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Leon S, Parbhoo P, Meel R. Impact of the SARS-CoV-2 pandemic on acute coronary syndrome patients admitted to an urban academic hospital in Soweto, South Africa. Pan Afr Med J 2024; 47:160. [PMID: 38974696 PMCID: PMC11226766 DOI: 10.11604/pamj.2024.47.160.37066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 02/25/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction recent worldwide data has shown a concerning decline in the number of acute coronary syndrome (ACS) related admissions and percutaneous coronary intervention (PCI) procedures during the coronavirus disease 2019 (COVID-19) pandemic. We suspected a similar trend at Chris Hani Baragwanath Hospital (CHBAH). Methods a retrospective descriptive study was conducted to evaluate and compare all ACS-related admissions to the cardiac care unit (CCU) at CHBAH in the pre-COVID-19 (November 2019 to March 2020) and during COVID-19 periods (April 2020 to August 2020). Results the study comprised 182 patients with a mean age of 57.9 ±10.9 years (22.5% females). Of these, 108 (59.32%) patients were admitted in the pre-COVID-19 period and 74 (40.66%) during COVID-19 (p=0.0109). During the pre-COVID-19 period, 42.9% of patients had ST-segment-elevation myocardial infarction (STEMI), 39.2% with non-ST-segment -elevation myocardial infarction (NSTEMI) and unstable angina (UA) was noted in 18.52%. In contrast, STEMI was noted in 50%, NSTEMI in 43.24% and UA in 6.76% of patients during the COVID-19 period. A statistically significant difference in STEMI and NSTEMI-related admissions was not noted, however, there was a greater number of admissions for UA during the pre-COVID-19 period (18.52% vs 6.76%, P =0.013). Only a third of the patients with STEMI received thrombolysis during the pre-and COVID-19 periods (30.4% vs 37.8%, P=0.47). No difference in the number of PCI procedures was noted between the pre-and during the COVID-19 periods (78.7% vs 72.9%, P=0.37). Conclusion there was a difference in overall ACS admissions to the CCU between pre-and during COVID-19 periods, however no difference between STEMI and NSTEMI in both periods. A higher number of UA admissions was noted during the pre-COVID-19 period. During both periods, the use of thrombolysis was low for STEMI and no difference in PCI was noted.
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Affiliation(s)
- Suzan Leon
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Priya Parbhoo
- Department of Internal Medicine, Division of Cardiology, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruchika Meel
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Darbes LA, El Ayadi AM, Gilvydis JM, Morris J, Raphela E, Naidoo E, Grignon JS, Barnhart S, Lippman SA. Depression and HIV Care-seeking Behaviors in a Population-based Sample in North West Province, South Africa. AIDS Behav 2023; 27:3852-3862. [PMID: 37329471 PMCID: PMC10598108 DOI: 10.1007/s10461-023-04102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/19/2023]
Abstract
Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09-1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.
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Affiliation(s)
- Lynae A Darbes
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Alison M El Ayadi
- Department of Obstetrics and Gynecology, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer M Gilvydis
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, WA, USA
| | - Jessica Morris
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Elsie Raphela
- International Training and Education Center for Health (I-TECH), South Africa, Pretoria, Republic of South Africa
| | - Evasen Naidoo
- International Training and Education Center for Health (I-TECH), South Africa, Pretoria, Republic of South Africa
| | - Jessica S Grignon
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), South Africa, Pretoria, Republic of South Africa
| | - Scott Barnhart
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Schools of Medicine and Public Health, University of Washington, Seattle, WA, USA
| | - Sheri A Lippman
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
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Selohilwe O, Fairall L, Bhana A, Kathree T, Zani B, Folb N, Lund C, Thornicroft G, Petersen I. Challenges and opportunities for implementation and dissemination of a task- sharing counselling intervention for depression at primary health care level in South Africa. Int J Ment Health Syst 2023; 17:7. [PMID: 36998053 PMCID: PMC10064738 DOI: 10.1186/s13033-023-00575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/08/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The treatment gap for mental health services is a growing public health concern. A lay-counselling service located at primary health care (PHC) level could potentially help to close the large treatment gap for common mental disorders in South Africa. The aim of this study was to understand multilevel factors contributing to implementation and potential dissemination of such a service for depression at PHC level. METHODS Process qualitative data of the lay-counselling service for patients with depressive symptoms was collected alongside a pragmatic randomized controlled trial evaluating a collaborative care model that included a lay-counselling service for patients with depressive symptoms. Semi-structured key informant interviews (SSI) were conducted with a purposive sample of PHC providers (lay-counsellors, nurse practitioners, operational managers), lay-counsellor supervisors, district and provincial managers, and patients in receipt of services. A total of 86 interviews were conducted. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection as well as Framework Analysis to determine barriers and facilitators for implementation and dissemination of the lay-counselling service. RESULTS Facilitators identified include supervision and support available for counsellors; person focused counselling approach; organizational integration of the counsellor within facilities. Barriers included lack of organizational support of the counselling service, including lack of counselling dedicated space; high counsellor turnover, resulting in a counsellor not available all the time; lack of an identified cadre to deliver the intervention in the system; and treatment of mental health conditions including counselling not included within mental health indicators. CONCLUSIONS Several system level issues need to be addressed to promote integration and dissemination of lay-counselling services within PHC facilities in South Africa. Key system requirements are facility organizational readiness for improvement of integration of lay-counselling services; formal recognition of counselling services provided by lay counsellors as well as inclusion of lay counselling as a treatment modality within mental health treatment data element definitions and the need for diversification of the roles of psychologists to include training and supervision of lay counsellors was also emphasized.
