Implementing civic engagement within mental health services in South East Asia: a systematic review and realist synthesis of current evidence

Karina Lovell,Helen Brooks,Diana Rose,Irman Irmansyah,Budi-Anna Keliat,Bagus Utomo,Karen James,Herni Susanti,Jessica Waddingham,Erminia Colucci

doi:10.1186/s13033-020-00352-z

Abstract

IntroductionCivic engagement (CE) has the potential to transform mental health services and could be particularly important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. Research from high income countries has found many challenges associated with the meaningful implementation of CE in practice, but this has been underexplored in LIMCS and in South East Asia (SEA) in particular.MethodsWe completed a realist synthesis and systematic review of peer reviewed publications and grey literature to identify the context and actions which promote successful implementation of CE approaches in SEA. We used a theory-driven approach—realist synthesis—to analyse data and develop context-mechanism-outcome configurations that can be used to explain how civic engagement approaches operate in South East Asian contexts. We worked closely with patient and public representatives to guide the review from the outset.ResultsFifty-seven published and unpublished articles were included, 24 were evaluations of CE, including two Randomized Controlled Trials. The majority of CE interventions featured uptake or adaptation of Western models of care. We identified important cultural differences in the enactment of civic engagement in SEA contexts and four mechanisms which, alongside their contextual barriers and facilitators, can be used to explain how civic engagement produces a range of outcomes for people experiencing mental health problems, their families and communities. Our review illustrates how CE interventions can be successfully implemented in SEA, however Western models should be adapted to fit with local cultures and values to promote successful implementation. Barriers to implementation included distrust of services/outside agencies, stigma, paternalistic cultures, limited resource and infrastructure.ConclusionOur findings provide guidance for the implementation of CE approaches within SEA contexts and identify areas for further research. Due to the collectivist nature of many SEA cultures, and the impact of shared traumas on community mental health, CE might best be implemented at community level, with a focus on relational decision making.Registration This review is registered on PROSPERO: CRD42018087841.

Highlights

Civic engagement (CE) has the potential to transform mental health services and could be important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health
The rights of people with mental health problems to be involved as equals in decisions about their care are guaranteed by the Convention on the Rights of Persons with Disabilities, ratified by over 150 countries, a wide range of violations have been reported in LMICs [9]
Realist synthesis aims to discover “what works for whom, under what circumstances, how and why?” by exploring interactions between context, mechanisms of action and outcomes of an intervention [33]. This was our chosen approach because (i) it is useful when evaluating complex interventions, such as civic engagement, which are likely to work in different ways when implemented in different settings (ii) it allows for the synthesis of a diverse range of data sources, and (iii) it elicits detailed and practical information, which can be used by policy makers, managers and service users in the planning and implementation of programmes

Summary

Introduction

Civic engagement (CE) has the potential to transform mental health services and could be important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. The involvement of people with experience of mental health problems in the design and delivery of services forms a central part of modern mental health research, policy and guidance [7, 8], and CE is a key focus of the WHO strategy for strengthening health systems globally [2] It is important for mental health systems in low and middle-income countries (LMICs), which are rapidly developing to respond to the substantial burden of mental health difficulties. The rights of people with mental health problems to be involved as equals in decisions about their care are guaranteed by the Convention on the Rights of Persons with Disabilities, ratified by over 150 countries, a wide range of violations have been reported in LMICs [9] Stigma towards those with mental health problems is pervasive in LMICs which represents a significant barrier to the implementation of civic engagement activities [10–12]. Such vulnerabilities to human rights abuse and stigma towards those with mental health problems have been reported in Western contexts [13]

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