How do systems achieve their goals? The role of implementation in mental health systems improvement

Abstract

Effectively addressing mental health and substance use problems are important challenges faced globally. People experiencing such problems encounter many societal barriers that can affect their ability to participate as full members of society and have life expectancies much shorter than the general population. Policies to address mental health and substance use problems require the mobilization of multiple sectors, such as health, education, and justice. While there is strong evidence for programs and services that work, and there are policy directions aimed at achieving better service experiences and improved health and social outcomes, there is a lack of knowledge about how to get these policies and programs embedded effectively into daily practice – a process called implementation. The objective of this dissertation is to advance the understanding of implementation strategies for addressing such complex challenges through five original scientific contributions. The first is a critical interpretive synthesis of existing literature to generate a theoretical framework of the implementation process from the perspective of a policy goal by integrating findings from the public policy, implementation science and knowledge translation fields. Next is a two-part comparative case study exploring how policy implementation was structured and the strategies used in large, well-developed mental health systems. Last is a two-part in-depth examination of mental health policy implementation efforts in Ontario, Canada, beginning with an analysis of the development and implementation of the province’s mental health strategy, followed by an examination of the role that citizens and other stakeholder groups played in its implementation. Together these studies contribute theoretical, substantive and methodological insights toward understanding the effective implementation of policy directions for complex social challenges. Better implementation means more citizens can benefit from effective policies and programs that are needed across populations.