Heeding the Call of an Innovative Paradigm for Mental Health Interventions in Low- and Middle-income Countries

A recent initiative in Kenya (15) demonstrates how an intervention that integrated all of these practices built on the strengths of the community and served as a “disruptive innovation”—that is, a simpler solution with greater affordability and accessibility compared with conventional approaches that enabled uptake of mental health care by a previously ignored population or excluded community (16). Using codesign and participatory methods, CREATE Kenya (Community Recovery Achieved Through Entrepreneurism) focused on an approach that integrated two major initiatives: a social enterprise (a community business hiring people with serious mental illnesses) and a context-sensitive and peer-facilitated evidence-based psychosocial rehabilitation toolkit, which offered individuals with serious mental illness and their families an opportunity to build knowledge about mental illness and self-management strategies. The social enterprise created the context for collaborations with local business organizations and government agencies that shared the goal of advancing the economic vitality of the community. The initiative also engaged hospital service providers, family members, disability advocates, and peers in building connections with mental health service users, learning about the practical elements of the initiative, and considering how innovations might be implemented more broadly. CREATE built on similar approaches previously developed and carried out in low-resource settings (17) by strengthening the peer support model aspect of such approaches, repositioning the primary identity of service users as something other than “mentally ill,” and integrating the psychosocial rehabilitation support directly into the business setting and employee role.

The CREATE process was dynamic and had unplanned events and obstacles. Like many businesses, the initial social enterprise did not survive financially, and labor disputes in the mental health system disrupted the momentum of collaborations with health care professionals. However, through their experiences working with the business, the initial seven individuals with mental illness who were hired gained business acumen and knowledge of relevant social structures, and these acquired assets were subsequently invested in new business undertakings, both individual and collective. These individuals also began speaking about mental illness proudly and openly in the community, engaging with local politicians, and asserting a presence at local community events. The initiative sparked the creation of a more formal peer network and a registered local self-help group. Qualitative evaluation found that individual-level changes included dramatic alterations in behavior, such that participants moved from life patterns characterized by inertia, alienation, and problematic social behaviors to patterns of productivity, self-care, and positive social interactions. Evaluation of the initiative also indicated that increases in daily productivity by family members with serious mental illness led to improvement in relationships within the family and reduced sense of burden among family members (15).

Innovations that seek to address complex and seemingly intractable problems must often target institutions and the ingrained thinking and processes that go with them in order to create new and disruptive paradigms in the process of social change (18, 19). To effect change in unpredictable, nonlinear and context-sensitive scenarios, a systems change approach that integrates a broad and diverse group of stakeholders is needed (18).

The CREATE team recognized the futility of approaching mental health inequities in a LMIC as a problem of mental illness that could be addressed by conventional, Western-driven biomedical models. Instead, the issue was viewed as a result of resource and power imbalance and was addressed through a multimodal, collaborative approach that sought to disrupt existing models and empower people in the community with serious mental illness who had become socially marginalized and essentially voiceless. This partnership not only leveraged available funding, expertise, and commitment, but, more importantly, it also used social enterprise, empowerment education, and health literacy to shift the roles and self-perceptions of people with serious mental illness and their families as well as the perspectives of individuals in positions of power within Kenyan institutions. Such a shift helped to reduce stigma and create opportunities for people with mental illness in their communities. The result was an evolutionary process of change that was unpredictable in course, responsive to emerging opportunity, and increasingly driven by people with mental illness.

Multiple barriers to change initiatives, many of them attitudinal, exist in Kenya and other LMICs with respect to mental illness (20). People with serious mental illness generally maintain a low social status, and most are reluctant or unable to serve as their own advocates. Social enterprises are often perceived as charities, rather than legitimate businesses, and their employees are expected to be paid lower than market wages. People with serious mental illness in Kenya and other LMICs have limited access to information about their health conditions and how to self-advocate within the health system and local communities (20). Well-meaning service providers are constrained in their efforts to advance novel practices both within and beyond the institutions where they work, with finances being a major barrier.

Furthermore, the local environment in some LMICs may include a host of other subtle forces that work against such community development initiatives. Notably, these include local tribalism and rejection of official channels, skepticism regarding the commitment of nongovernmental organizations and researchers from wealthy nations and their ability to honor local priorities and create sustainable change, a culture of corruption and bribery related to securing needed supports, and the typically slow response to official and nonofficial requests for information. With CREATE, engagement of local mental health experts and the hiring of a local community developer as the project manager were critical to ensuring sensitivity to the local culture and to navigating challenging, unspoken onsite barriers. Additional research is needed to support the system-level change model implemented in this setting, to create replicable change models for similarly complex contexts, and to ensure sustainability of the movement.

Lessons learned through this endeavor can be similarly applied to HICs, where people with serious mental illness are also often marginalized. Although social enterprise–driven approaches have been used in these HICs, costly individualized and provider-driven models remain the dominant strategy. There is a need for less medicalized and more integrative approaches to mental health interventions that combat stigma, build partnerships, and restore power to vulnerable individuals. Disruptive approaches to systems change are the emerging solutions to the long-established and perplexing inequities on the road to creating more equitable, sustainable, and thriving societies.