Health Policy and Planning Advance Access published March 31, 2015 Health Policy and Planning, 2015, 1–9 doi: 10.1093/heapol/czv016 Original article
Developing a holistic policy and intervention framework for global mental health Akwatu Khenti,1,2 Ste´fanie Fre´el,1,3 Ruth Trainor,1 Sirad Mohamoud,1,3 Pablo Diaz,1,4 Erica Suh,1 Sireesha J Bobbili1 and Jaime C Sapag1,5,6,7,* 1
Office of Transformative Global Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, 2Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, 3Health System Strategy and Policy Division, Ontario Ministry of Health and Long-Term Care, Toronto, Ontario, Canada, 4 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada and 5Department of Public Health 6 Department of Family Medicine, School of Medicine, Pontificia Universidad Cato´lica de Chile, Santiago, Chile and 7 Department of Psychiatry, University of Toronto, Ontario, Canada *Corresponding author. Office of Transformative Global Health, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office 4002-C, Toronto, ON M5S 2S1, Canada. E-mail: [email protected] Accepted on 11 February 2015
Abstract Introduction: There are significant gaps in the accessibility and quality of mental health services around the globe. A wide range of institutions are addressing the challenges, but there is limited reflection and evaluation on the various approaches, how they compare with each other, and conclusions regarding the most effective approach for particular settings. This article presents a framework for global mental health capacity building that could potentially serve as a promising or best practice in the field. The framework is the outcome of a decade of collaborative global health work at the Centre for Addiction and Mental Health (CAMH) (Ontario, Canada). The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights. Methods: Grounded in CAMH’s research, programme evaluation and practical experience in developing and implementing mental health capacity building interventions, this article presents the iterative learning process and impetus that formed the basis of the framework. A developmental evaluation (Patton M.2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press.) approach was used to build the framework, as global mental health collaboration occurs in complex or uncertain environments and evolving learning systems. Results: A multilevel framework consists of five central components: (1) holistic health, (2) cultural and socioeconomic relevance, (3) partnerships, (4) collaborative action-based education and learning and (5) sustainability. The framework’s practical application is illustrated through the presentation of three international case studies and four policy implications. Lessons learned, limitations and future opportunities are also discussed. Conclusion: The holistic policy and intervention framework for global mental health reflects an iterative learning process that can be applied and scaled up across different settings through appropriate modifications. Key words: Addiction, capacity building, global health, mental health, primary health care
C The Author 2015; all rights reserved. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. V
1
2
Health Policy and Planning, 2015, Vol. 0, No. 0
Key Messages • • • •
We present an innovative framework for global mental health that stems from a decade of collaborative global health work. The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights. The multilevel framework resulted in the inclusion of five central components: holistic health, cultural and socioeconomic relevance, partnerships, capacity building and sustainability. This flexible global mental health framework is transferrable to any area of global capacity building, and can serve as a practical guide for policy- and decision makers, as well as health-care professionals around the world.
Introduction Mental health remains a relatively low-priority policy area around the world, as exemplified by minimal average annual expenditures in both high-income countries, where it is reportedly 10 years of OTGH’s global mental health experience in various continents and countries. This includes the critical analysis of existing evidence of global action that acts as the foundation for the HPIF and provides a comprehensive guide for capacity building, useful for achieving effective and sustainable impacts. Finally, the evaluation research approach used to develop the framework included context as an essential element of global health. The approach reflected the importance of social, cultural and political context for fostering mental health services and systems (Aarons et al. 2012). Nevertheless, there are limitations of the framework. First of all, a restricted number of global health initiatives were analysed and provided the basis for the development of the HPIF. This represents a potential threat to the external validity and the generalizability of the model (Bratt 2000). Second, the HPIF cannot be considered a rigid model and therefore is not applicable to every situation in the same manner. Each global health collaboration is unique and occurs in a particular context. As a result, culturally competent adaptations that meet the specific needs of particular initiatives must be taken into consideration. Finally, reports and other documents used as the foundation for the development of the HPIF may have contained potential biases. For instance, restricted resources, challenges in assessing the final impact of an initiative and validity threats of evaluation instruments were not accounted for and should also be considered limitations. This article touches on the wealth of lessons that have been garnered through feedback from external observers and ongoing and systematic evaluations. The ultimate goal of OTGH’s capacity building initiatives are to strengthen mental health-care systems that are interdependent with social systems, relevant to local dynamics and address the needs of people with addictions and mental health disorders and their communities. The collaborative elements of OTGH partnerships, especially the foundational pillars that have been outlined, have effectively sustained a wide variety of initiatives. The durability of numerous partnerships over a 10-year period attests to the potential of the framework. Ongoing and systematic evaluation, including external feedback, allowed for growth and evolution to take place. Planning processes ran more smoothly once participants gained full confidence in the approach and the commitment of all partners to its implementation.
