. 2020 Nov 6;35(Suppl 2):ii112–ii123. doi: 10.1093/heapol/czaa124

Table 2.

Country-specific strategies and adaptations for the implementation of SMHP in EMR

ToC factors	Egypt	Pakistan	Iran
Key strategies^a	1. Formulation of implementation team within an existing agency (General Secretariat of Mental Health and Addiction Treatment) of the ministry of health (MoH) with historical collaboration with the Department of Environmental, Population and Health Education of the ministry of education (MoE). Rationale: The strategic position of the implementation team within MoH and straddling MoH-MoE will facilitate cross-collaboration between MoE and MoH needed for the scale-up of the programme. 2. Inclusion of NGOs (e.g. Save the Children) who are already working in promoting child health at scale with external funds in the implementation team. Rationale: This will facilitate increased resources for the initial rollout and adoption of the programme.	1. Selection of a government tertiary health institution to lead large-scale implementation. Rationale: The MOH and MOE are both well-represented in the tertiary health institution—and this will facilitate cross-sectoral collaboration among these two ministries. The tertiary health institution also has existing capacity in training, and historical collaboration with schools and primary health-care systems. 2. Signing of an official memorandum of understanding (MOU) between the MOE and MOH. Rationale: The initial MOU provides a legitimate framework for support and collaboration among different sub- agencies under these respective ministries for implementation. It is anticipated that additional MOUs will be required in future.	1. High-level negotiations between the MoH and MoE which preserved the role of the MoE as the principal agent responsible for programme activities at the school level, and MoH providing supervisory support to the schools, and oversight at other levels, including the referral pathways for specialized services. Rationale: The high-level negotiation among the two ministries led to compromise and collaboration without which the SMHP programme would not have been implemented.
Contextual adaptation^b	1. Elevating the role of school psychologists (instead of teachers) to deliver targeted interventions. They also provide training to teachers, serve as supervisors, and as first point of referral for specialized care. Rationale: The professional background of school psychologists and their role in the educational system makes them more suitable in delivering the SMHP. The training and skills that they received from MoH trainers are strong motivating factors, which also solidifies their placement within the school system. 2. Establishment of a primary mental health centre where the school psychologists engage directly with parents and community members (and also provide targeted mental health interventions with support of psychiatrists from other levels of care). Rationale: The primary mental health centre will facilitate the psychologist’s activities at the school and serve as a referral centre for identified cases, linking the school system with the health services delivery system. The primary mental health centre provides efficiency in that it increases the reach of the limited number psychologists, rather than having some schools without psychologists. 3. Engaging with the nascent national health insurance scheme to incorporate the scale-up (and funding) for SMHP as a preventative health strategy for mental health at the primary health-care level. Rationale: The national health insurance scheme is just rolling out and has plans and resources to scale-up to all of the country. The SMHP can piggyback on this scheme to facilitate scale-up.	1. Synchronizing the timing of teachers’ training on SMHP with the school academic calendar. Rationale: This will facilitate participation among teachers and school administrators, and also minimize the additional burden to teachers and administrators. 2. Clarifying roles among various individuals involved within the school system e.g. emphasizing the role of teachers to promote mental health (and not to provide targeted interventions) and to identify children requiring mental health care for prompt referral first to champion teachers who are expected to work with parents to guide the child’s access to the health system. Rationale: Teachers are already overextended on multitasks, and it was important to limit their role in the delivery of the programme to prevent overburdening them and to ensure their participation.	1.Inclusion of MOE’s counselling centres (which function as referral centres for school-aged children experiencing mental health problems within the MoE structure, providing counselling and psychological interventions). These counselling centres are then linked to Community Mental Health Centers (CMHC) which are community-based psychiatric health care facilities within the MoH structure for cases requiring specialized services. Rationale: Linking MoE and MoH services will foster co-operation at the primary care level, integration of mental health services for school children, and increased uptake of MoH specialized mental health services unavailable within the MoE system. 2. Exclusion of primary care physicians (PCPs) from the referral pathway of cases requiring specialized care. These children are referred directly by teachers from schools to the counselling centres and then to the CHMC, as the first point of contact in the health services delivery system. Rationale: PCPs in Iran may lack resources and expertise to provide adequate mental health care
Intervention adaptation^c	1. Addition of a targeted intervention module on learning difficulties, self-harm and bullying which are prevalent mental health conditions in Egypt. Rationale: The addition of this module makes the SMHP programme more responsive to the specific mental health needs in Egypt.	1. Translation of the SMHP manual to Urdu, addition of a module on teacher self-care, use of culturally and age- appropriate case examples to illustrate key steps in interventions. Rationale: These changes will enhance the acceptability and easy application of the interventions. 2. Reframing the mental health conditions described in the SMHP programme as internalizing and externalizing problems. Rationale: This change will reduce labelling of children and stigma related to specific mental health diagnosis. 3. Adding a section on how to conduct parent–teacher interaction for teachers and others delivering the SMHP. Rationale: This change will improve teachers’ efficacy to interact more effectively with parents to facilitate the delivery of the programme.	1. Prioritizing teachers’ activities to focus on screening and identification of children with mental health needs (and not delivery of any targeted intervention). Rationale: This change will minimize any increased workload (or perception of increased workload) to teachers. 2. Prioritizing counsellors’ activities at MOE’s counselling centres to provide targeted interventions within the SMHP. Rationale: These trainings are viewed as additional qualification and knowledge expertise in mental health which is desirable to MOE counsellors. Thus, the trainings will provide incentives to counsellors under the MoE to support the delivery of the SMHP.

