Documenting the Contextualization and Implementation of mhGAP-HIG in Post-earthquake Nepal

Background: The burden of mental health is increased in humanitarian settings, and needs to be addressed in emergency situations. The World Health Organization has recently released the mental health Global Action Programme Humanitarian Intervention Guide (mhGAP-HIG) in order to scale up mental health service delivery in humanitarian settings through task-shifting. This study aims to evaluate, contextualize and identify possible barriers and challenges to mhGAP-HIG manual content, training and implementation in post-earthquake Nepal.

Methods: This qualitative study was conducted in Kathmandu, Nepal. Key informant interviews were conducted with fourteen psychiatrists involved in a mhGAP-HIG Training of Trainers and Supervisors (ToTS) in order to assess the mhGAP-HIG, ToTS training, and the potential challenges and barriers to mhGAP-HIG implementation. Themes identified by informants were supplemented by process notes taken by the researcher during observed training sessions and meetings.

Results: Key themes emerging from key informant interviews include the need to take three factors into account in manual contextualization: culture, health systems and the humanitarian setting. This includes translation of the manual into the local language, adding or expanding upon conditions prevalent in Nepal, and more consideration to improving feasibility of manual use by non-specialists.

Conclusion: The mhGAP-HIG must be tailored to specific humanitarian settings for effective implementation. This study shows the importance of conducting a manual contextualization workshop prior to training in order to maximize the feasibility and success in training health care workers in mhGAP.

Barriers and Facilitators to Adoption of Genomic Services for Colorectal Care within the Veterans Health Administration.

We examined facilitators and barriers to adoption of genomic services for colorectal care, one of the first genomic medicine applications, within the Veterans Health Administration to shed light on areas for practice change. We conducted semi-structured interviews with 58 clinicians to understand use of the following genomic services for colorectal care: family health history documentation, molecular and genetic testing, and genetic counseling. Data collection and analysis were informed by two conceptual frameworks, the Greenhalgh Diffusion of Innovation and Andersen Behavioral Model, to allow for concurrent examination of both access and innovation factors. Specialists were more likely than primary care clinicians to obtain family history to investigate hereditary colorectal cancer (CRC), but with limited detail; clinicians suggested templates to facilitate retrieval and documentation of family history according to guidelines. Clinicians identified advantage of molecular tumor analysis prior to genetic testing, but tumor testing was infrequently used due to perceived low disease burden. Support from genetic counselors was regarded as facilitative for considering hereditary basis of CRC diagnosis, but there was variability in awareness of and access to this expertise. Our data suggest the need for tools and policies to establish and disseminate well-defined processes for accessing services and adhering to guidelines.