The study evaluated the Integrated Scaling Approach, or ISA, across agencies operating within a state supported employment system. It used a concurrent mixed-methods design: descriptive quantitative measures tracked implementation and service reach, while 12 focus groups and two individual interviews with 25 participants explored facilitators and barriers to scaling and sustainment. Participants included frontline staff, supervisors, program managers and a representative from the state Mental Health Authority. The Vocational Rehabilitation agency withdrew from active participation during implementation and did not participate in the interviews.

Thinking Skills for Work, or TSW, was the evidence-based practice selected for the trial. It is a cognitive remediation intervention designed to improve employment outcomes among people with serious mental health conditions by targeting cognitive functioning. TSW also had a defined intervention manual and training guide, which the researchers treated as criteria for dissemination readiness. The field trial was conducted in Georgia, which had 23 high-fidelity Individual Placement and Support programs serving more than 4,000 people annually at recruitment. The state Mental Health Authority and Vocational Rehabilitation agency initially expressed interest in the initiative.

ISA was organized into preparation, implementation and sustainment phases. Preparation activities included engaging state administrators, introducing TSW to participating agencies, adapting a marketing toolkit, creating agency- and system-level implementation teams, and providing a 10-week online, self-paced training program. During implementation, technical assistance focused on integrating TSW into billing, documentation and workflow. Providers then completed a five-month certification program with remote supervision emphasizing skill development, fidelity and case-based problem-solving. The sustainment phase emphasized a 10-week Train-the-Trainer program and periodic technical assistance.

Nine of the 23 supported employment agencies enrolled, representing 39% of the state’s active programs, and the participants operated 12 sites. Eight of the nine agencies completed all three ISA phases. During implementation, 18 of 20 program managers, or 90%, participated in monthly technical assistance sessions, while 19 of 34 staff members across the agencies completed training and became certified in TSW. Providers approached 61 clients during implementation; 57, or 93%, enrolled and received TSW. Another 28 clients enrolled during sustainment, bringing the total to 85 supported employment clients served during the field trial. All nine agencies had 16 staff complete Train-the-Trainer certification.

Interviews and focus groups identified several features associated with implementation. Participants described TSW as flexible enough to fit different agency contexts and individual client needs. Structured hybrid training combined didactic instruction with extended practice-based supervision, which respondents associated with greater staff confidence and perceived competence. Implementation-team meetings supported cross-agency learning, accountability and problem-solving, while regular technical assistance kept TSW visible amid competing service demands. State endorsement also supported participation by signaling the legitimacy and potential value of the intervention.

Long-term sustainment was not achieved. Pandemic-related funding reductions and workforce disruptions produced staff shortages, with some agencies reporting losses of one-third to one-half of their supported employment staff. Staff were redeployed to other services, some training was interrupted, and agencies did not use the TSW marketing toolkit because they were concerned they could not meet demand. Clients also faced barriers to engagement, including prioritizing personal health over work, reluctance to begin a new intervention and avoidance of in-person services. The state’s Vocational Rehabilitation system lost 75% of its staffing as funding shifted to COVID-19 relief.

System-level changes were also associated with weaker sustainment incentives. Leadership and staffing changes at the Mental Health Authority and Vocational Rehabilitation agency disrupted plans to reimburse TSW as part of supported employment services, reducing agencies’ incentives to maintain the practice. These changes also halted proposed modifications to supported employment fidelity measures that would have recognized TSW as a service component, making integration more difficult for some agencies. The study therefore associated the failure to sustain TSW with unstable funding, policy support, reimbursement mechanisms and staffing rather than with a complete absence of agency interest. Participants also described the tension between supported employment expectations for rapid placement and the time required to deliver TSW.

The study establishes short-term implementation outcomes, not the intervention’s effectiveness in improving employment, and it does not show that the ISA caused long-term sustainment. Eight of nine agencies completed all phases, staff certification and internal training capacity were achieved, and 85 clients received TSW, but adoption and sustainment were distinct outcomes and early implementation did not predict maintenance. The authors concluded that integrated workforce, organizational and system strategies can facilitate uptake, even during substantial disruption, but they argued that durable policy and funding support are needed for sustained scale-up. Because the trial covered one state under exceptional pandemic conditions, future assessment of ISA with other evidence-based practices and in more stable systems remains necessary.

Subject of Research: A mixed-methods field trial of the Integrated Scaling Approach for implementing Thinking Skills for Work in Georgia supported employment programs

Article Title: Outcomes of the Integrated Scaling Approach: scaling an evidence-based employment intervention in public mental health systems

Article References: Farkas, M., Trolley-Hanson, A., McGurk, S. R., Burke-Miller, J. K., Braverman, D., Khare, C., & Mueser, K. T. (2026). Outcomes of the Integrated Scaling Approach: scaling an evidence-based employment intervention in public mental health systems. Frontiers in Psychiatry, 17, Article 1867975. https://doi.org/10.3389/fpsyt.2026.1867975

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1867975

Keywords: implementation science, supported employment, Thinking Skills for Work, cognitive remediation, mental health systems, scale-up, workforce capacity, implementation sustainability, COVID-19 disruptions, Georgia, Outcomes, Integrated

Following Joanna Briggs Institute methodology and reporting under PRISMA-ScR guidance, the authors searched PubMed, PsycINFO and Web of Science for publications issued from January 2015 through October 2025. Eligible findings were then synthesised thematically. Twenty-one articles reached full-text assessment, but three met the inclusion criteria.

