Background

Many evidence-based mental health and psychosocial support (MHPSS) interventions require a substantial clinical workforce that is not typically available in low-resource humanitarian settings; these settings can encompass a range of emergency situations such as armed conflicts and war and disasters triggered by natural, industrial and technological hazards.^{Reference Tol, Barbui, Galappatti, Silove, Betancourt and Souza1} Current evidence-based interventions for mental and behavioural health problems also tend to focus on a single mental disorder and reach individuals rather than groups. The high resource requirements are a key factor contributing to low levels of implementation of evidence-based MHPSS interventions in low-resource humanitarian settings.^{Reference Tol, Leku, Lakin, Carswell, Augustinavicius and Adaku2} To address this deficit, psychological interventions that target a wider range of problems including psychological distress more broadly, that can be delivered without a specialised workforce, and that reach larger numbers of people during delivery have been developed and tested.^{Reference Tol, Augustinavicius, Carswell, Leku, Adaku and Brown3} Building on evidence of benefits, innovative approaches are now needed for scaling up such interventions. In this context, we refer to ‘scaling up’ as ‘deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and programme development on a lasting basis’.⁴

In the field of global mental health, scaling up has historically been implemented vertically (i.e. within government health institutions) and horizontally (i.e. in new contexts). Both the vertical and horizontal type of scale-up aligns with international recommendations of integrating mental health in non-specialised healthcare settings (e.g. primary care), which is an important pathway to scale.⁵ Multi-sectoral integration is another viable scale-up pathway, which has been underutilised for MHPSS in humanitarian contexts.^{Reference Bammer, O'Rourke, O'Connell, Neuhauser, Midgley and Klein6} We propose that integration of MHPSS into programmes and sectors outside health represents a complementary pathway to scale, alongside integration of MHPSS with health programmes. Widely used humanitarian consensus guidelines, including the Inter Agency Standing Committee MHPSS guidelines for emergency settings, provide specific recommendations for integrating MHPSS programmes within diverse sectors of humanitarian response. These include food security and nutrition, education, shelter and site planning, and water and sanitation.⁷ These recommendations are supported by growing recognition of the need to more holistically address population needs in humanitarian settings, given that the well-being of crisis-affected populations is determined by interrelated health and social factors.^{Reference Greene, Likindikoki, Rees, Bonz, Kaysen and Misinzo8} Multi-sectoral integration requires strong partnerships and collaboration outside traditional siloes.^{Reference Greene, Likindikoki, Rees, Bonz, Kaysen and Misinzo8} In addition to more comprehensively addressing humanitarian needs, multi-sectoral integration may also facilitate more rapid and widespread scale-up of evidence-based MHPSS interventions within diverse types of existing humanitarian programming, as this provides more opportunities for implementation. An argument for the integration of MHPSS interventions in diverse (non-health) sectors of humanitarian programming rests on the observation that mental health and psychosocial concerns are often tied in complex bidirectional relationships with other humanitarian needs (e.g. protection from violence and livelihoods).^{Reference Greene, Likindikoki, Rees, Bonz, Kaysen and Misinzo8,Reference Greene, Rees, Likindikoki, Bonz, Joscelyne and Kaysen9} For example, people who experience poverty are at higher risk of common mental disorders, and these common mental disorders in turn elevate the risk of (further) experiences of poverty.^{Reference Lund10} Addressing these interlinked concerns may result in more sustainable and cost-efficient impacts.

SH+ 360

To exemplify an integration-focused model, we present SH+ 360, a model for scaling up the evidence-based MHPSS intervention called Self Help Plus (SH+). SH+ is a low-intensity guided self-help intervention that provides strategies for managing psychological distress and coping with adversity broadly.^{Reference Tol, Leku, Lakin, Carswell, Augustinavicius and Adaku2,Reference Riello, Purgato, Bove, Tedeschi, MacTaggart and Barbui11} SH+ has been tested in different contexts, including among South Sudanese refugee adult women, and is currently being tested among South Sudanese refugee men in Uganda.^{Reference Tol, Leku, Lakin, Carswell, Augustinavicius and Adaku2} Other studies in Europe and Turkey have tested SH+ with refugees and asylum seekers from various backgrounds.^{Reference Purgato, Carswell, Tedeschi, Acarturk, Anttila and Au12,Reference Acarturk, Uygun, Ilkkursun, Carswell, Tedeschi and Batu13} Progressions and challenges from piloting to scaling have been described elsewhere.^{Reference Beets, von Klinggraeff, Weaver, Armstrong and Burkart14,Reference Yamey15} The major challenges specific to SH+ 360 delivery include quality control in training, supervision, and monitoring and evaluation; these are described in the SH+ 360 model component section.

