Mental Health Social Interventions: Creating a Framework for Evidence-Based Cultural Adaptation in Social Work Research

Background and Purpose:

Recent estimates suggest that about four out of five people in low- and middle-income countries (LMIC) in need of mental health services do not receive treatment. In Sierra Leone, a post-conflict country now responding to the emergency situation caused by the Ebola Virus Disease (EVD), the mental health treatment gap exceeds 95% with just one psychiatrist for a population over six million.

The application of social interventions is an important opportunity to address the mental health treatment gap through strategies which facilitate participation, empowerment and mobilise existing community resources. However, one of the primary challenges of adapting social interventions is developing ‘socially robust’ strategies that capture the nature of the social, political and cultural environment central to shaping mental wellbeing and recovery from distress.

In this study, we developed an evidence-informed framework to adapt a social intervention aimed to enhance the capacity of mental health workers in the resource-poor environment of Sierra Leone. The framework is grounded in scientific evidence, social work theory, a participatory approach to stakeholder engagement, and underlying principles of capacity building.

Methods:

The study was conducted in partnership with key mental health stakeholders in Sierra Leone and the United Kingdom (e.g., policy makers; NGOs; researchers; educators; Sierra Leone Diaspora; and a variety of service providers). We used collaborative intervention framework methodology in four phases: 1) systematic review of social interventions adapted for LMIC (n=23 studies) 2) ethnographic feasibility study 3) social intervention model and training programme development 4) piloting of training programme and evaluation of intervention model fidelity (n=20 nurses).

Quantitative (questionnaires and process evaluations) and qualitative (interviews, observations and focus groups) data were collected over a three-year period. Quantitative data were analysed using SPSS 22.0 and qualitative data were assessed using Framework Analysis in Nvivo 10.0.

Results:

The application of a four-phase approach enabled flexibility to respond to the changing needs of communities in Sierra Leone amid an emergency situation and to identify a series of cultural adaptations without compromising the core elements of the original mental health social intervention. As Sierra Leone’s workforce does not include mental health social workers, we piloted the intervention with nurses whose skills were limited with regard to engaging social networks.

A multi-level framework consists of five components 1) mental health addressed on levels of individuals (micro), families/friends (meso) and communities (macro) 2) cultural and socioeconomic relevance 3) research partnerships 4) collaborative education and capacity building 5) sustainability. The framework’s practical application is illustrated through the presentation of the adapted intervention model, training materials, implementation evaluation results and lessons learned, and future opportunities for scaling up.

Conclusions and Implications:

Reducing the mental health treatment gap requires local engagement, particularly when adapting interventions to be used with new communities and practice settings. Our study illustrates one approach that can be used to enhance the transportability of social work interventions that build capacity of the existing workforce and mobilise community resources at a low cost. Through appropriate modifications this framework can be applied and scaled-up across different settings globally.