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Affiliation(s)
- One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
- School of Life Course & Population Sciences, King's College London, London, UK
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
- Health Systems Research Unit, South African Medical Research Centre, Durban, 4091, South Africa
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
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Brooke-Sumner C, Petersen-Williams P, Sorsdahl K, Kruger J, Mahomed H, Myers B. Strategies for supporting the implementation of a task-shared psychological intervention in South Africa's chronic disease services: qualitative insights from health managers' experiences of project MIND. Glob Health Action 2022; 15:2123005. [PMID: 36178292 PMCID: PMC9542686 DOI: 10.1080/16549716.2022.2123005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Although evidence indicates that task-shared psychological interventions can reduce mental health treatment gaps in resource-constrained settings, systemic barriers have limited their widespread implementation. Evidence on how to sustain and scale such approaches is scant. This study responds to this gap by examining the experiences of South African health managers involved in the implementation of a task-shared counselling service for Project MIND. OBJECTIVES To qualitatively describe managers' experiences of implementing the MIND programme and their insights into potential strategies for supporting sustained implementation. METHODS Two focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with managers of urban and rural primary care facilities in the Western Cape province. All managers were female and 30-50 years old. FGDs and IDIs used an identical semi-structured topic guide to explore the experiences of the MIND programme and perceived barriers to sustained implementation. Normalisation process theory (NPT) guided the thematic analysis. RESULTS Four themes emerged that mapped onto the NPT constructs. First, managers noted that their relational work with staff to promote support for the intervention and reduce resistance was key to facilitating implementation. Second, managers emphasised the need for staff reorientation and upskilling to foster openness to mental health practice and for adequate time for quality counselling. Third, managers underscored the importance of strengthening linkages between the health and social service sectors to facilitate delivery of comprehensive mental health services. Finally, managers recommended ongoing monitoring of the service and communication about its impacts as strategies for supporting integration into routine practice. CONCLUSIONS Findings contribute to the emerging literature on strategies to support implementation of task-shared interventions in low- and middle-income countries. The findings highlight the leadership role of managers in identifying and actioning these strategies. Investing in managers' capacity to support implementation of psychological interventions is critical for scale-up of these mental health innovations.
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Affiliation(s)
- Carrie Brooke-Sumner
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, South Africa
| | - Petal Petersen-Williams
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, South Africa
| | - James Kruger
- Metro Health Services, Western Cape Government: Health, Bellville Health Park, Cape Town, South Africa
| | - Hassan Mahomed
- Metro Health Services, Western Cape Government: Health, Bellville Health Park, Cape Town, South Africa
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- CONTACT Bronwyn Myers Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town7501, South Africa
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Petersen I, Selohilwe O, Georgeu-Pepper D, Ras CJ, Zani B, Petrus R, Anderson L, Mntambo N, Kathree T, Bhana A, Thornicroft G, Fairall L. A collaborative care package for depression comorbid with chronic physical conditions in South Africa. BMC Health Serv Res 2022; 22:1465. [PMID: 36457094 PMCID: PMC9717432 DOI: 10.1186/s12913-022-08874-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION A task-sharing collaborative care model for integrated depression care for South Africa's burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges. METHODS The Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of 'modifications made' and 'actual implementation' introduced in the 'Getting messier with TIDieR' framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts. RESULTS In the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger. CONCLUSION The need for in-country co-designed collaborative care models, and 'implementation heavy' implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- Institute for Global Health, University College London, London, UK
| | - One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | | | - Christy-Joy Ras
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Ruwayda Petrus
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Lauren Anderson
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- Health Systems Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Overport, Durban, South Africa
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
- Global Health Institute, King’s College London, London, UK
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Lafontaine S, Rassy J, Duval-Martin AL, Girard A, Marceau M, Gallagher F, Hébert M, Jacques MC. Nursing Interventions Designed to Improve Healthcare in General Healthcare Settings for Adults Living with Mental Illness: A Scoping Review. Issues Ment Health Nurs 2022; 43:955-970. [PMID: 35658729 DOI: 10.1080/01612840.2022.2083736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
People living with mental illness have difficulty obtaining quality physical care services. Nurses find it hard to fully assume their role and adopt a person-centered approach when they care for people with both physical and mental health problems. A scoping review was carried out to document the breadth and depth of literature on nurse interventions designed to improve nursing care in general healthcare settings for adults living with mental illness. Two researchers independently screened titles, abstracts and full documents to obtain publications, and the relevant data was extracted from individual studies. Of the 384 studies identified, 16 documents were included in the study. Few interventions have been the subject of scientific publications and they are scattered in their objectives and very heterogeneous in their content. Interventions are often included in a large program that may be difficult to apply in various care settings. There are many different nursing roles and activities in care-management and in support of behavioral changes although their main measured outcomes differ. This study highlights a tendency for interventions to relegate people with mental health problems to specialized services, which reinforces the dichotomization of services and does not favor a holistic and person-centered approach. There is an urgent need to develop and evaluate nursing interventions in general healthcare settings for adults living with mental illness. The development of relevant continuing education and training must take into account both the point of view of the people living with mental illness and that of nurses.
