Perceptions of health managers and professionals about mental health and primary care integration in Rio de Janeiro: a mixed methods study

The role of local health officers in advancing public health and primary care integration: lessons from the ongoing Universal Health Coverage reforms in the Philippines

The COVID-19 pandemic has highlighted the persistent fragmentation of health systems and has amplified the necessity for integration. This issue is particularly pronounced in decentralise settings, where fragmentation is evident with poor coordination that impedes timely information sharing, efficient resource allocation and effective response to health threats. It is within this context that the Philippine Universal Health Care law introduced reforms focusing on equitable access and resilient health systems through intermunicipal cooperation, enhancing primary care networks and harnessing digital health technologies-efforts that underline the demand for a comprehensively integrated healthcare system. The WHO and the global community have long called for integration as a strategy to optimise healthcare delivery. The authors contend that at the core of health system integration lies the need to synchronise public health and primary care interventions to enhance individual and population health. Drawing lessons from the implementation of a pilot project in the Philippines which demonstrates an integrated approach to delivering COVID-19 vaccination, family planning and primary care services, this paper examines the crucial role of local health officers in the process, offering insights and practical lessons for engaging these key actors to advance health system integration. These lessons may hold relevance for other low-ncome and middle-income economies pursuing similar reforms, providing a path forward towards achieving universal health coverage.

Integration measurement and its applications in low- and middle-income country health systems: a scoping review

BACKGROUND

Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use.

METHODS

Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data.

RESULTS

We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use.

CONCLUSION

We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Positive mental health for all serving the under-served

Mental disorders are major contributors to global burden of disease measured in Disability Adjusted Life Years (7% of all disease burden in 2017). Large treatment gaps for these disorders exist in all parts of the world. In India, overall treatment gap for mental disorders was found to be 83%. Women, children and adolescents, ethnic minorities, LGBTQ+ community, elderly and those living in remote and inaccessible areas have disproportionately higher rates of mental illness. They face unique and characteristic barriers to access to mental healthcare which increases treatment gap. These gaps have persisted despite global efforts and interventions to mitigate these barriers. Hence, there is a need to find alternatives to reduce mental health gap in these groups. Positive Mental Health interventions focuson well-being and health promoting activities, rather than on illness. The potential role of these interventions in promoting mental health and reducing treatment gap has been explored in this article.

Socioeconomic and racial/ethnic inequalities in depression prevalence and the treatment gap in Brazil: A decomposition analysis

Depression is a major global health burden and there are stark socioeconomic inequalities in both the prevalence of depression and access to treatment for depression. In Brazil, racial/ethnic inequalities are of particular concern, but the factors contributing to these inequalities remain mostly unknown. This paper firstly explores determinants of depression and the treatment gap (i.e., untreated afflicted individuals) in Brazil and identifies if socio-economic and health system factors explain changes over time. Secondly, it analyses income and racial/ethnic inequalities in depression and the treatment gap and identifies factors explaining inequalities through decomposition methods. Data from two waves (2013 and 2019) of a representative household-based survey are used. In 2019, 10.8% of adults were depressed, but over 70% of depressed adults did not receive care. Black or brown/mixed Brazilians were more likely to have untreated depression, and region of residence was the most important determinant of these racial/ethnic inequalities. Notably, 44.6% of the difference in the treatment gap between white individuals and black and brown/mixed individuals was not explained by differences in observables, which could potentially be due to discrimination or difficulties in accessing treatment due to other non-observable characteristics. Employment, age, exposure to violence and physical activity are the main contributing factors to income inequalities in depression. These results suggest that policies aimed at improving the levels of exposure of lower-income individuals to risk factors may positively impact mental health and mental health inequalities, while addressing inequalities in service provision and resourcing for mental health and tackling barriers to access stemming from discrimination are essential to bridge the treatment gap equitably.