These studies represented three different national settings: the United States, India and the Netherlands. Across the included reports, exchange programmes were associated by their participants with greater awareness of both shared clinical problems and differences among settings. Participants also recognised more clearly how culture and the organisation of mental health care interact with clinical practice.

Professional development emerged as a third major theme in the thematic synthesis. These results describe the benefits reported in a small set of pilot studies rather than a demonstrated effect on care. The review does not establish that cross-national exchanges improve treatment decisions, service delivery or health outcomes for children and adolescents.

Nor can its three included studies identify a universally preferable programme design or determine which exchange format works best for particular participants or settings. The findings are also constrained by the limited number and geographic scope of eligible publications, which prevents strong conclusions about the reach or consistency of the observed themes. The authors recommend further research to assess the added value and cost-effectiveness of cross-national exchange formats and to examine which approaches suit which participants and settings.

The review was preregistered on the Open Science Framework, and its authors state that additional evidence is needed to clarify the value of the programmes. In its current form, the evidence supports a cautious conclusion: cross-national clinical exchange in child psychiatry can raise awareness of cultural and health-system differences and contribute to professional learning, but the review does not demonstrate downstream clinical benefits.

Subject of Research: Scoping review of cross-national clinical exchange in child and adolescent psychiatry

Article Title: Cross-national clinical exchange in child psychiatry across cultural contexts and mental health systems: a scoping review

Article References: de Veen, B. T. H., Bringmann, K. F., Herpers, P. C. M., Staal, W. G., Scholte, R. H. J., van Dongen-Boomsma, M., & Deschamps, P. (2026). Cross-national clinical exchange in child psychiatry across cultural contexts and mental health systems: a scoping review. BMC Medical Education. https://doi.org/10.1186/s12909-026-10356-x

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10356-x

Keywords: child psychiatry, cross-national exchange, scoping review, cultural context, mental health systems, clinical education, professional development, United States, India, Netherlands, Cross-national, clinical

The guideline in question is the WHO Guideline: recommendations on digital interventions for health system strengthening, known as WHO-GRDI. Released in 2019, it distils the global evidence on nine categories of digital health intervention, from birth and death notification and drug stock management to telemedicine, targeted client communication, patient tracking, health worker decision support and digital training. The problem, the researchers argue, is that guidelines like this are written for the world in general, not for any particular health system in particular. In countries where electricity is unreliable, networks drop and health workers are already stretched thin, an unadapted guideline can sit on a shelf. Guideline adaptation — a systematic, participatory process that preserves the integrity of the original recommendations while customising them for local laws, resources and culture — is widely seen as a faster and cheaper alternative to developing new guidelines from scratch, yet detailed accounts of how to do it for mental health systems have been scarce.

The team structured the entire project around the Knowledge to Action cycle, a widely used implementation science framework that moves from identifying a problem, through adapting knowledge to local context, to implementing, monitoring and sustaining change. Lagos was a deliberately pragmatic choice. The state already runs the Mental Health in Primary Care programme, or MeHPriC, which operationalises the WHO’s mhGAP strategy in 57 designated flagship primary health centres, each staffed with doctors, nurses, midwives, community health extension workers, pharmacy technicians and counsellors. MeHPriC had already demonstrated clinical and cost-effectiveness in treating depression, anxiety, substance use disorders and epilepsy, but its processes were largely manual, with only scattered use of SMS messages, WhatsApp and emergency phone lines.

The project unfolded in four phases: planning, adaptation, implementation and evaluation. In the planning phase, the researchers established a Local Steering Committee of project members and independent local experts in digital intervention, guideline development, programme implementation and qualitative research, alongside a separate Stakeholders’ Forum drawing in psychiatrists, psychologists, primary care workers, technology providers, policymakers and nongovernmental organisations. Early dissemination through existing unions of nurses, midwives, community health workers and general practitioners helped secure cooperation from the outset. Ethics approval came from both the Lagos State University Teaching Hospital and the WHO itself.