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Affiliation(s)
| | - Jessica Rassy
- School of Nursing, Université de Sherbrooke, Longueuil, Canada
| | | | - Ariane Girard
- School of Nursing, Université de Sherbrooke, Sherbrooke, Canada
| | - Mélanie Marceau
- School of Nursing, Université de Sherbrooke, Sherbrooke, Canada
| | | | - Maude Hébert
- School of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, Canada
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Cumbe VFJ, Muanido AG, Turner M, Ramiro I, Sherr K, Weiner BJ, Flaherty BP, Sharma M, Faduque F, Xerinda ER, Wagenaar BH. Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial. Implement Sci 2022; 17:37. [PMID: 35668423 PMCID: PMC9169330 DOI: 10.1186/s13012-022-01213-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique. METHODS Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels. DISCUSSION This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs. TRIAL REGISTRATION ClinicalTrials.gov; NCT05103033 ; 11/2/2021.
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Affiliation(s)
- Vasco F J Cumbe
- Provincial Health Directorate, Sofala Province, Ministry of Health, Beira, Mozambique.
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
- Department of Psychiatry, Beira Central Hospital, Beira, Mozambique.
| | | | - Morgan Turner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Brian P Flaherty
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Flávia Faduque
- Provincial Health Directorate, Manica Province, Ministry of Health, Chimoio, Mozambique
| | | | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Kemp CG, Mntambo N, Weiner BJ, Grant M, Rao D, Bhana A, Gigaba SG, Luvuno ZPB, Simoni JM, Hughes JP, Petersen I. Pushing the bench: A mixed methods study of barriers to and facilitators of identification and referral into depression care by professional nurses in KwaZulu-Natal, South Africa. SSM - MENTAL HEALTH 2021; 1:100009. [PMID: 34541564 PMCID: PMC8443051 DOI: 10.1016/j.ssmmh.2021.100009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Integration of mental health and chronic disease services in primary care could reduce the mental health treatment gap and improve associated health outcomes in low-resource settings. Low rates of nurse identification and referral of patients with depression limit the effectiveness of integrated mental health care; the barriers to and facilitators of identification and referral in South Africa and comparable settings remain undefined. This study explored barriers to and facilitators of nurse identification and referral of patients with depressive symptoms as part of integrated mental health service delivery in KwaZulu-Natal, South Africa. DESIGN Triangulation mixed methods study incorporating qualitative and quantitative data. METHODS Data collection, analysis, and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Participants were professional nurses at ten primary health care facilities in Amajuba, KwaZulu-Natal, South Africa. Qualitative data collection involved semi-structured interviews targeting specific CFIR constructs with high- and low-referring nurses. Deductive and inductive coding were used to derive primary themes related to barriers and facilitators. Quantitative data collection involved a structured questionnaire assessing determinants explored in the interviews. Qualitative comparative analysis was used to identify the necessary or sufficient conditions for high and low nurse referral. RESULTS Twenty-two nurses were interviewed. Primary themes related to insufficient training, supervision, and competency; emotional burden; limited human and physical resources; perceived patient need for integrated services; and intervention acceptability. Sixty-eight nurses completed questionnaires. Quantitative results confirmed and expanded upon the qualitative findings. Low self-assessed competency was a consistent barrier to appropriate service delivery. CONCLUSIONS To promote the success of integrated care in a context of severe staff shortages and over-burdened providers, implementation strategies including direct training, structured supervision, and routine behavioral health screening tools are warranted. Interventions to improve mental health literacy of patients as well as emotional support for nurses are also needed.