Leveraging Stakeholder Engagement and Virtual Environments to Develop a Strategy for Implementation of Adolescent Depression Services Integrated Within Primary Care Clinics of Mozambique

Psychiatric disorders are the number one cause of disability in adolescents worldwide. Yet, in low- and middle-income countries (LMIC), where 90% of adolescents reside, mental health services are extremely limited, and the majority do not have access to treatment. Integration of mental health services within primary care of LMICs has been proposed as an efficient and sustainable way to close the adolescent mental health treatment gap. However, there is limited research on how to effectively implement integrated mental health care in LMIC. In the present study, we employed Implementation Mapping to develop a multilevel strategy for integrating adolescent depression services within primary care clinics of Maputo, Mozambique. Both in-person and virtual approaches for Implementation Mapping activities were used to support an international implementation planning partnership and promote the engagement of multilevel stakeholders. We identified determinants to implementation of mental health services for adolescents in LMIC across all levels of the Consolidated Framework for Implementation Research, of which of 25% were unique to adolescent-specific services. Through a series of stakeholder workshops focused on implementation strategy selection, prioritization, and specification, we then developed an implementation plan comprising 33 unique strategies that target determinants at the intervention, patient, provider, policy, and community levels. The implementation plan developed in this study will be evaluated for delivering adolescent depression services in Mozambican primary care and may serve as a model for other low-resource settings.

[Mental healthcare in Brazil: a multifaceted study in four large cities]

This study aimed to assess characteristics of healthcare networks in four large Brazilian cities (Campinas, Fortaleza, Porto Alegre, and São Paulo), in the provision of mental healthcare. The following outcomes were used: (i) place of identification of the mental health problem; (ii) mental healthcare in primary care; (iii) pharmaceutical care in mental health; and (iv) social rehabilitation. This is a mixed-methods study with a concurrent and sequential approach, conducted with 10 administrators and 1,642 users of Centers for Psychosocial Care (CAPS, in Portuguese) in the four cities. The study showed the persistence of high-complexity services such as hospitals as the site for initial identification of mental health problems in Campinas (40% of users) and Fortaleza (37%); low proportion of mental health treatment in primary care (Fortaleza, 23%); differences between cities in psychotropic medication prescription in primary care (Porto Alegre, 68%; São Paulo, 64%; Campinas, 39%; Fortaleza, 31%) and in shortages of prescribed medication (higher in Fortaleza, 58%; lower in Campinas, 28%); and overall frailty in enabling return to work (lower in São Paulo, 17%; higher in Campinas, 39%), with better overall results regarding religion and leisure activities (higher in São Paulo, 53% and 56%, respectively). The study contributes to the discussion of the Brazilian scenario of mental healthcare, with evidence of persistent inequalities in the national context, pointing to gaps in some mental healthcare network configurations with the potential for better performance and longitudinal follow-up.

[Mental Health Global Action Programme (mhGAP) in Chile: Lessons Learned and Challenges for Latin America and the CaribbeanPrograma de ação mundial para reduzir as lacunas em saúde mental (mhGAP) no Chile: aprendizados e desafios para América Latina e Caribe]

Objetivos.

Presentar la metodología de evaluación integral de la implementación del Programa de Acción Mundial para Superar las Brechas en Salud Mental (mhGAP) en Chile y exponer sus resultados.

Métodos.

Estudio evaluativo de corte transversal basado en una encuesta a referentes clave del programa, desplegados en los 29 servicios públicos de salud del país, y entrevistas individuales y grupos focales con actores clave y expertos. El foco de la evaluación estuvo en la relevancia e impacto del mhGAP en la prestación de servicios de salud mental y en la implementación del programa.

Resultados.

Los participantes evaluaron positivamente la implementación progresiva del mhGAP en Chile, en particular: 1) manifestaron contar con mejores herramientas de detección, diagnóstico y tratamiento de trastornos frecuentes, y estrategias eficientes de derivación; 2) calificaron todos los módulos como importantes; los más relevantes fueron autolesión/suicidio (x¯ = 4,77) y trastornos mentales y conductuales del niño y el adolescente (x¯ = 4,58); 3) evaluaron favorablemente las Jornadas Nacionales y sus réplicas y su contribución al éxito de la implementación del mhGAP; 4) coincidieron en la necesidad de incorporar nuevos actores, fortalecer algunos aspectos y ampliar la información sobre el programa.

Conclusiones.

La implementación del mhGAP en Chile constituye un caso emblemático de aprendizaje, apoyado por el desarrollo de la salud mental comunitaria y la salud familiar, entre otros factores. Lo logrado abre una oportunidad única para continuar avanzando en la implementación de este programa en el país y transmitir esta experiencia a otros contextos de América Latina y el Caribe.