Conclusion As global mental health capacity building continues to fall short of the necessary resource requirements, innovations in delivery mechanisms will continue to be critical for providing effective, efficient and sustainable initiatives. The proposed framework is one such platform. The HPIF can be used by health professionals and policymakers to identify and address existing mental health gaps in their local contexts. This holistic model may be applied to any area of global mental health capacity building and can serve as a practical guide for health and social care professionals around the world. Although the HPIF has proven to be consistent with evidence-based best practice literature, the framework’s long-term impact will need to be assessed. This framework advances the human rights and dignity of persons with mental illness through its promotion of cultural sensitivity to their needs and interests as well as its focus on the full engagement of individuals and communities.
A HOLISTIC FRAMEWORK FOR GLOBAL MENTAL HEALTH
Acknowledgements The analysed global mental health initiatives would not have been possible without the support and commitment of our many partners in various countries. We express our gratitude to all of them. Conflict of interest: None declared.
Funding The preparation of this manuscript was funded by the Centre for Addiction and Mental Health (CAMH) through its operational support for the work of the Office of Transformative Global Health (OTGH).
References Aarons GA, Glisson C, Green PD et al. 2012. The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study. Implementation Science 7: 56. doi:10.1186/1748-5908-7-56. Ayas K, Zeniuk N. 2001. Project based learning: building communities of reflective practitioners. Management Learning 32: 61–76. Bass J, Bolton P, Murray L. 2007. Do not forget culture when studying mental health. The Lancet 370: 918–9. Bratt MM. 2000. Collaborative institutional research. Journal of Child and Family Nursing 3: 251–8. CAIPE. 2002. Interprofessional education - A definition. http://www.caipe. org.uk/about-us/defining-ipe/, accessed 30 June 2013. Centre for Disease Control and Prevention. 2013. http://www.cdc.gov/cancer/ crccp/sem.htm, accessed 13 August 2013. Creswell JW, Plano Clark VL. 2011. Designing and Conducting Mixed Methods Research. 2nd edn, California: Sage Publications. Demyttenaere K, Bruffaerts R, Posada-Villa J et al. 2004. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Journal of the American Medical Association 291: 2581–90. Dooley J. 1997. A complex adaptive systems model of organization change. Nonlinear Dynamics, Psychology, and Life Sciences 1: 69–97. Fitzpatrick JL. 2012. Collaborative evaluation within the larger evaluation context. Evaluation Program Planning 35: 558–63. Freire P. 2006. Pedagogy of the Oppressed. 30th Anniversary edn, New York: The Continuum International Publishing Group. Frichionne G, Borba C, Alem A et al. 2012. Capacity building in global mental health: professional training. Harvard Review of Psychiatry 20: 47–57. Frye A, Hemmer P. 2012. Program evaluation models and related theories: AMEE Guide No. 67. Medical Teacher 34: e288–99. Gaboury I. 2009. Interprofessional collaboration within Canadian integrative healthcare clinics: key components. Social Science & Medicine 69: 707–15. Godoy-Ruiz P, Cole DC, Lenters L, McKenzie K. 2015. Developing collaborative approaches to international research: perspectives of new global health researchers. Global Public Health 1–23. DOI: 10.1080/ 17441692.2014.999814. Guijt I, Kusters CSL, Lont H, Visser I. 2012. Developmental Evaluation: Applying complexity concepts to enhance innovation and use. Report from an Expert Seminar with Dr. Michael Quinn Patton. Centre for Development Innovation, Wageningen University & Research centre. Jenkins R, Baingana F, Ahmad R, McDaid D, Atun R. 2011. Social, economic, human rights and political challenges to global mental health. Mental Health in Family Medicine 8: 87–96. Kleinman A, Good B (eds). 1985. Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkley: University of California Press. Kleinman A. 2009. Global mental health: a failure of humanity. The Lancet 374: 603–4. Lega F, Prenestini A, Spurgeon P. 2013. Is management essential to improving the performance and sustainability of health care systems and