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Affiliation(s)
- Christopher G. Kemp
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Bryan J. Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Merridy Grant
- Centre for Rural Health, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Psychiatry and Behavioral Medicine, University of Washington, Seattle, WA, USA
| | - Arvin Bhana
- Centre for Rural Health, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
- SA Medical Research Council, Health Systems Research Unit, Durban, South Africa
| | | | | | - Jane M. Simoni
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Inge Petersen
- Centre for Rural Health, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
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9
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Petersen I, Kemp CG, Rao D, Wagenaar BH, Sherr K, Grant M, Bachmann M, Barnabas RV, Mntambo N, Gigaba S, Van Rensburg A, Luvuno Z, Amarreh I, Fairall L, Hongo NN, Bhana A. Implementation and Scale-Up of Integrated Depression Care in South Africa: An Observational Implementation Research Protocol. Psychiatr Serv 2021; 72:1065-1075. [PMID: 33691487 PMCID: PMC8410621 DOI: 10.1176/appi.ps.202000014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND People with chronic general medical conditions who have comorbid depression experience poorer health outcomes. This problem has received scant attention in low- and middle-income countries. The aim of the ongoing study reported here is to refine and promote the scale-up of an evidence-based task-sharing collaborative care model, the Mental Health Integration (MhINT) program, to treat patients with comorbid depression and chronic disease in primary health care settings in South Africa. METHODS Adopting a learning-health-systems approach, this study uses an onsite, iterative observational implementation science design. Stage 1 comprises assessment of the original MhINT model under real-world conditions in an urban subdistrict in KwaZulu-Natal, South Africa, to inform refinement of the model and its implementation strategies. Stage 2 comprises assessment of the refined model across urban, semiurban, and rural contexts. In both stages, population-level effects are assessed by using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework with various sources of data, including secondary data collection and a patient cohort study (N=550). The Consolidated Framework for Implementation Research is used to understand contextual determinants of implementation success involving quantitative and qualitative interviews (stage 1, N=78; stage 2, N=282). RESULTS The study results will help refine intervention components and implementation strategies to enable scale-up of the MhINT model for depression in South Africa. NEXT STEPS Next steps include strengthening ongoing engagements with policy makers and managers, providing technical support for implementation, and building the capacity of policy makers and managers in implementation science to promote wider dissemination and sustainment of the intervention.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Christopher G Kemp
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Deepa Rao
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Bradley H Wagenaar
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Kenneth Sherr
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Merridy Grant
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Max Bachmann
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Ruanne V Barnabas
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Sithabisile Gigaba
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - André Van Rensburg
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Zamasomi Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Ishmael Amarreh
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Lara Fairall
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Nikiwe N Hongo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
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10
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Janse van Rensburg A, Kathree T, Breuer E, Selohilwe O, Mntambo N, Petrus R, Bhana A, Lund C, Fairall L, Petersen I. Fuzzy-set qualitative comparative analysis of implementation outcomes in an integrated mental healthcare trial in South Africa. Glob Health Action 2021; 14:1940761. [PMID: 34402770 PMCID: PMC8381905 DOI: 10.1080/16549716.2021.1940761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Integrating mental health services into primary healthcare platforms is an established health systems strategy in low-to-middle-income countries. In South Africa, this was pursued through the Programme for Improving Mental Health Care (PRIME), a multi-country initiative that relied on task-sharing as a principle implementation strategy. Towards better describing the implementation processes, qualitative comparative analysis was adopted to explore causal pathways in the intervention. OBJECTIVE This study aimed to explore factors that could have influenced key outcomes of an integrated mental healthcare intervention in South Africa. METHODS Drawing from an embedded multiple case study design, the analysis used qualitative comparative analysis. Focusing on nine PHC clinics in the Dr Kenneth Kaunda District as cases, with depression reduction scores set as outcome measures, trial data variables were modelled in a hypothetical causal process. A fuzzy-set qualitative comparative analysis was performed by 1) developing the research questions, 2) developing the fuzzy set, 3) testing necessity and 4) testing sufficiency. These steps were undertaken collaboratively among the research team. RESULTS The data were calibrated during several meetings among team members to gain a degree of consensus. Necessity analyses suggested that none of the causal conditions exceeded the threshold of necessity and triviality, and confirmed the inclusion of relevant variables in line with the proposed models. Sufficiency analyses produced two configurations, which were subjected to standard and specific analyses. Ultimately, the results suggested that none of the causal conditions were necessary for a reduction in depression scores to occur, while programme fidelity was identified as a sufficient condition for a reduction in scores to occur. CONCLUSIONS The study highlights the importance of understanding implementation pathways to enable better integration of mental health services within primary healthcare in low-to-middle-income settings. It underlines the importance of programme fidelity in achieving the goals of implementation.