ToC factors

Egypt

Pakistan

Iran

Key strategies^a

1. Formulation of implementation team within an existing agency (General Secretariat of Mental Health and Addiction Treatment) of the ministry of health (MoH) with historical collaboration with the Department of Environmental, Population and Health Education of the ministry of education (MoE).

Rationale: The strategic position of the implementation team within MoH and straddling MoH-MoE will facilitate cross-collaboration between MoE and MoH needed for the scale-up of the programme.

2. Inclusion of NGOs (e.g. Save the Children) who are already working in promoting child health at scale with external funds in the implementation team.

Rationale: This will facilitate increased resources for the initial rollout and adoption of the programme.

1. Selection of a government tertiary health institution to lead large-scale implementation.

Rationale: The MOH and MOE are both well-represented in the tertiary health institution—and this will facilitate cross-sectoral collaboration among these two ministries. The tertiary health institution also has existing capacity in training, and historical collaboration with schools and primary health-care systems.

2. Signing of an official memorandum of understanding (MOU) between the MOE and MOH.

Rationale: The initial MOU provides a legitimate framework for support and collaboration among different sub- agencies under these respective ministries for implementation. It is anticipated that additional MOUs will be required in future.

1. High-level negotiations between the MoH and MoE which preserved the role of the MoE as the principal agent responsible for programme activities at the school level, and MoH providing supervisory support to the schools, and oversight at other levels, including the referral pathways for specialized services.

Rationale: The high-level negotiation among the two ministries led to compromise and collaboration without which the SMHP programme would not have been implemented.

Contextual adaptation^b

1. Elevating the role of school psychologists (instead of teachers) to deliver targeted interventions. They also provide training to teachers, serve as supervisors, and as first point of referral for specialized care.

Rationale: The professional background of school psychologists and their role in the educational system makes them more suitable in delivering the SMHP. The training and skills that they received from MoH trainers are strong motivating factors, which also solidifies their placement within the school system.

2. Establishment of a primary mental health centre where the school psychologists engage directly with parents and community members (and also provide targeted mental health interventions with support of psychiatrists from other levels of care).

Rationale: The primary mental health centre will facilitate the psychologist’s activities at the school and serve as a referral centre for identified cases, linking the school system with the health services delivery system. The primary mental health centre provides efficiency in that it increases the reach of the limited number psychologists, rather than having some schools without psychologists.

3. Engaging with the nascent national health insurance scheme to incorporate the scale-up (and funding) for SMHP as a preventative health strategy for mental health at the primary health-care level.

Rationale: The national health insurance scheme is just rolling out and has plans and resources to scale-up to all of the country. The SMHP can piggyback on this scheme to facilitate scale-up.

1. Synchronizing the timing of teachers’ training on SMHP with the school academic calendar.

Rationale: This will facilitate participation among teachers and school administrators, and also minimize the additional burden to teachers and administrators.

2. Clarifying roles among various individuals involved within the school system e.g. emphasizing the role of teachers to promote mental health (and not to provide targeted interventions) and to identify children requiring mental health care for prompt referral first to champion teachers who are expected to work with parents to guide the child’s access to the health system.

Rationale: Teachers are already overextended on multitasks, and it was important to limit their role in the delivery of the programme to prevent overburdening them and to ensure their participation.

1.Inclusion of MOE’s counselling centres (which function as referral centres for school-aged children experiencing mental health problems within the MoE structure, providing counselling and psychological interventions). These counselling centres are then linked to Community Mental Health Centers (CMHC) which are community-based psychiatric health care facilities within the MoH structure for cases requiring specialized services.

Rationale: Linking MoE and MoH services will foster co-operation at the primary care level, integration of mental health services for school children, and increased uptake of MoH specialized mental health services unavailable within the MoE system.

2. Exclusion of primary care physicians (PCPs) from the referral pathway of cases requiring specialized care. These children are referred directly by teachers from schools to the counselling centres and then to the CHMC, as the first point of contact in the health services delivery system.

Rationale: PCPs in Iran may lack resources and expertise to provide adequate mental health care

Intervention adaptation^c

1. Addition of a targeted intervention module on learning difficulties, self-harm and bullying which are prevalent mental health conditions in Egypt.

Rationale: The addition of this module makes the SMHP programme more responsive to the specific mental health needs in Egypt.

1. Translation of the SMHP manual to Urdu, addition of a module on teacher self-care, use of culturally and age- appropriate case examples to illustrate key steps in interventions.

Rationale: These changes will enhance the acceptability and easy application of the interventions.

2. Reframing the mental health conditions described in the SMHP programme as internalizing and externalizing problems.

Rationale: This change will reduce labelling of children and stigma related to specific mental health diagnosis.

3. Adding a section on how to conduct parent–teacher interaction for teachers and others delivering the SMHP.

Rationale: This change will improve teachers’ efficacy to interact more effectively with parents to facilitate the delivery of the programme.

1. Prioritizing teachers’ activities to focus on screening and identification of children with mental health needs (and not delivery of any targeted intervention).

Rationale: This change will minimize any increased workload (or perception of increased workload) to teachers.

2. Prioritizing counsellors’ activities at MOE’s counselling centres to provide targeted interventions within the SMHP.

Rationale: These trainings are viewed as additional qualification and knowledge expertise in mental health which is desirable to MOE counsellors. Thus, the trainings will provide incentives to counsellors under the MoE to support the delivery of the SMHP.

Key strategies are approaches that determined the successful rollout of the entire programme, including those that were crucial for facilitating the described preconditions in each country.

Contextual adaptations are changes to the internal environment (e.g. culture, norms and arrangements) within the implementing agencies, including key implementers or changes to the external environment (e.g. political, economic systems).

Intervention adaptations are changes to the intervention (primarily the SMHP manual) to facilitate its delivery in a specific context.