9 organizations? A systematic review and a roadmap for future studies. Value in Health 16: 546–51. Minas H. 2012. The Centre for International Mental Health approach to mental health system development. Harvard Review of Psychiatry 20: 37–46. Patel V, Chowdhary N, Rahman A, Verdeli H. 2011. Improving access to psychological treatments: lessons from developing countries. Behaviour and Research Therapy 49: 523–8. Patton M. 2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press. Prince M, Patel V, Saxena S et al. 2007. No health without mental health. The Lancet 370: 859–77. Ravens R. 1982. The Origin and Growth of Action Learning. Kent: CartwellGratt. Saraceno B, Ommeren M, Batniji R et al. 2007. Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet 370(9593): 1164–74. Saxena S, Sharan P, Garrido M, Saraceno B. 2006. World Health Organization’s Mental Health Atlas 2005: implications for policy development. World Psychiatry 5: 179–84. Scott AJ, Wilson RF. 2011. Upstream ecological risks for overweight and obesity among African American youth in a rural town in the Deep South, 2007. Preventing Chronic Disease 8: A17. Sidle J, Were E, Wools-Kaloustian K et al. 2006. A needs assessment to build international research ethics capacity. Journal of Empirical Research on Human Research Ethics 1: 23–38. Summerfield D. 2008. How scientifically valid is the knowledge base of global mental health. British Medical Journal 336: 992–4. Sweat MD, Denison JA. 1995. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS 9: S251–7. Talbot Y, Takeda S, Riutort M, Bhattacharyya O. 2009. Capacity-building in family health: innovative in-service training program for teams in Latin America. Canadian Family Physician 55: 613–6. Tarricone R. 2013. Setting the scene: the challenges of universal health coverage and the contribution of management education. Value in Health 16: 54–6. Thornicroft G, Cooper S, Van Bortel T, Kakuma R, Lund C. 2012. Capacity building in global mental health research. Harvard Review of Psychiatry 20: 13–24. United Nations General Assembly. 1991. The Protection of Persons with Mental Illness and the Improvement of Mental Health Care. http://www.un. org/documents/ga/res/46/a46r119.htm, accessed 12 August 2013. Vella J. 2002. Learning to Listen, Learning to Teach: The Power of Dialogue in Education Adults. New York: John Wiley and Sons Inc. Whiteford HA, Degenhardt L, Rehm J et al. 2013. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 382: 1575–86. doi: 10.1016/S01406736(13)61611-6. WHO. 2008. mhGAP Mental Health Gap Action Programme Scaling Up Care for Mental, Neurological, and Substance Use Disorders. Geneva: WHO. WHO. 2010. Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group. Geneva: World Health Organization. WHO. 2011. Mental Health Atlas. Geneva: Department of Mental Health and Substance Abuse, World Health Organization Geneva. WHO. 2012. Zero Draft. Global Mental Health Action Plan 2013–2020. Geneva: WHO. WHO. 2013a. Sixty-sixth World Health Assembly Closes with Concern Over New Global Health Threat. http://www.who.int/mediacentre/news/releases/ 2013/world_health_assembly_20130527/en/, accessed 12 August 2013. WHO. 2013b. WHO MIND – Mental Health in Development. http://www. who.int/mental_health/policy/en/, accessed 12 August 2013. Yarbrough DB, Shulha LM, Hopson RK, Caruthers FA. 2011. The Program Evaluation Standards: A Guide for Evaluators and Evaluation Users. 3rd edn, Thousand Oaks, CA: Sage Publications. Yasamy MT. 2007. Mental health challenges and possible solutions. La Revue de Sante´ de la Mediterrane´e orientale, 14, 114–22.