Development of SH+ 360

Our approach to bringing SH+ to scale has undergone multiple iterations. Initially, we proposed scaling up SH+ through a more conventional model, that is, expanding the training and implementation workforce of HealthRight International that tested the intervention in-country. Through reflection, stakeholder consultation and iterative development, our model evolved into SH+ 360, which in its present form centres around the creation of a technical support hub. We now intend to scale up SH+ through a model of tailored support (SH+ 360) that will facilitate the integration of SH+ into routine programming of selected partners operating at scale across diverse humanitarian sectors (i.e. multi-sectoral integration). Under SH+ 360, HealthRight International will not directly deliver SH+ but will support humanitarian partners as they integrate core model components into their own existing humanitarian programming to ensure ownership and sustainability of implementation.

SH+ 360 model components

The core components of SH+ 360 (Fig. 1) align with the programme cycle, beginning with completing an assessment of needs and resources with partner organisations. This needs and resources assessment enables both HealthRight International and partner organisations to understand (a) how SH+ may be adapted to meet unique population needs and (b) how SH+ could be embedded into specific services and training programmes that are already being delivered by partner organisations. The SH+ format was intended to be generic; adapting the intervention for implementation in new sociocultural contexts is critical. HealthRight International will support partners in translating and adapting SH+ according to their needs and help to identify non-specialists within their organisations that can be trained to serve as SH+ facilitators. Using a digital mental health support assessment for MHPSS called Ensuring Quality in Psychological Support, the skills of non-specialists facilitating SH+ delivery can be assessed before, during and after a training programme to ensure quality delivery.¹⁶ As people experiencing mild to moderate forms of psychological distress benefit most from SH+, those experiencing more severe psychological distress should be immediately referred for specialised services. Thus, HealthRight International will support partners in developing recruitment, screening and referral procedures. Each partner organisation will then implement SH+, with support from HealthRight International. One major challenge that we foresee that is specific to scaling SH+ is quality control, as we will be training other organisations to implement SH+. To mitigate this challenge, we aim to co-design an SH+-specific monitoring and evaluation subsystem that can be added into partner organisation's existing systems, making it possible to track key indicators and maintain quality at each level of SH+ implementation. Indicators will reflect outcomes, outputs and processes ascertained from SH+ participants, facilitators and programme records and will be jointly analysed.

Fig. 1 SH+ 360 core components align with the programme cycle. The planning phase corresponds to needs assessment, translation, and adaptation and training. The implementation phase corresponds to implementing SH+, and the evaluation phase corresponds to the monitoring and evaluation component. NGO, non-governmental organisation.

SH+ 360 application and testing

Approaches to scaling up need to be tested before they are implemented broadly.^{Reference Schafer, Harper-Shehadeh, Carswell, van't Hof, Hall and Malik17} SH+ 360 will be tested in Uganda through initial integration of SH+ into existing health programmes currently delivered by one partner and into gender-based violence, reproductive health, peaceful coexistence and livelihoods programmes currently delivered by another partner. HealthRight International will manage the SH+ 360 technical support hub that will support integration and implementation. Application and testing of the SH+ 360 model of scaling up can be understood through operational, implementation and financial elements.

Future directions

Few MHPSS interventions in humanitarian settings have been successfully scaled up, and innovative approaches to scale are needed to address this implementation gap. Multi-sectoral integration with health and non-health programmes represents a promising opportunity to enhance the reach of evidence-based interventions while meeting diverse needs more comprehensively. With limited practical guidance on the steps required to prepare for and implement scalable MHPSS interventions such as SH+, the SH+ 360 model represents a novel platform for knowledge-sharing, co-design and supported uptake. Initial tests of the SH+ 360 model will offer key insight into partnership development, barriers and facilitators to integration, as well as various implementation factors when SH+ is delivered within real-world humanitarian programming.