Knowledge translation to policy agenda-setting
: understanding mental health as a policy priority in the context of South Africa

Student thesis: Doctoral ThesisDoctor of Philosophy


Background Mental health is a critical determinant of health, and globally government-level action is needed to overcome the substantial gaps in provision of quality treatment,and for integration into primary and community care settings. But in many low- and middle-income countries (LMICs) mental health is widely absent from the policy agenda, despite the fact that up to 90% of people with mental conditions do not receive treatment. Ever more evidence on effective and cost-effective treatments is available, but the translation of research knowledge into policy is a ‘wicked’ complex problem, which is often slow, ineffective or failing. One reason may lie in the complexities of policymakers’ decision-making processes. Behavioural science methods have been effectively used to aid peoples’ decision-making in public health but have so far not been applied to support policymakers.
Aims & Objectives The overarching aim of this study is to investigate the inter-relationships of research evidence and mental health policy making in LMICs and more specifically South Africa,with a specific focus on agenda-setting and behavioural incentives, and to develop an actionable framework to guide and support knowledge translation and evidence based mental health policy making.The specific aims and objectives of the study were: Aim 1: To analyse theories of inter-relationships of research evidence and mental health policy making; Objective 1.1: To identify and select the most suitable actionable theoretical framework on inter-relationships of research evidence and mental health policy making in LMICs;Aim 2: To develop and validate an actionable framework for mental health research to policy agenda-setting; Objective 2.1: To develop a preliminary conceptual framework, based on the theoretical models and frameworks identified in the systematic review (of Objective 1.1), which targets the policy agenda-setting stage;Objective 2.2: To validate the preliminary framework (developed in Objective 2.1), to ensure it is applicable to inter-relationships of mental health research evidence and policy making on provincial, national and global levels; Aim 3: To apply and empirically test the new conceptual framework against case studies on micro (district) and meso (national) levels in South Africa, and macro(global) level; Objective 3.1: To apply, test and analyse the research evidence to policy agenda-setting process against the validated theoretical framework (derived from Objective 2.2), using the Prime, Emerald and FundaMentalSDG projects as case  studies; Objective 3.2: To test which mechanisms have been effective and whether behavioural incentives have been effectively applied; Objective 3.3: To develop key findings and a revised, empirically validated framework; Aim 4: To provide recommendations for improving research and policy interrelationships for mental health in LMICs; Objective 4.1: To synthesise the key findings and develop evidence-based recommendations and effective mechanisms for mental health research and policy agenda-setting in LMICs. 
Methods Using a qualitative methods approach, a systematic review was conducted of theories on knowledge translation in LMICs and mental health, using the BeHEMoTh method(Booth & Carroll, 2015) (Chapter 2). The EVITA (EVIdence To policy Agenda-setting)framework was developed from the key components derived in the systematic review. EVITA was revised and validated through two newly developed validation tools for mental health policy priority-setting and overall validity, and in-depth expert interviews. Next, the EVITA framework was empirically tested against three case studies at district (PRIME project) and national (Emerald project) levels in the context of South Africa, and at the global level (FundaMentalSDG initiative) of the UN Sustainable Development Goals (SDGs). Qualitative data were collected from expert interviews and documentary analysis, and analysed against the EVITA Framework and the MINDSPACE framework for behavioural insights (Dolan et al., 2010), using Iterative Categorisation (IC) (Neale, 2016).
Results Agenda-setting was identified as a research theory gap in the context of mental health knowledge translation in LMICs (Votruba et al., 2018) (Chapter 3). Therefore,the EVITA framework for knowledge translation to policy agenda-setting wasdeveloped, theoretically validated and tested empirically (Votruba et al.,2020)(Chapter 4). The key findings were: (1) Mental health research translation to the policy agenda occurs in a complex, fluid system that includes multiple ‘research clouds’, ‘policy spheres’ and other networks; (2) Mental health research policy agenda-setting is based on key individuals and intermediaries and their interrelationships; and (3) Key challenges and strategies for successful research to policy agenda impact are usually known, but are frequently not strategically addressed and implemented. Mechanisms to support the translation of mental health evidence to policy agenda setting include: Strategic long-term planning; continuous relationship building;capacity building; alignment and framing of the research; targeting multiple policy agendas; and engagement with implementation stakeholders and advocacy coalitions. The findings also suggest that behavioural incentives can improve research uptake in policy, and may therefore be applied to support knowledge translation interventions to policy agenda-setting. A revised EVITA framework and key findings were presented. 
Conclusion This study investigated mental health research and policy inter-relationships in LMICand specifically South Africa. It presented the development of the new EVITA framework which combined knowledge translation theories with a policy agenda setting focus. The framework was theoretically and empirically validated, and includes behavioural incentives as novel, useful mechanisms for improving evidence based policy making in public mental health. The EVITA framework was found to aid in understanding mental health research policy inter-relationships and has the potential to improve the challenging process of research evidence translation and uptake on the policy agenda in LMICs. More research is needed to understand if EVITA can be applied to other contexts, such as other LMICs, high income countries(HICs), or other low priority health policy issues.
Date of Award1 Apr 2021
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorGraham Thornicroft (Supervisor) & Jonathan Grant (Supervisor)

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