The adaptation phase began with a hard-nosed assessment of whether Lagos was even ready. The team reviewed Nigeria’s mental health law, national mental health policy, task-shifting policy and National Health ICT Strategic Framework, and mapped existing digital health projects through the WHO’s Digital Health Atlas and a Nigerian digital health dashboard. The connectivity picture was surprisingly strong: by August 2021 Nigeria had more than 188 million active mobile lines, over 140 million people accessing the internet by phone, 48 percent broadband penetration and a call setup success rate of 98.9 percent. Notably, of 12 reviewed digital health projects in Nigeria, none focused on mental health — confirming the unmet need. Five independent raters then appraised the WHO-GRDI itself using the AGREE-II instrument, the international standard for guideline quality, scoring it 79.3 percent overall, with particularly strong marks for editorial independence and clarity. An 11-member Contextualization and Adaptation Panel of mental health specialists, primary care experts, policymakers, technology providers and linguists then worked through multiple rounds of structured feedback and formal consensus to produce a locally tailored draft, which was externally reviewed by professional bodies and 60 consulted stakeholders.

The adapted guideline emerged with eight rather than nine recommendations. Birth and death notification were merged into a single recommendation, since Lagos facilities record live deliveries, stillbirths and deaths with the same staff and systems. The word telemedicine was dropped entirely as ambiguous to local workers, and health worker decision support was relabelled clinical decision support. During planning workshops, stakeholders used the Theoretical Domains Framework to surface barriers and facilitators, then ranked the recommendations using a modified Delphi technique. Five were judged feasible for a pilot within the project’s timeline: drug stock notification, client-to-health-provider communication, health worker supervision and communication, targeted client communication and clinical decision support. The rest were set aside for want of infrastructure or priority.

The pilot itself ran for three months in five randomly selected flagship primary health centres, one from each administrative district. In each clinic, 11 health workers already involved in MeHPriC received mobile phones or tablets preloaded with project materials, and 55 health workers plus five supervising mental health specialists were trained over two weeks. Evaluation used validated implementation science instruments: the Acceptability of Intervention Measure, Intervention Appropriateness Measure and Feasibility of Intervention Measure, each scored on five-point Likert scales, supplemented by a perceived effectiveness rating and the 12-item Organizational Readiness for Implementing Change scale completed by health workers and managers. Altogether, 150 clients, 50 health workers, a five-member mental health team and five health managers participated in the assessment.

The headline results were encouraging. Recommendations on drug stock notification, health worker supervision and communication, and targeted client communication scored high across the board — perceived effectiveness between 80.0 and 92.0 percent, acceptability between 80.5 and 91.0 percent, appropriateness between 84.0 and 90.0 percent and feasibility between 81.0 and 90.0 percent. Organizational readiness was uniformly high, with a mean ORIC score of 55.62 out of 60, and no significant difference between frontline workers and managers. But two recommendations fell short. Client-to-health-provider communication scored between 65.6 and 73.4 percent, and clinical decision support between 78.0 and 79.0 percent on acceptability and effectiveness. The qualitative data explain why. Workers felt that emergencies such as suicidal crises demand face-to-face contact, worried about guilt and clinical liability if a remote patient deteriorated, and resented unpaid work extending beyond their capacity. On decision support, many found the electronic mhGAP guide too prescriptive and felt that checking a device in front of a patient undermined the patient’s self-esteem and the therapeutic relationship. Practical complaints about electricity, network connectivity, device safety and the need for more training rounded out the concerns.

The authors draw three main lessons for anyone attempting similar work in a low- or middle-income country. First, robust stakeholder engagement before, during and after adaptation is essential, and existing professional networks are the most efficient conduit for it. Second, policymakers should ensure a digital strategy, supporting infrastructure, legislation, governance frameworks and training plans are in place before attempting implementation of guideline recommendations. Third, integrating new recommendations into an already functioning programme — as the team did with MeHPriC’s existing mobile phone backup — makes the manual-to-digital transition far smoother. The team has prepared evidence briefs for Lagos policymakers and plans continued policy dialogues. The study does carry limitations: Lagos is Nigeria’s most developed state, the pilot was short at three months, and not all WHO-GRDI recommendations were implemented. Still, the authors argue the work offers valuable information for adapting and implementing the WHO-GRDI and other health systems guidelines, and they call for further research embracing the views and experiences of end-users to understand the balance between the generalizability and local adaptability of health systems guidelines. An ongoing feasibility trial of the electronic mhGAP app in Nepal and Nigeria is expected to inform the next round of implementation decisions.

Subject of Research: Adaptation and pilot implementation of the WHO guideline on digital interventions for strengthening mental health systems in Lagos State, Nigeria

Article Title: Adaptation and pilot implementation of the WHO guideline on digital intervention to strengthen mental health systems in Lagos state, Nigeria

Article References: Adewuya, A. O., Abdulmalik, J., Abimbola, S., Oladipo, O. E., Dahiru, A., Shettima, F., Fasawe, A., Fahim, C., Marten, R., Yangchen, S., & Straus, S. (2026). Adaptation and pilot implementation of the WHO guideline on digital intervention to strengthen mental health systems in Lagos state, Nigeria. Health Research Policy and Systems, 24(S1), Article 74. https://doi.org/10.1186/s12961-026-01463-8

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01463-8

Keywords: WHO-GRDI, digital health, mental health systems, Nigeria, Lagos, guideline adaptation, implementation science, primary health care, mHealth, mhGAP, low- and middle-income countries, health policy