONS: To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.

[Mental Health Global Action Programme (mhGAP) in Chile: Lessons Learned and Challenges for Latin America and the CaribbeanPrograma de ação mundial para reduzir as lacunas em saúde mental (mhGAP) no Chile: aprendizados e desafios para América Latina e Caribe]. / Programa de Acción Mundial para Superar las Brechas en Salud Mental (mhGAP) en Chile: aprendizajes y desafíos para América Latina y el Caribe.

OBJECTIVES: Present the methodology for comprehensive evaluation of the implementation of the Mental Health Global Action Programme (mhGAP) in Chile and describe the program's results. METHODS: Cross-sectional evaluative study based on a survey of key program informants deployed in 29 public health services in the country, as well as individual interviews and focus groups with key actors and experts. The evaluation was focused on the relevance and impact of mhGAP on the provision of mental health services and on the implementation of the program. RESULTS: The participants gave a positive evaluation of the progressive implementation of mhGAP in Chile. In particular: 1) They reported having better tools for detecting, diagnosing, and treating common disorders, and efficient referral strategies; (2) They rated all modules as important, the most relevant being self-harm/suicide (x¯ = 4.77) and mental and behavioral disorders in children and adolescents (x¯ = 4.58); (3) They favorably assessed the National Mental Health Day training courses and the subsequent courses repeated at the local level, indicating that these courses contributed to successful implementation of mhGAP; (4) They agreed on the need to incorporate new actors, strengthen certain aspects, and expand information on the program. CONCLUSIONS: The implementation of mhGAP in Chile is an emblematic example of learning supported by the development of community mental health and family health, among other factors. These accomplishments offer a unique opportunity to continue advancing the implementation of this program in the country and to implement this experience in other contexts in Latin America and the Caribbean.

OBJETIVOS: Apresentar a metodologia de avaliação completa da implementação do Programa de ação mundial para reduzir as lacunas em saúde mental (Mental Health GAP, mhGAP) no Chile e descrever seus resultados. MÉTODOS: Estudo avaliativo transversal baseado em levantamento realizado com profissionais de referência do programa, distribuídos em 29 serviços de saúde da rede pública do país, e entrevistas individuais e grupos focais com as principais partes interessadas e especialistas. O enfoque da avaliação foi a relevância e o impacto do mhGAP na prestação de serviços de saúde mental e a implementação do programa. RESULTADOS: Os participantes do estudo avaliaram positivamente a implementação progressiva do mhGAP no Chile. Em particular, 1) eles afirmaram possuir recursos melhores para detecção, diagnóstico e tratamento de transtornos frequentes e estratégias de encaminhamento eficientes; 2) classificaram todos os módulos como importantes, com destaque a autoagressão/suicídio (x¯ = 4,77) e transtornos mentais e de comportamento em crianças e adolescentes (x¯ = 4,58); 3) avaliaram de forma favorável a realização das Jornadas Nacionais de Saúde Mental e suas iterações em nível local contribuindo ao sucesso da implementação do mhGAP e 4) concordaram com a necessidade de atrair mais interessados, reforçar alguns aspectos e ampliar a divulgação do programa. CONCLUSÕES: A implementação do mhGAP no Chile é um caso emblemático de aprendizado apoiado no avanço da saúde mental comunitária e saúde da família, entre outros fatores. Esta conquista cria uma oportunidade única para continuar a expandir a implementação do programa no país e disseminar esta experiência a outros contextos na América Latina e Caribe.

Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review.

BACKGROUND: Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions. METHODS: PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR). RESULTS: A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven. CONCLUSION: Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.

Stigma in health facilities: why it matters and how we can change it.

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge-both approaches and methods-regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development's Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.

Evaluation of a Pilot Intervention to Reduce Mental Health and Addiction Stigma in Primary Care Settings.

Healthcare environments are not exempt from the impact of stigma against mental illness and addiction, which contributes to barriers to client access and appropriate treatment. To address this concern, healthcare organizations have a growing interest in mental illness and addiction anti-stigma anti-discrimination programming as part of their staff-wide professional development. Though standard interventions demonstrate effectiveness in the short and mid-term, the evidence for long-term change is inconclusive. A flexible, innovative intervention was developed in collaboration with community health care centres to reduce mental illness and addiction stigma and discrimination at an organizational level. A mixed methods approach was utilized to develop the intervention design and evaluate the effectiveness of the intervention. 137 people participated in the survey component of the study and five senior management staff in interviews. Quantitative results showed that the intervention was effective in changing attitudes toward mental illness (e.g. 5,9% improvement in OMS-HC score, p < 0,05) and substance use problems (e.g. 8.4% reduction in social distance for heroin dependence, p < 0.05). Qualitative findings were positive for indicators of observed improvement in mental health knowledge and behaviour. The implications for future research that allows for the further evaluation of multicomponent anti-stigma interventions in healthcare settings are discussed.