Bridging the mental health treatment gap: effects of a collaborative care intervention (matrix support) in the detection and treatment of mental disorders in a Brazilian city

Objective

To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention (matrix support).

Design

Dynamic cohort design with retrospective time-series analysis. Structured secondary data on medical visits to general practitioners of all study clinics were extracted from the municipal electronic records database. Annual changes in the odds of mental disorders diagnoses and antidepressants prescriptions were estimated by multiple logistic regression at visit and patient-year levels with diagnoses or prescriptions as outcomes. Annual changes during two distinct stages of the intervention (stage 1 when it was restricted to mental health (2005–2009), and stage 2 when it was expanded to other areas (2010–2015)) were compared by adding year–period interaction terms to each model.

Setting

49 primary care clinics in the city of Florianópolis, Brazil.

Participants

All adults attending primary care clinics of the study setting between 2005 and 2015.

Results

3 131 983 visits representing 322 100 patients were analysed. At visit level, the odds of mental disorder diagnosis increased by 13% per year during stage 1 (OR 1.13, 95% CI 1.11 to 1.14, p<0.001) and decreased by 5% thereafter (OR 0.95, 95% CI 0.94 to 0.95, p<0.001). The odds of incident mental disorder diagnoses decreased by 1% per year during stage 1 (OR 0.99, 95% CI 0.98 to 1.00, p=0.012) and decreased by 7% per year during stage 2 (OR 0.93, 95% CI 0.92 to 0.93, p<0.001). The odds of antidepressant prescriptions in patients with a mental disorder diagnosis increased by 7% per year during stage 1 (OR 1.07, 95% CI 1.05 to 1.20, p<0.001); this was driven by selective serotonin reuptake inhibitor prescriptions which increased 14% per year during stage 1 (OR 1.14, 95% CI 1.12 to 1.18, p<0.001) and 9% during stage 2 (OR 1.09, 95% CI 1.08 to 1.10, p<0.001). The odds of incident antidepressant prescriptions did not increase during stage 1 (OR 1.00, 95% CI 0.97 to 1.02, p=0.665) and increased by 3% during stage 2 (OR 1.03, 95% CI 1.00 to 1.04, p<0.001). Changes per year were all significantly greater during stage 1 than stage 2 (p values for interaction terms <0.05), except for antidepressant prescriptions during visits (p=0.172).

Conclusion

The matrix support intervention may increase diagnosis and treatment of mental disorders when inter-professional collaboration is adequately supported. Competing demands to the primary care teams can subsequently reduce these effects. Future studies should assess clinical outcomes and identify active components and factors associated with successful implementation.

Challenges and barriers in mental healthcare systems and their impact on the family: A systematic integrative review

The aim of this systematic integrative review is to analyse the challenges and barriers found in mental healthcare systems and the impact they have on the family. Searches were made of the Web of Science, Scopus, Medline and Cochrane databases using terms relating to mental health, family care and healthcare systems. We included and critically evaluated studies published in English between 2015 and 2019 that directly or indirectly analysed public mental health policies and the consequences they have for the family. We analysed our findings following the inductive content analysis approach. A total of 32 articles that met quality indicators were identified. Very closely related structural, cultural, economic and healthcare barriers were found that contribute to the treatment gap in mental health. The family covers the care systems' deficiencies and weaknesses, and this leads to overload and a diminishing quality of life for caregivers. It is acknowledged that people with mental illness and their families should be able to participate in the development of policies and thus contribute to strengthening mental healthcare systems worldwide.