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Affiliation(s)
- André Janse van Rensburg
- Centre for Rural Health, University of KwaZulu-Natal, School of Nursing and Public Health, Durban, South Africa
| | - Tasneem Kathree
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Erica Breuer
- Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - One Selohilwe
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ntokozo Mntambo
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ruwayda Petrus
- Department of Psychology, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- Centre for Rural Health, University of KwaZulu-Natal & South African Medical Research Council, Durban, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, University of Cape Town & Centre for Global Mental Health, King's College London, Cape Town, South Africa
| | - Lara Fairall
- Centre for Knowledge Translation, University of Cape Town, Cape Town, South Africa
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
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11
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van Ginneken N, Chin WY, Lim YC, Ussif A, Singh R, Shahmalak U, Purgato M, Rojas-García A, Uphoff E, McMullen S, Foss HS, Thapa Pachya A, Rashidian L, Borghesani A, Henschke N, Chong LY, Lewin S. Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries. Cochrane Database Syst Rev 2021; 8:CD009149. [PMID: 34352116 PMCID: PMC8406740 DOI: 10.1002/14651858.cd009149.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries. OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care. SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019). SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs. PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs). DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs). Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects. Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention. MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs). Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination. Intervention effects *Unless indicated, comparisons were usual care at T2. "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence. Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists); g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death); e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08); b. may have uncertain effects on symptoms/functioning/SU/AEs. Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11); d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects. Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11); b. may have uncertain effects on symptoms/functioning/SU/AEs. PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU. Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13); c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13); c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs; b. may have uncertain effects on recovery/symptoms(PTS)/functioning. AUTHORS' CONCLUSIONS PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.
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Affiliation(s)
- Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Amin Ussif
- Norwegian Institute of Public Health, Oslo, Norway
| | - Rakesh Singh
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ujala Shahmalak
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Antonio Rojas-García
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah McMullen
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | | | - Ambika Thapa Pachya
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Anna Borghesani
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Lee-Yee Chong
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Rohwer A, Uwimana Nicol J, Toews I, Young T, Bavuma CM, Meerpohl J. Effects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open 2021; 11:e043705. [PMID: 34253658 PMCID: PMC8276295 DOI: 10.1136/bmjopen-2020-043705] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes. DESIGN Systematic review. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019. ELIGIBILITY CRITERIA We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care. DATA EXTRACTION AND SYNTHESIS Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation. RESULTS Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty). CONCLUSIONS Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations. PROSPERO REGISTRATION NUMBER CRD42018099314.
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Affiliation(s)
- Anke Rohwer
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jeannine Uwimana Nicol
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Charlotte M Bavuma
- Kigali University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Joerg Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Effectiveness of a task-sharing collaborative care model for identification and management of depressive symptoms in patients with hypertension attending public sector primary care clinics in South Africa: pragmatic parallel cluster randomised controlled trial. J Affect Disord 2021; 282:112-121. [PMID: 33412490 DOI: 10.1016/j.jad.2020.12.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/21/2020] [Accepted: 12/24/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND We tested the real-world effectiveness of a collaborative task-sharing model on depressive symptom reduction in hypertensive Primary Health Care (PHC) patients in South Africa. METHOD A pragmatic parallel cluster randomised trial in 20 clinics in the Dr Kenneth Kaunda district, North West province. PHC clinics were stratified by sub-district and randomised in a 1:1 ratio. Control clinics received care as usual (CAU), involving referral to PHC doctors and/or mental health specialists. Intervention clinics received CAU plus enhanced mental health training and a lay counselling referral service. Participant inclusion criteria were ≥ 18 years old, Patient Health Questionnaire-9 (PHQ-9) score ≥ 9 and receiving hypertension medication. Primary superiority outcome was ≥ 50% reduction in PHQ-9 score at 6 months. Statistical analyses comprised mixed effects regression models and a non-inferiority analysis. TRIAL REGISTRATION NUMBER NCT02425124. RESULTS Between April 2015 and October 2015, 1043 participants were enrolled (504 intervention and 539 control); 82% were women; half were ≥ 55 years. At 6 and 12 months follow-up, 91% and 89% of participants were interviewed respectively. One control group participant committed suicide. There was no significant difference in the primary outcome between intervention (N=256/456) and control (N=232/492) groups (55.9% versus 50.9%; adjusted risk difference = -0.04 ([95% CI = -0.19; 0.11], p = 0.6). The difference in PHQ-9 scores was within the defined equivalence limits at 6 and 12 months for the non-inferiority analysis. LIMITATIONS The trial was limited by low exposure to depression treatment by trial participants and by observed co-intervention in control clinics CONCLUSIONS: Incorporating lay counselling services within collaborative care models does not produce superior nor inferior outcomes to models with specialist only counselling services. FUNDING This work was supported by the UK Department for International Development [201446] as well as the National Institute of Mental Health, United States of America, grant number 1R01MH100470-01. Graham Thornicroft is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College London and King's College Hospital NHS Foundation Trust.
