Can Reciprocal Innovation Improve U.S. Mental Health Care?

In places such as Tanzania, the idea of training peers to help people cope with mental health challenges is one borne of necessity. Fewer than 100 psychiatrists and psychologists practice in the country, which has a population of more than 68 million, meaning that professional mental health care is difficult to find for all but the most extreme cases. 

But as more peer-based counseling programs demonstrate promising evidence of success, some experts are asking, why not try them everywhere?

“It’s not just about needing to task share due to lack of resources,” says Dorothy Dow, M.D., an associate professor of pediatrics and global health who leads a peer-mentored program in Tanzania for adolescents living with HIV. “We think it actually may be a better way to approach mental health.”

Launched at the Kilimanjaro Christian Medical Centre (KCMC) in 2016, Dow’s program enrolls adolescents living with HIV in a series of group discussions, led by trained peer counselors who help youth cope with the stigma and isolation that can often accompany their diagnosis. Called Sauti ya Vijana, Swahili for “the voice of youth,” the project has proved effective in keeping youth on schedule with HIV medications and has since been expanded to multiple sites across four regions in Tanzania.

But Tanzanian youth are not alone in dealing with the mental health challenges of living with HIV. In September, Dow and colleagues published research showing that more than 20 percent of adolescents who receive treatment at one U.S. HIV clinic reported symptoms of depression on a standard mental-health assessment survey, comparable to what the team has observed among youth enrolling in Sauti ya Vijana.

Peer counseling can offer a more approachable way for youth to open up about those struggles, Dow says, noting they are often more willing to disclose difficulties to someone who shares their life experiences.

“I think a lot of youth can improve when they feel heard and are able to develop some problem-solving skills,” she says. “In the U.S., sometimes we leap-frog over that first step, and a program like ours could help provide that initial support.”

Dow says she has heard strong interest from U.S. HIV clinics in adapting a peer-based program, but funding remains a challenge. There are also logistical obstacles, including patient confidentiality restrictions and the smaller number of youth living with HIV in the U.S., which in some communities might make it harder to hold in-person group sessions.

But the possibility of bringing a program designed for a resource-limited environment to meet emerging needs in the U.S. reflects a growing trend. Sometimes called “reciprocal innovation,” the concept is fueled by the recognition that interventions designed for low-income countries often find creative ways to work around scarcity, such as shifting tasks to non-specialists or delivering services through less formal settings such as a peer group.

“Given how scarce mental health resources are in the U.S., we have a lot to learn from innovations developed through our work with colleagues in low-resource settings around the world,” says Eve Puffer, Ph.D., director of the Duke Center for Global Mental Health. 

During the Covid-19 pandemic, for example, Puffer adapted a family support intervention that she developed with colleagues in Kenya to provide an outlet for families in North Carolina to process the multiple colliding stresses of the pandemic. She has continued to refine the model for use in other U.S. communities, and she says several Duke colleagues are investigating ways to apply what they’ve learned in global settings to address mental health challenges closer to home.

“Together, we’ve found ways to deliver evidence-based care efficiently through approaches like task sharing and streamlined delivery models,” Puffer says. “High-income countries are only beginning to adopt these models, and [Dow’s project] shows there’s great potential in this kind of reciprocal innovation.”