[Social support, self-rated health, treatment adherence and effectiveness in patients with type II diabetes and hypertension]. / Apoyo social percibido en pacientes con Hipertensión Arterial y Diabetes Mellitus tipo II en Atención Primaria y su relación con autopercepción de salud.

BACKGROUND: A high level of social support (SS) is associated with better health outcomes in many conditions, such as chronic diseases. AIM: To describe the level of SS in patients with Hypertension and type II Diabetes at Primary Health Care level in Chile and its association with self-rated health, adherence to treatment and better glycemic and blood pressure control. MATERIAL AND METHODS: SS was measured using a social support inventory previously validated in Chile. Self-Rated Health was assessed with a single non-comparative general question; adherence to medication was assessed using the four-item Morisky medication adherence scale. Blood glucose and blood pressure control were also assessed. A logistic regression was performed to estimate Prevalence Odds Ratio (POR) and Robust Poisson method to estimate the Prevalence Ratio (PR). RESULTS: Eighty three percent of the 647 participants evaluated high for SS. There was a significant correlation between SS and Self-rated health (POR 2.32; 95% confidence intervals (CI) 1.19-11.23; PR 1.18; 95% CI 1.07-1.31). No statistically significant association was observed with medication adherence, glycemic or blood pressure control. CONCLUSIONS: High levels of SS were found. The association between self-rated health suggests that SS interventions targeting vulnerable subgroups would be worthwhile.

What makes a medical school socially accountable in Latin America? A report from a Latin American panel based on a qualitative approach.

BACKGROUND: Latin America is a region with huge health inequalities and a tremendous growth in the number of medical schools during the last decades. The role of the medical schools in reducing health inequality has not been systematically explored. METHODS: A qualitative framework method was used to explore the meaning, barriers, and facilitators of the concept of the social accountability of medical schools in Latin America. Twenty nine Latin American academic leaders from seven countries participated in an expert panel discussion. The Atlas ti.7 software was used to analyze the information. RESULTS: Social accountability was identified as a core dimension of the mission of medical schools. The panel identified a gradient of three dimensions associated with social accountability. First, a formative dimension related to student selection, curricular structure and community based learning initiatives. Second, a societal dimension associated with institutional mission, community partnerships, and social research projects. Third, a political dimension related with involvement in health policies and primary care engagement. Lack of accreditation standards was identified as a main barrier to improve social accountability. CONCLUSIONS: Latin American leaders consider that medical schools should develop specific formative, societal, and political initiatives in order to be socially accountable.

Mental health and addictions capacity building for community health centres in Ontario.

PROBLEM ADDRESSED: In recent years, there has been increased recognition in Canada of the need to strengthen mental health services in primary health care (PHC). Collaborative models, including partnerships between PHC and specialized mental health care providers, have emerged as effective ways for improving access to mental health care and strengthening clinical capacity. Primary health care physicians and other health professionals are well positioned to facilitate the early detection of mental disorders and provide appropriate treatment and follow-up care, helping to tackle stigma toward mental health problems in the process. OBJECTIVE OF PROGRAM: This 4-year mental health and addiction capacity-building initiative for PHC addressed competency needs at the individual, interprofessional, and organizational levels. PROGRAM DESCRIPTION: The program included 5 key components: a needs assessment; interprofessional education; mentoring; development of organizational mental health and addiction action plans for each participating community health centre; and creation of an advanced resource manual to support holistic and culturally competent collaborative mental health care. A comprehensive evaluation framework using a mixed-methods approach was applied from the initiation of the program. A total of 184 health workers in 10 community health centres in Ontario participated in the program, including physicians, nurses, social workers, and administrative staff. CONCLUSION: Evaluation findings demonstrated high satisfaction with the training, improved competencies, and individual behavioural and organizational changes. By building capacity to integrate holistic and culturally appropriate care, this competency-based program is a promising model with strong potential to be adapted and scaled up for PHC organizations nationally and internationally.

Collaborative mental health services in primary care systems in Latin America: contextualized evaluation needs and opportunities.

AIM: This study examined Latin American evaluation needs regarding the development of a collaborative mental health care (CMHC) evaluation framework as seen by local key health-care leaders and professionals. Potential implementation challenges and opportunities were also identified. METHODS: This multisite research study used an embedded mixed methods approach in three public health networks in Mexico, Nicaragua and Chile. Local stakeholders participated: decision-makers in key informant interviews, front-line clinicians in focus groups and other stakeholders through a survey. The analysis was conducted within site and then across sites. RESULTS: A total of 22 semi-structured interviews, three focus groups and 27 questionnaires (52% response rate) were conducted. Participants recognized a strong need to evaluate different areas of CMHC in Latin America, including access, types and quality of services, human resources and outcomes related to mental disorders, including addiction. A priority was to evaluate collaboration within the health system, including the referral system. Issues of feasibility, including the weaknesses of information systems, were also identified. CONCLUSION: Local stakeholders strongly supported the development of a comprehensive evaluation framework for CMHC in Latin America and cited several dimensions and contextual factors critical for inclusion. Implementation must allow flexibility and adaptation to the local context.