Developing a holistic policy and intervention framework for global mental health Akwatu Khenti,1,2 Ste´fanie Fre´el,1,3 Ruth Trainor,1 Sirad Mohamoud,1,3 Pablo Diaz,1,4 Erica Suh,1 Sireesha J Bobbili1 and Jaime C Sapag1,5,6,7,* 1
Office of Transformative Global Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, 2Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, 3Health System Strategy and Policy Division, Ontario Ministry of Health and Long-Term Care, Toronto, Ontario, Canada, 4 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada and 5Department of Public Health 6 Department of Family Medicine, School of Medicine, Pontificia Universidad Cato´lica de Chile, Santiago, Chile and 7 Department of Psychiatry, University of Toronto, Ontario, Canada *Corresponding author. Office of Transformative Global Health, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office 4002-C, Toronto, ON M5S 2S1, Canada. E-mail: [email protected] Accepted on 11 February 2015
Abstract Introduction: There are significant gaps in the accessibility and quality of mental health services around the globe. A wide range of institutions are addressing the challenges, but there is limited reflection and evaluation on the various approaches, how they compare with each other, and conclusions regarding the most effective approach for particular settings. This article presents a framework for global mental health capacity building that could potentially serve as a promising or best practice in the field. The framework is the outcome of a decade of collaborative global health work at the Centre for Addiction and Mental Health (CAMH) (Ontario, Canada). The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights. Methods: Grounded in CAMH’s research, programme evaluation and practical experience in developing and implementing mental health capacity building interventions, this article presents the iterative learning process and impetus that formed the basis of the framework. A developmental evaluation (Patton M.2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press.) approach was used to build the framework, as global mental health collaboration occurs in complex or uncertain environments and evolving learning systems. Results: A multilevel framework consists of five central components: (1) holistic health, (2) cultural and socioeconomic relevance, (3) partnerships, (4) collaborative action-based education and learning and (5) sustainability. The framework’s practical application is illustrated through the presentation of three international case studies and four policy implications. Lessons learned, limitations and future opportunities are also discussed. Conclusion: The holistic policy and intervention framework for global mental health reflects an iterative learning process that can be applied and scaled up across different settings through appropriate modifications. Key words: Addiction, capacity building, global health, mental health, primary health care
C The Author 2015; all rights reserved. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. V
1
2
Health Policy and Planning, 2015, Vol. 0, No. 0
Key Messages • • • •
We present an innovative framework for global mental health that stems from a decade of collaborative global health work. The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights. The multilevel framework resulted in the inclusion of five central components: holistic health, cultural and socioeconomic relevance, partnerships, capacity building and sustainability. This flexible global mental health framework is transferrable to any area of global capacity building, and can serve as a practical guide for policy- and decision makers, as well as health-care professionals around the world.
Introduction Mental health remains a relatively low-priority policy area around the world, as exemplified by minimal average annual expenditures in both high-income countries, where it is reportedly 10 years of OTGH’s global mental health experience in various continents and countries. This includes the critical analysis of existing evidence of global action that acts as the foundation for the HPIF and provides a comprehensive guide for capacity building, useful for achieving effective and sustainable impacts. Finally, the evaluation research approach used to develop the framework included context as an essential element of global health. The approach reflected the importance of social, cultural and political context for fostering mental health services and systems (Aarons et al. 2012). Nevertheless, there are limitations of the framework. First of all, a restricted number of global health initiatives were analysed and provided the basis for the development of the HPIF. This represents a potential threat to the external validity and the generalizability of the model (Bratt 2000). Second, the HPIF cannot be considered a rigid model and therefore is not applicable to every situation in the same manner. Each global health collaboration is unique and occurs in a particular context. As a result, culturally competent adaptations that meet the specific needs of particular initiatives must be taken into consideration. Finally, reports and other documents used as the foundation for the development of the HPIF may have contained potential biases. For instance, restricted resources, challenges in assessing the final impact of an initiative and validity threats of evaluation instruments were not accounted for and should also be considered limitations. This article touches on the wealth of lessons that have been garnered through feedback from external observers and ongoing and systematic evaluations. The ultimate goal of OTGH’s capacity building initiatives are to strengthen mental health-care systems that are interdependent with social systems, relevant to local dynamics and address the needs of people with addictions and mental health disorders and their communities. The collaborative elements of OTGH partnerships, especially the foundational pillars that have been outlined, have effectively sustained a wide variety of initiatives. The durability of numerous partnerships over a 10-year period attests to the potential of the framework. Ongoing and systematic evaluation, including external feedback, allowed for growth and evolution to take place. Planning processes ran more smoothly once participants gained full confidence in the approach and the commitment of all partners to its implementation.