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14
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Schmaling K, Kaplan RM, Porzsolt F. Efficacy and effectiveness studies of depression are not well-differentiated in the literature: a systematic review. BMJ Evid Based Med 2021; 26:28-30. [PMID: 32188642 DOI: 10.1136/bmjebm-2020-111337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the literature on the treatment of depression, efficacy and effectiveness research have different purposes and should apply different research methodologies. OBJECTIVE The purpose of the study was to review characteristics of depression treatment studies identified using efficacy or effectiveness search terms. We considered subject inclusion and exclusion criteria; numbers of subjects enrolled and the proportion in the primary analyses; inclusion of a Consolidated Standards of Reporting Trials (CONSORT) flow diagram; use of random assignment; use of placebo control conditions; lengths of treatment and follow-up; primary outcome variable; trial registration; journal impact factor. STUDY SELECTION Studies indexed as efficacy AND 'real-world' AND depression or effectiveness AND 'real-world' AND depression in PubMed up to 18 May 2019. FINDINGS 27 studies met the inclusion criteria: 13 effectiveness studies, 6 efficacy studies and 8 studies indexed as both effectiveness and efficacy. Studies identified as effectiveness, efficacy, or both differed on three outcome measures: the inclusion criteria were lengthier for efficacy than for effectiveness studies; efficacy studies were more likely to have a placebo control condition than effectiveness studies; and the journal impact factor was lower for effectiveness studies than for studies from the efficacy search or studies identified by both searches. CONCLUSIONS Efficacy and effectiveness research hypothetically use different methodologies, but the efficacy and effectiveness literatures in the treatment of depression were comparable for most of the coded characteristics. The lack of distinguishable characteristics suggests that variably applied terminology may hinder efforts to narrow the gap between research and practice. PROSPERO REGISTRATION NUMBER: #CRD42019136840.
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Affiliation(s)
- Karen Schmaling
- Psychology, Washington State University, Vancouver, Washington, USA
| | - Robert M Kaplan
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California, USA
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15
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Hurst JR, Agarwal G, van Boven JFM, Daivadanam M, Gould GS, Wan-Chun Huang E, Maulik PK, Miranda JJ, Owolabi MO, Premji SS, Soriano JB, Vedanthan R, Yan L, Levitt N. Critical review of multimorbidity outcome measures suitable for low-income and middle-income country settings: perspectives from the Global Alliance for Chronic Diseases (GACD) researchers. BMJ Open 2020; 10:e037079. [PMID: 32895277 PMCID: PMC7478040 DOI: 10.1136/bmjopen-2020-037079] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/28/2020] [Accepted: 07/18/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES There is growing recognition around the importance of multimorbidity in low-income and middle-income country (LMIC) settings, and specifically the need for pragmatic intervention studies to reduce the risk of developing multimorbidity, and of mitigating the complications and progression of multimorbidity in LMICs. One of many challenges in completing such research has been the selection of appropriate outcomes measures. A 2018 Delphi exercise to develop a core-outcome set for multimorbidity research did not specifically address the challenges of multimorbidity in LMICs where the global burden is greatest, patterns of disease often differ and health systems are frequently fragmented. We, therefore, aimed to summarise and critically review outcome measures suitable for studies investigating mitigation of multimorbidity in LMIC settings. SETTING LMIC. PARTICIPANTS People with multimorbidity. OUTCOME MEASURES Identification of all outcome measures. RESULTS We present a critical review of outcome measures across eight domains: mortality, quality of life, function, health economics, healthcare access and utilisation, treatment burden, measures of 'Healthy Living' and self-efficacy and social functioning. CONCLUSIONS Studies in multimorbidity are necessarily diverse and thus different outcome measures will be appropriate for different study designs. Presenting the diversity of outcome measures across domains should provide a useful summary for researchers, encourage the use of multiple domains in multimorbidity research, and provoke debate and progress in the field.