Are people-centred mental health services acceptable and feasible in Timor-Leste? A qualitative study

People-centred mental healthcare is an influential concept for health system strengthening and sustainable development that has been developed and promoted primarily in Western contexts. It characterizes service users, families and communities as active participants in health system development. However, we have limited understanding of how well people-centred mental healthcare aligns with the multiplicity of peoples, cultures, languages and contexts in low- and middle-income countries (LMICs). Timor-Leste, a lower-middle income country in South-East Asia, is in the process of strengthening its National Mental Health Strategy 2018-22 to align with people-centred mental healthcare. To support the implementation of this Strategy, this study investigated the acceptability and feasibility of people-centred mental health services in Timor-Leste. In-depth semi-structured individual (n = 57) and group interviews (n = 15 groups) were conducted with 85 adults (≥18 years). Participants were service users, families, decision-makers, service providers and members of civil society and multilateral organizations across national and sub-national sites. Government and non-government mental health and social care was also observed. Framework analysis was used to analyse interview transcripts and observation notes. The study found that the ecology of mental healthcare in Timor-Leste is family-centred and that government mental health services are largely biomedically oriented. It identified the following major challenges for people-centred mental health services in Timor-Leste: different sociocultural perceptions of (in)dividual personhood, including a diminished status of people with mental illness; challenges in negotiating individual and family needs; a reliance on and demand for biomedical interventions; and barriers to health service access and availability. Opportunities for people-centred mental healthcare are better available within the social and disability sectors, which focus on social inclusion, human rights and peer support. Accounting for local cultural knowledge and understandings will strengthen design and implementation of people-centred mental healthcare in LMIC settings.

Challenges for implementing a global mental health agenda in Brazil: The "silencing" of culture

Since its emergence in 2007, Global Mental Health has been a growing and polemic area of study, research and practice in mental health worldwide. Despite having a significant endogenous academic production and innovative policy experiences, the Brazilian mental health field and its actors make few references to, and scarcely dialogue with, the Global Mental Health agenda. This article explores an aspect of this divergence between Global Mental Health initiatives and public mental health care in Brazil regarding the role of culture within mental health policies and practices. Our hypothesis is that part of this difficulty can be attributed to the low relevance of the cultural dimension for the Brazilian mental health field, here referred to as the "silencing of culture." We examine the possible historical roots of this process with reference to theories of "anthropophagy" and "cultural uniformity" in the context of Brazilian cultural matrices. We then describe two recent experiences in public mental health care that incorporate cultural competence through the work of community health workers and the example of community therapy. We argue that the development of cultural competence can be decisive in enabling an improved dialogue between research and practice in Brazilian mental health and global mental health initiatives.

Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries

Integration of services into primary health care for people with common mental disorders is considered a key strategy to improve access to mental health care in low-income and middle-income countries, yet services at the primary care level are largely unavailable. We did a systematic review to understand the barriers and facilitators in the implementation of mental health programmes. We searched five databases and included studies published between Jan 1, 1990, and Sept 1, 2017, that used qualitative methods to assess the implementation of programmes for adults with common mental disorders at primary health-care settings in low-income and middle-income countries. The Critical Appraisal Skills Programme Qualitative Checklist was used to assess the quality of eligible papers. We used the so-called best fit framework approach to synthesise findings according to the Consolidated Framework for Implementation Research. We identified 24 papers for inclusion. These papers described the implementation of nine programmes in 11 countries. Key factors included: the extent to which an organisation is ready for implementation; the attributes, knowledge, and beliefs of providers; complex service user needs; adaptability and perceived advantage of interventions; and the processes of planning and evaluating the implementation. Evidence on implementation of mental health programmes in low-income and middle-income countries is scarce. Synthesising results according to the Consolidated Framework for Implementation Research helped to identify key areas for future action, including investment in primary health-care strengthening, capacity building for health providers, and increased support to address the social needs of service users.

Delivering a complex mental health intervention in low-resource settings: lessons from the implementation of the PRIME mental healthcare plan in primary care in Sehore district, Madhya Pradesh, India

BACKGROUND

The PRogramme for Improving Mental health care (PRIME) designed, implemented and evaluated a comprehensive mental healthcare plan (MHCP) for Sehore district, Madhya Pradesh, India.AimsTo provide quantitative measures of outputs related to implementation processes, describe the role of contextual factors that facilitated and impeded implementation processes, and discuss what has been learned from the MHCP implementation.

METHOD

A convergent parallel mixed-methods design was used. The quantitative strand consisted of process data on mental health indicators whereas the qualitative strand consisted of in-depth interviews and focus group discussions with key stakeholders involved in PRIME implementation.