Conclusion As global mental health capacity building continues to fall short of the necessary resource requirements, innovations in delivery mechanisms will continue to be critical for providing effective, efficient and sustainable initiatives. The proposed framework is one such platform. The HPIF can be used by health professionals and policymakers to identify and address existing mental health gaps in their local contexts. This holistic model may be applied to any area of global mental health capacity building and can serve as a practical guide for health and social care professionals around the world. Although the HPIF has proven to be consistent with evidence-based best practice literature, the framework’s long-term impact will need to be assessed. This framework advances the human rights and dignity of persons with mental illness through its promotion of cultural sensitivity to their needs and interests as well as its focus on the full engagement of individuals and communities.
A HOLISTIC FRAMEWORK FOR GLOBAL MENTAL HEALTH
Acknowledgements The analysed global mental health initiatives would not have been possible without the support and commitment of our many partners in various countries. We express our gratitude to all of them. Conflict of interest: None declared.
Funding The preparation of this manuscript was funded by the Centre for Addiction and Mental Health (CAMH) through its operational support for the work of the Office of Transformative Global Health (OTGH).
References Aarons GA, Glisson C, Green PD et al. 2012. The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study. Implementation Science 7: 56. doi:10.1186/1748-5908-7-56. Ayas K, Zeniuk N. 2001. Project based learning: building communities of reflective practitioners. Management Learning 32: 61–76. Bass J, Bolton P, Murray L. 2007. Do not forget culture when studying mental health. The Lancet 370: 918–9. Bratt MM. 2000. Collaborative institutional research. Journal of Child and Family Nursing 3: 251–8. CAIPE. 2002. Interprofessional education - A definition. http://www.caipe. org.uk/about-us/defining-ipe/, accessed 30 June 2013. Centre for Disease Control and Prevention. 2013. http://www.cdc.gov/cancer/ crccp/sem.htm, accessed 13 August 2013. Creswell JW, Plano Clark VL. 2011. Designing and Conducting Mixed Methods Research. 2nd edn, California: Sage Publications. Demyttenaere K, Bruffaerts R, Posada-Villa J et al. 2004. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Journal of the American Medical Association 291: 2581–90. Dooley J. 1997. A complex adaptive systems model of organization change. Nonlinear Dynamics, Psychology, and Life Sciences 1: 69–97. Fitzpatrick JL. 2012. Collaborative evaluation within the larger evaluation context. Evaluation Program Planning 35: 558–63. Freire P. 2006. Pedagogy of the Oppressed. 30th Anniversary edn, New York: The Continuum International Publishing Group. Frichionne G, Borba C, Alem A et al. 2012. Capacity building in global mental health: professional training. Harvard Review of Psychiatry 20: 47–57. Frye A, Hemmer P. 2012. Program evaluation models and related theories: AMEE Guide No. 67. Medical Teacher 34: e288–99. Gaboury I. 2009. Interprofessional collaboration within Canadian integrative healthcare clinics: key components. Social Science & Medicine 69: 707–15. Godoy-Ruiz P, Cole DC, Lenters L, McKenzie K. 2015. Developing collaborative approaches to international research: perspectives of new global health researchers. Global Public Health 1–23. DOI: 10.1080/ 17441692.2014.999814. Guijt I, Kusters CSL, Lont H, Visser I. 2012. Developmental Evaluation: Applying complexity concepts to enhance innovation and use. Report from an Expert Seminar with Dr. Michael Quinn Patton. Centre for Development Innovation, Wageningen University & Research centre. Jenkins R, Baingana F, Ahmad R, McDaid D, Atun R. 2011. Social, economic, human rights and political challenges to global mental health. Mental Health in Family Medicine 8: 87–96. Kleinman A, Good B (eds). 1985. Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkley: University of California Press. Kleinman A. 2009. Global mental health: a failure of humanity. The Lancet 374: 603–4. Lega F, Prenestini A, Spurgeon P. 2013. Is management essential to improving the performance and sustainability of health care systems and