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Affiliation(s)
- John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Gina Agarwal
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Meena Daivadanam
- Deptartment of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Food, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
- Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
- Deptartment of Global Public Health, Karolinska Institutet, Solna, Sweden
- International Maternal and Child Health Division, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Gillian Sandra Gould
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Erick Wan-Chun Huang
- Respiratory and Environmental Epidemiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
- Division of Thoracic Medicine, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Pallab K Maulik
- Research, The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Prasanna School of Public Health, Manipal, India
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - M O Owolabi
- Medicine, University of Ibadan College of Medicine, Ibadan, Nigeria
| | | | - Joan B Soriano
- Universidad Autónoma de Madrid, Madrid, Spain
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Rajesh Vedanthan
- Department of Population Health and Department of Medicine, NYU Langone Health, New York, New York, USA
| | - Lijing Yan
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Naomi Levitt
- Medicine, University of Cape Town, Cape town, South Africa
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16
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Bukola G, Bhana A, Petersen I. Planning for child and adolescent mental health interventions in a rural district of South Africa: a situational analysis. J Child Adolesc Ment Health 2020; 32:45-65. [PMID: 32552512 DOI: 10.2989/17280583.2020.1765787] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: The aim of this study was to conduct a situational analysis as part of formative work to inform the development of community-based mental health services for children and adolescents at a district level. The purpose of the situational analysis was to determine the current state of child and adolescent mental health (CAMH), the available resources for CAMH, the range of services provided, and the existing pathways to CAMH care in a low-resource district with a view to developing a district mental health plan to improve access to CAMH services. Methods: Data for this situational analysis was collected from a rural district in the KwaZulu-Natal province using mixed methods. The qualitative component explored various stakeholders' (n = 26) perspectives using semi-structured interviews. The quantitative data for the study was collected using an adaptation of the situation analysis tool developed by the PRIME consortium. Results: The findings revealed the need to strengthen all the basic building blocks of the health system due to the weaknesses identified in the current CAMH care system in the district. The result of the situational analysis revealed that the provision of CAMH services in the district is sparse, uncoordinated, and not prioritised. Discussion: The findings of the study highlighted a severe shortage of specialised CAMH services in the district, poor integration of CAMH services into primary health care, and at the community platform there are deficits in the integrated school health programme. Further, the lack of a coordinated intersectoral collaborative system and well-defined referral pathways were revealed. Conclusion: The study highlights various challenges facing CAMH services at the Amajuba district. While these are not new, the study contributes to our understanding of the district level factors that may hinder the development of a district CAMH plan.
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Affiliation(s)
- Gbotemi Bukola
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Inge Petersen
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
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17
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Patient-level predictors of detection of depressive symptoms, referral, and uptake of depression counseling among chronic care patients in KwaZulu-Natal, South Africa. Glob Ment Health (Camb) 2020; 7:e18. [PMID: 32913657 PMCID: PMC7443607 DOI: 10.1017/gmh.2020.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 06/04/2020] [Accepted: 06/10/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Integration of depression treatment into primary care could improve patient outcomes in low-resource settings. Losses along the depression care cascade limit integrated service effectiveness. This study identified patient-level factors that predicted detection of depressive symptoms by nurses, referral for depression treatment, and uptake of counseling, as part of integrated care in KwaZulu-Natal, South Africa. METHODS This was an analysis of baseline data from a prospective cohort. Participants were adult patients with at least moderate depressive symptoms at primary care facilities in Amajuba, KwaZulu-Natal, South Africa. Participants were screened for depressive symptoms prior to routine assessment by a nurse. Generalized linear mixed-effects models were used to estimate associations between patient characteristics and service delivery outcomes. RESULTS Data from 412 participants were analyzed. Nurses successfully detected depressive symptoms in 208 [50.5%, 95% confidence interval (CI) 38.9-62.0] participants; of these, they referred 76 (36.5%, 95% CI 20.3-56.5) for depression treatment; of these, 18 (23.7%, 95% CI 10.7-44.6) attended at least one session of depression counseling. Depressive symptom severity, alcohol use severity, and perceived stress were associated with detection. Similar factors did not drive referral or counseling uptake. CONCLUSIONS Nurses detected patients with depressive symptoms at rates comparable to primary care providers in high-resource settings, though gaps in referral and uptake persist. Nurses were more likely to detect symptoms among patients in more severe mental distress. Implementation strategies for integrated mental health care in low-resource settings should target improved rates of detection, referral, and uptake.
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Petersen I, Bhana A, Fairall LR, Selohilwe O, Kathree T, Baron EC, Rathod SD, Lund C. Evaluation of a collaborative care model for integrated primary care of common mental disorders comorbid with chronic conditions in South Africa. BMC Psychiatry 2019; 19:107. [PMID: 30943947 PMCID: PMC6448306 DOI: 10.1186/s12888-019-2081-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 03/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing CMDs to improve health outcomes. The aim of this study was thus to evaluate a task shared integrated collaborative care package of care for chronic patients with co-existing depressive and alcohol use disorder (AUD) symptoms. METHODS The complex intervention strengthened capacity of primary care nurse practitioners to identify, diagnose and review symptoms of CMDs among chronic care patients; and implemented a stepped up referral system, that included clinic-based psychosocial lay counsellors, doctors and mental health specialists. Under real world conditions, in four PHC facilities, a repeat cross-sectional Facility Detection Survey (FDS) assessed changes in capacity of nurses to correctly detect CMDs in 1310 patients before implementation and 1246 patients following implementation of the intervention at 12 months; and a non-randomly assigned comparison group cohort study comprising 373 screen positive patients with depressive symptoms using the Patient Health Questionnaire-9 (PHQ9) at baseline, evaluated responses of patients correctly identified and referred for treatment (intervention arm) or not identified and referred (control arm) at three and 12 months. RESULTS The FDS showed a significant increase in the identification of depression and AUD from pre-implementation to 12-month post-implementation. Depression: (5.8 to 16.4%) 95% CI [2.9, 19.1]); AUD: (0 to 13.8%) 95% CI [0.6-24.9]. In the comparison group cohort study, patients with depressive symptoms having more than a 50% reduction in PHQ-9 scores were greater in the treatment group (n = 69, 55.2%) compared to the comparison group (n = 49, 23.4%) at 3 months (RR = 2.10, p < 0.001); and 12 months follow-up (intervention: n = 57, 47.9%; comparison: n = 60, 30.8%; RR = 1.52, p = 0.006). Remission (PHQ-9 ≤ 5) was greater in the intervention group (n = 32, 26.9%) than comparison group (n = 33, 16.9%) at 12 months (RR = 1.72, p = 0.016). CONCLUSION A task shared collaborative stepped care model can improve detection of CMDs and reduce depressive symptoms among patients with chronic conditions under real world conditions.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, Howard College, University of KwaZulu-Natal, Durban, South Africa.