RESULTS

The implementation of the MHCP in Sehore district in Madhya Pradesh, India, demonstrated that it is feasible to establish structures (for example Mann-Kaksha) and operationalise processes to integrate mental health services in a 'real-world' low-resource primary care setting. The key lessons can be summarised as: (a) clear 'process maps' of clinical interventions and implementation steps are helpful in monitoring/tracking the progress; (b) implementation support from an external team, in addition to training of service providers, is essential to provide clinical supervision and address the implementation barriers; (c) the enabling packages of the MHCP play a crucial role in strengthening the health system and improving the context/settings for implementation; and (d) engagement with key community stakeholders and incentives for community health workers are necessary to deliver services at the community-platform level.

CONCLUSIONS

The PRIME implementation model could be used to scale-up mental health services across India and similar low-resource settings.Declaration of interestNone.

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers

Background

The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas.

Purpose

The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs).

Methods

This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC.

Results

Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care.

Conclusion

There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework

Background

Uptake of clinical guideline recommendations into routine practice requires changes in attitudes and behaviors of the health care providers. The World Health Organization (WHO) has heavily invested in public health and health promotion globally by developing policy recommendations to guide clinical practice; however, clinical guidelines are often not applied. The success of the implementation of any guidelines depends on consideration of existing barriers and adequately addressing them. Therefore, exploring the context specific barriers and facilitators affecting the primary care providers (PCPs) in Mbarara district, Uganda may provide a practical way of addressing the identified barriers thus influence the PCPs action towards integration of mental healthcare services into PHC.

Methods

We adopted a theoretical model of behavior change; Capability, Opportunity and Motivation developed to understand behavior (COM-B). This was a cross-sectional study which involved using a semi-structured qualitative interview guide to conduct in-depth interviews with PCP’s (clinical officers, nurses and midwives).

Results

Capability - inadequacy in knowledge about mental disorders; more comfortable managing patients with a mental problem diagnosis than making a new one; knowledge about mental health was gained during pre-service training; no senior cadre to consultations in mental health; and burdensome to consult the Uganda Clinical Guidelines (UCG). Opportunity - limited supply of hard copies of the UCG; guidelines not practical for local setting; did not regularly deal with clients having mental illness to foster routine usage of the UCG; no sensitization about the UCG to the intended users; and no cues at the health centers to remind the PCPs to use UCG. Motivation - did not feel self-reliant; not seen the UCG at their health facilities; lack of trained mental health specialists; conflicting priorities; and no regulatory measures to encourage screening for mental health.

Conclusions

Efforts to achieve successful integration of mental health services into PHC need to fit in the context of the implementers; thus the need to adapt the UCG into local context, have cues to enforce implementation, and optimize the available expertize (mental healthcare providers) in the process.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3684-7) contains supplementary material, which is available to authorized users.

A Carteira de Serviços de Saúde do Município do Rio de Janeiro e as ações em saúde na Atenção Primária no Brasil

Resumo Objetivou-se identificar a oferta de ações e procedimentos pelas equipes de saúde da família (eSF), tendo por base a Carteira de Serviços (CS) do Município do Rio de Janeiro (MRJ) e os principais fatores associados a esta oferta, nos diferentes estratos populacionais. Foram utilizados dados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, aplicado a 17.202 eSF, de junho a setembro de 2012 no Brasil. Foram variáveis desfecho: eSF pertencer ao MRJ; eSF ofertar todos os nove procedimentos da CS-MRJ. Foram conduzidas análises uni, bi e multivariada. Evidenciou-se melhor desempenho do MRJ em relação aos demais grandes centros urbanos (EP6#) (p < 5%) em 10 das 14 ações de saúde analisadas. O prontuário eletrônico apresentou 96% de implantação nas eSF do MRJ, contrastando com 34% nas dos EP6# e 14% no Brasil. Tanto no MRJ quanto no EP6# encontrou-se baixa oferta de serviços de saúde mental (cerca de 56%). Enquanto a oferta de procedimentos de baixa complexidade foi um problema maior nos grandes centros, a oferta de ações em saúde nas diferentes linhas de cuidado foi um problema maior nos municípios pequenos. No geral, o MRJ mostrou melhor desempenho quando comparado à média de municípios de grande porte. A carteira de serviço pareceu ser um importante instrumento gerencial.