title: Using workshops to develop theories of change in five low and middle income countries: lessons from the programme for improving mental health care (PRIME).
abstract: BACKGROUND
  The Theory of Change (ToC) approach has been used to develop and evaluate complex health initiatives in a participatory way in high income countries. Little is known about its use to develop mental health care plans in low and middle income countries where mental health services remain inadequate.
  
  
  OBJECTIVE
  ToC workshops were held as part of formative phase of the Programme for Improving Mental Health Care (PRIME) in order 1) to develop a structured logical and evidence-based ToC map as a basis for a mental health care plan in each district; (2) to contextualise the plans; and (3) to obtain stakeholder buy-in in Ethiopia, India, Nepal, South Africa and Uganda. This study describes the structure and facilitator's experiences of ToC workshops.
  
  
  METHODS
  The facilitators of the ToC workshops were interviewed and the interviews were recorded, transcribed and analysed together with process documentation from the workshops using a framework analysis approach.
  
  
  RESULTS
  Thirteen workshops were held in the five PRIME countries at different levels of the health system. The ToC workshops achieved their stated goals with the contributions of different stakeholders. District health planners, mental health specialists, and researchers contributed the most to the development of the ToC while service providers provided detailed contextual information. Buy-in was achieved from all stakeholders but valued more from those in control of resources.
  
  
  CONCLUSIONS
  ToC workshops are a useful approach for developing ToCs as a basis for mental health care plans because they facilitate logical, evidence based and contextualised plans, while promoting stakeholder buy in. Because of the existing hierarchies within some health systems, strategies such as limiting the types of participants and stratifying the workshops can be used to ensure productive workshops.
authors.affiliation: Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch 7700, Cape Town, South Africa.
authors.forename: Erica
authors.initials: E
authors.lastname: Breuer
authors.affiliation: Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Mary J
authors.initials: MJ
authors.lastname: De Silva
authors.affiliation: Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, PO Box 9086 Addis Ababa, Ethiopia ; King's College London, Institute of Psychiatry, Department of Psychological Medicine, Centre for Affective Disorders and Affective Disorders Research Group, London, UK.
authors.forename: Abebaw
authors.initials: A
authors.lastname: Fekadu
authors.affiliation: Transcultural Psychosocial Organization Nepal, Baluwatar, Box 8974, Kathmandu, GPO, Nepal.
authors.forename: Nagendra Prasad
authors.initials: NP
authors.lastname: Luitel
authors.affiliation: Sangath, HN - 6, Rishi Nagar, Char Imli, Bhopal, Madhya Pradesh, India.
authors.forename: Vaibhav
authors.initials: V
authors.lastname: Murhar
authors.affiliation: Butabika National Mental Hospital, Kampala, Uganda.
authors.forename: Juliet
authors.initials: J
authors.lastname: Nakku
authors.affiliation: School of Psychology, University of KwaZulu-Natal, Howard College Campus, Durban 4000, South Africa.
authors.forename: Inge
authors.initials: I
authors.lastname: Petersen
authors.affiliation: Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch 7700, Cape Town, South Africa.
authors.forename: Crick
authors.initials: C
authors.lastname: Lund
keywords: Health planning; Mental health; Programme design; Programme evaluation; Theory of change