Barriers and drivers to stakeholder engagement in global mental health

Engagement with diverse stakeholders, including policy makers, care providers and service users and communities, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature.

Methods
We conducted semi-structured qualitative interviews with 29 recipients of Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of projects. We used framework analysis to identify key themes related to implementation barriers and drivers. This paper reports on barriers and drivers to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this journal.

Results
Barriers and drivers to stakeholder engagement were identified across four themes: (1) Contextual Considerations, (2) Resources, (3) Participation, Uptake and Empowerment, and (4) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as drivers. Stigma at the institutional, community and individual level was also identified as a substantial barrier to engagement.

Conclusion
The findings of this study are relevant to implementers in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement by investing in high-quality formative research, supporting capacity building for policy engagement, investing in longer-term funding schemes to support sustainable partnerships and scale-up, thus fostering successful engagement and supporting effective implementation of global mental health innovations.

Background
Stakeholder engagement is essential for successful implementation in global mental health (GMH) [1] and has been identified as a priority by prominent GMH initiatives [2, 3]. Stakeholder engagement has also been identified as an essential skill for GMH implementers [4]. There is, however, little research that explicitly identifies barriers, drivers and best practices for stakeholder engagement in GMH.

‘Engagement’ in the GMH implementation context is defined by Roberts et al. [5] as “processes by which stakeholders are enabled to support or contribute to an intervention.” GMH implementation may involve a broad spectrum of stakeholders, including: policy makers (national and international), funders, service planners and managers, non-governmental organizations, service-users, their families and caregivers, members of the broader community, the media, service providers (specialist, non-specialist, and lay health providers), traditional healers, spiritual leaders, and representatives of other related sectors (e.g. education, housing, social services, etc.) [6,7,8,9].

Although literature detailing the processes of stakeholder engagement in GMH is not extensive, a number of barriers and drivers have been described. Engagement of policy makers is seen as fundamental to GMH implementation. Barriers to policy engagement include the low priority given to mental health at both national and international levels and the subsequent poor allocation of resources to mental health by national governments and international funding agencies [1, 8, 10, 11]. Additional factors such as competing priorities [9] and limited discretion for decision-making and priority setting [8] make policy engagement challenging. Despite these barriers, “policy windows” such as existing or emerging mental health policies and legislation may act as drivers for policy engagement [6].

Mental health care providers, working both within and outside of the health sector, are also an essential stakeholder group. Barriers to engaging primary care providers in the delivery of mental health interventions include reluctance to take on new tasks due to a large burden of work in busy primary care settings [9, 11], lack of adequate compensation, [6] and low perceived self-efficacy [12,13,14]. Activities designed to actively engage local providers, however, can act as important drivers, as observed by Davies and Lund who state that activities such as group and individual meetings and engaging with care providers prior to implementation are essential steps in promoting implementation success [6].

Despite extensive research from high-income countries on the engagement of service users, families and caregivers in mental health service implementation, research from LMICs in this area is limited [8, 15, 16]. In studies from India [17] and Ethiopia [18], barriers to mental health policy engagement by service users and caregivers included unfamiliarity by service users with the concept of and opportunities for policy engagement. Stigma, including in the health system, in the community and self-stigma was also identified as a barrier. Limited resources, including financial support, space and training and low access to mental health care also restricted the potential for engagement. Despite these considerable challenges, engagement with service users and their families and caregivers is essential for successful implementation, helping to reduce stigma, improve knowledge and attitudes towards mental health and increase help-seeking [9, 12]. Engaging service users and families in mental health policy and program development is also essential to improving mental health service access, availability and appropriateness [16]. Engagement with service users and community members, from the inception of research and implementation planning can promote an essential understanding of community concepts of mental health and the acceptability of planned interventions [12]. User-led research and participatory research methodologies such as community-based participatory research [19] and Theory of Change [20] can help to engage service users throughout the research process and ensure they are actively involved in priority setting, knowledge creation and dissemination.

Stakeholder engagement is an essential component of GMH implementation, and the gap in literature points to a need for research in this area. This study represents an opportunity to explore the perspectives of a group of GMH grantees working across different regions, target conditions and intervention models to further understand the challenges and drivers of stakeholder engagement in GMH.