Participatory Model of Mental Health Programming: Lessons Learned from Work in a Developing Country.

Participatory action research provides a framework for conceptualizing the development of mental health programs in schools and communities. A participatory intervention model is best characterized by a collaborative process in which the partners together create interventions to facilitate individual and cultural change. In this article, we describe the application of a participatory model for creating school-based mental health services in a developing country where such services are non-existent. In particular, we describe the process of identifying individual and cultural factors relevant to mental health in the target culture. The article concludes with a discussion of lessons learned with regard to the importance of formative research and collaboration with stakeholders to ensure cultural specificity of interventions, and the potential for participatory action research to contribute to strengthening our commitment to research-based school psychological practice. Recent trends in school psychology emphasize participation of key stakeholders (e.g., teachers, parents, community members) in addressing the needs of students. For example, school reform efforts reflect a participatory model through the use of a team-based approach (Adelman, 1995; Curtis & Stollar, 1996). Current models of consultation call for collaboration with teachers and families (Christenson & Conoley, 1992; Rosenfield & Gravois, 1996; Sheridan, Kratochwill, & Bergan, 1996). In this article, we propose a participatory intervention model to guide school-based mental health programming. We describe the application of the model in a developing country in which school-based mental health services are non-existent. This example provides the opportunity to examine closely the process of program development through participation of key stakeholders We conclude with lessons learned from our work in a developing country and discussion of implications for mental health program development and school psychology practice in the United States. Participatory Intervention Model Figure 1 presents a model of program development that is consistent with a participatory action research model (see Nastasi, 1998). A participatory intervention model is best characterized by a collaborative process in which the partners together create interventions to facilitate individual and cultural change. Partners in program development include representatives from constituencies with a vested interest and/ or necessary resources. For example, in school-based mental health interventions, partners are likely to include teachers, school administrators, parents, students, school mental health staff, community mental health agency staff, community leaders, and policy makers. Partnership is the catalyst for program development and for individual and social-cultural change. The first component of participatory program development--participatory program design--corresponds to the program design stage of traditional models, that is, the stage during which program goals are identified and the intervention program (e.g., strategies, curriculum) is planned. The process of program development begins with formative research focused upon identifying and assessing individual and cultural variables that are critical to the change process. Data from formative research are used by the partners to identify culture-specific goals and to develop a culture-specific intervention model. In the process of participatory program design, the psychologist-researcher does not present an intervention for acceptance but through dialogue with stakeholders creates an intervention. In the participatory process, all members of the team hold equal status, contribute equally to the generation of ideas and decision making, and work toward consensus. In this way, program acceptability becomes a by-product of program design. The second component of participatory program development--participatory program implementation--involves the modification of the culture-specific model to fit the needs and resources of specific contexts (e.g., one school) and populations (e.g., inner-city adolescents). From an ecological perspective, adaptation of the program model refers to the creation of an ecological niche: a person-environment fit that enables optimal development and functioning (cf. Bronfenbrenner, 1989). Thus the question becomes, "What modifications are necessary to achieve an ecological niche for the local culture and participants? " Answering that question requires identifying (a) the essential elements of the intervention, that is, those elements that are requisite for achieving program goals, and (b) what modifications are necessary to implement the essential elements within the local context but still preserve the critical components of the intervention. Hence, program implementation also requires collecting data about the needs, resources, values, language, and behavior of the specific target group. This is done in partnership with program participants (those who implement and those who receive the intervention). The assumption is that the better the ecological fit, the greater the likelihood of program acceptability, proper implementation, and sustainability. To ensure effective program implementation, continuing data collection or formative/process evaluation is necessary. This data collection provides the opportunity to monitor implementation and modify the program to facilitate an optimal fit between the intervention and the participants. Traditional conceptions of program integrity or fidelity require documentation of the extent to which a prescribed intervention plan is followed. In contrast, the focus in participatory intervention is documentation of the program as implemented within a specific context. From a research perspective, the goal is to identify the critical and non-critical elements of the intervention across multiple personand culture-specific adaptations. Critical elements are those that are linked to target program outcomes. Noncritical elements are those that can vary across contexts or persons to foster acceptable interventions but do not interfere with the achievement of target outcomes. The third component of participatory program development--participatory program evaluation--involves the documentation of efficacy, that is, examination of the impact of the intervention. This component addresses the question, "What essential changes have occurred in the direction of the program goals? " The response to this question requires assessment of program impact at multiple points in time, throughout and following the intervention process. Hence, target skill level is the standard against which performance is compared throughout the intervention (formative evaluation), immediately following the conclusion of the intervention (immediate outcome or summative evaluation), and at a later point in time (follow-up or delayed outcome). These changes in target competencies are interpreted with reference to the elements of the intervention (documented during program implementation) to determine which intervention components are essential to bring about the desired goals for the specific culture and person(s). Evaluation results are used to make necessary program modifications to enhance success within the local culture as well as to inform intervention theory. Developing School-Based Mental Health Services in Sri Lanka We present findings from the Mental Health Among Sri Lankan Youth project, conducted in Sri Lanka, an island situated in the Indian Ocean south of India. In its initial phase, this long-term project was focused upon developing a school-based mental health care service delivery model through coordination of government-funded health care and education. Project aims included developing culture-specific definitions of key individual and cultural constructs relevant to mental health; assessing within the professional community and youth sectors the needs and resources relevant to promoting mental health of Sri Lankan youth; assessing service provider training potential and needs to plan for establishment of international exchange programs; and building an infrastructure for mental health research, service delivery, and professional preparation. The information presented here was collected during a two-year period during several visits to Sri Lanka. Sri Lanka provided an opportune context for this work. First, free and accessible medical and educational services are available to the general population. Second, consistent with the developing world more generally, there is limited emphasis on mental health. However, professionals within the country recognize the importance of addressing mental health issues. Third, mental health services are limited due to the shortage of professionals (e.g., less than 20 psychiatrists in a country of 18 million and nonexistent psychological services) and training programs. Fourth, the extensive government-funded educational system provides an alternative context for provision of mental health services to the general population of children and youth. Finally, a well-established (14-year) collaborative relationship between social science and medical professionals from the U.S. and Sri Lanka made this project and extended work feasible. Collectively, these professionals-anthropologists, sociologists, psychiatrists, pediatricians, and a school psychologist-represent universities and non-governmental research and community service agencies from both countries who have extensive experience in schooland community-based health-related research and service. Preliminary data regarding the need for and provision of mental health services for Sri Lankan youth were gathered during a two-month visit to Sri Lanka in the Summer of 1995. Data sources included informal participant observation, key informant interviews, and collection of artifacts within the local and professional co