Table 1.

Implementation Challenges in the Delivery of Community-Based Mental Health Services in Rural Haiti and Strategies to Address Them.

Implementation challenge	Observation from the field	Proposed solutions
Determining local needs	Few if any epidemiological or other systematic investigations to characterize needs of community	Engage local knowledge to identify relevant mental health and psychosocial stressors and account for this when planning clinical services and resource allocation Follow patient encounters to guide quality improvement
Case finding	Passive case finding (where the patient is self-referred) misses many people who cannot or do not seek care	Educate the community and clinical staff to increase referrals and educate community health workers about mental disorders to encourage active case finding Develop a regular mobile clinic to service remote areas
Evaluation and diagnosis	Cultural variations in description of illness and manifestation of illness Ambiguous and sometimes misleading chief complaints Limited availability of laboratory tests	Develop and locally validate screening tools Conduct systematic interviews and expand reviews of systems to assess for comorbid illness Train local providers in a standard diagnostic approach and classification system Rule out mental disorders secondary to medical conditions using commonly available lab tests (for HIV, syphilis, anemia), history, and physical exam Provide ongoing supervision with specialist
Cognitive and academic problems	No standardized or validated tools in Haiti or in Haitian Creole to assess for cognitive problems, learning disorders, and intellectual disability	In the short term, improvise psychological and achievement tests based on local expectations of educational attainment In the longer term, adapt tools that may be less language-dependent for both patient and clinician and validate for use in the community
Substance use	Rare admission of alcohol or drug use	Obtain collateral information Work with local clinicians and patients on importance of issue and how to phrase the question
Neurologic problems	Psychiatrists are expected to treat neurologic illness	Perform and communicate history and neurological exam Create algorithms to treat epilepsy Consult with neurologists for complicated patients
Community understanding of mental illness	Patients may have beliefs about the nature of their illness such as Vodou, religion, or personal failings	Psychoeducation and the biopsychosocial model may incorporate important beliefs of illness where appropriate and challenge others that may be harmful
Therapy	Limited formal training in evidence-based therapies Patients unable to make regular appointments Limited number of clinicians	Provide training and supervision in evidence-based therapies or parts of evidence-based therapies Expand access to care through task-shifting and organizing non-specialists to deliver certain therapeutic services and meet community need/demand
Prescribing	Lack of familiarity with psychopharmacology among clinicians and other practitioners	Create training materials with focus on key aspects of prescribing (indications, contraindications, dosage form, dosing, interactions, side effects, special concerns) Create a prescribing guide tailored to the formulary
Medication	Need to avoid costly medications and stock-outs	Create a versatile formulary of generic medications Project usage of medications using clinic census and anticipated volume and obtain from low-cost suppliers
Follow-up and adherence	Follow-up was not consistent with appointment reminder alone	Educate staff and patients around treatment, management, and prognosis Provide written and phone appointment reminders Enlist community health workers to improve follow-up Co-create reasonable goals for adherence and recovery
Sustainability	Interventions may not promote the development of infrastructure that will provide enduring systemic change	Match program goals with national funding priorities and advocate for investment in appropriate mental health services at the national level Integrate mental health into an existing health system Manualize training based on clinical experience and the experience of training Facilitate task shifting and build local staff capacity for patient care, system management, research, and training Transition responsibilities to local team