9 organizations? A systematic review and a roadmap for future studies. Value in Health 16: 546–51. Minas H. 2012. The Centre for International Mental Health approach to mental health system development. Harvard Review of Psychiatry 20: 37–46. Patel V, Chowdhary N, Rahman A, Verdeli H. 2011. Improving access to psychological treatments: lessons from developing countries. Behaviour and Research Therapy 49: 523–8. Patton M. 2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press. Prince M, Patel V, Saxena S et al. 2007. No health without mental health. The Lancet 370: 859–77. Ravens R. 1982. The Origin and Growth of Action Learning. Kent: CartwellGratt. Saraceno B, Ommeren M, Batniji R et al. 2007. Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet 370(9593): 1164–74. Saxena S, Sharan P, Garrido M, Saraceno B. 2006. World Health Organization’s Mental Health Atlas 2005: implications for policy development. World Psychiatry 5: 179–84. Scott AJ, Wilson RF. 2011. Upstream ecological risks for overweight and obesity among African American youth in a rural town in the Deep South, 2007. Preventing Chronic Disease 8: A17. Sidle J, Were E, Wools-Kaloustian K et al. 2006. A needs assessment to build international research ethics capacity. Journal of Empirical Research on Human Research Ethics 1: 23–38. Summerfield D. 2008. How scientifically valid is the knowledge base of global mental health. British Medical Journal 336: 992–4. Sweat MD, Denison JA. 1995. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS 9: S251–7. Talbot Y, Takeda S, Riutort M, Bhattacharyya O. 2009. Capacity-building in family health: innovative in-service training program for teams in Latin America. Canadian Family Physician 55: 613–6. Tarricone R. 2013. Setting the scene: the challenges of universal health coverage and the contribution of management education. Value in Health 16: 54–6. Thornicroft G, Cooper S, Van Bortel T, Kakuma R, Lund C. 2012. Capacity building in global mental health research. Harvard Review of Psychiatry 20: 13–24. United Nations General Assembly. 1991. The Protection of Persons with Mental Illness and the Improvement of Mental Health Care. http://www.un. org/documents/ga/res/46/a46r119.htm, accessed 12 August 2013. Vella J. 2002. Learning to Listen, Learning to Teach: The Power of Dialogue in Education Adults. New York: John Wiley and Sons Inc. Whiteford HA, Degenhardt L, Rehm J et al. 2013. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 382: 1575–86. doi: 10.1016/S01406736(13)61611-6. WHO. 2008. mhGAP Mental Health Gap Action Programme Scaling Up Care for Mental, Neurological, and Substance Use Disorders. Geneva: WHO. WHO. 2010. Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group. Geneva: World Health Organization. WHO. 2011. Mental Health Atlas. Geneva: Department of Mental Health and Substance Abuse, World Health Organization Geneva. WHO. 2012. Zero Draft. Global Mental Health Action Plan 2013–2020. Geneva: WHO. WHO. 2013a. Sixty-sixth World Health Assembly Closes with Concern Over New Global Health Threat. http://www.who.int/mediacentre/news/releases/ 2013/world_health_assembly_20130527/en/, accessed 12 August 2013. WHO. 2013b. WHO MIND – Mental Health in Development. http://www. who.int/mental_health/policy/en/, accessed 12 August 2013. Yarbrough DB, Shulha LM, Hopson RK, Caruthers FA. 2011. The Program Evaluation Standards: A Guide for Evaluators and Evaluation Users. 3rd edn, Thousand Oaks, CA: Sage Publications. Yasamy MT. 2007. Mental health challenges and possible solutions. La Revue de Sante´ de la Mediterrane´e orientale, 14, 114–22.
