Developing a theory of change for implementing cognitive interventions in low-resource settings: The CognIFiEd study

Cognitive impairment affects over 75% of young people with first-episode psychosis (FEP), yet cognitive rehabilitation is rarely available within public mental health services in sub-Saharan Africa. This implementation gap reflects both limited intervention availability and insufficient planning for local service realities. This article describes the participatory development of a Theory of Change (ToC) for the CognIFiEd study, a task-shifted Compensatory Cognitive Training intervention for young adults with FEP across three tertiary psychiatric hospitals in South-West Nigeria. Guided by WHO ExpandNet, RE-AIM, the Consolidated Framework for Implementation Research and established ToC methods, 25 stakeholders, including young people with lived experience, caregivers, clinicians, facilitators, administrators, policymakers and implementation scientists, co-produced and validated an implementation logic model through five workshops. The ToC identifies four core inputs: trained non-specialist facilitators, culturally adapted manuals, low-technology SMS and print reinforcement systems, and stakeholder engagement structures. These support weekly group sessions, caregiver psychoeducation, digital reinforcement, supervision and outpatient integration. Immediate outputs include cognitive strategy use, retention, social reintegration and caregiver skill development, while proximal outcomes include neurocognition, functional capacity, self-efficacy and caregiver strain. The model also specifies assumptions, LMIC-specific barriers, mitigation pathways and an accountability ceiling for distinguishing pilot outcomes from longer-term system impacts.