| | - Arvin Bhana
- 0000 0001 0723 4123grid.16463.36Centre for Rural Health, Howard College, University of KwaZulu-Natal, Durban, South Africa ,0000 0001 0723 4123grid.16463.36Centre for Rural Health, Howard College, University of KwaZulu-Natal; Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
| | - Lara R. Fairall
- 0000 0004 1937 1151grid.7836.aKnowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - One Selohilwe
- 0000 0001 0723 4123grid.16463.36Centre for Rural Health, Howard College, University of KwaZulu-Natal, Durban, South Africa
| | - Tasneem Kathree
- 0000 0001 0723 4123grid.16463.36Centre for Rural Health, Howard College, University of KwaZulu-Natal, Durban, South Africa
| | - Emily C. Baron
- 0000 0004 1937 1151grid.7836.aAlan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Sujit D. Rathod
- 0000 0004 0425 469Xgrid.8991.9London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Crick Lund
- 0000 0004 1937 1151grid.7836.aAlan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa ,0000 0001 2322 6764grid.13097.3cCentre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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Brooke-Sumner C, Petersen-Williams P, Kruger J, Mahomed H, Myers B. 'Doing more with less': a qualitative investigation of perceptions of South African health service managers on implementation of health innovations. Health Policy Plan 2019; 34:132-140. [PMID: 30863845 PMCID: PMC6481285 DOI: 10.1093/heapol/czz017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 11/12/2022] Open
Abstract
Building resilience in health systems is an imperative for low- and middle- income countries. Health service managers' ability to implement health innovations may be a key aspect of resilience in primary healthcare facilities, promoting adaptability and functionality. This study investigated health service managers' perceptions and experiences of adopting health innovations. We aimed to identify perceptions of constraints to adoption and emergent behaviours in response to these constraints. A convenience sample of 34 facility, clinical service and sub-district level managers was invited to participate. Six did not respond and were not contactable. In-depth individual interviews in a private space at participants' place of work were conducted with 28 participants. Interviews were audio recorded and transcribed verbatim. NVivo 11 was used to store data and facilitate framework analysis. Study participants described constraints to innovation adoption including: staff lack of understanding of potential benefits; staff personalities, attitudes and behaviours which lead to resistance to change; high workload related to resource constraints and frequent policy changes inducing resistance to change; and suboptimal communication through health system structures. Managers reported employing various strategies to mitigate these constraints. These comprised (1) technical skills including participatory management skills, communication skills, community engagement skills and programme monitoring and evaluation skills, and (2) non-technical skills including role modelling positive attitudes, understanding staff personalities, influencing perceptions of innovations, influencing organizational climate and building trusting relationships. Managers have a vital role in the embedding of service innovations into routine practice. We present a framework of technical and non-technical skills that managers need to facilitate the adoption of health innovations. Future efforts to build managers' capacity to implement health innovations should target these competencies.
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Affiliation(s)
- Carrie Brooke-Sumner
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Petal Petersen-Williams
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - James Kruger
- Western Cape Government: Health, Norton Rose House, 8 Riebeeck Street, Cape Town, South Africa and
| | - Hassan Mahomed
- Western Cape Government: Health, Norton Rose House, 8 Riebeeck Street, Cape Town, South Africa and
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
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Thornicroft G, Ahuja S, Barber S, Chisholm D, Collins PY, Docrat S, Fairall L, Lempp H, Niaz U, Ngo V, Patel V, Petersen I, Prince M, Semrau M, Unützer J, Yueqin H, Zhang S. Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries. Lancet Psychiatry 2019; 6:174-186. [PMID: 30449711 DOI: 10.1016/s2215-0366(18)30298-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/24/2018] [Accepted: 07/27/2018] [Indexed: 11/19/2022]
Abstract
Integrated care is defined as health services that are managed and delivered such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and, according to their needs, throughout the life course. In this Review, we describe the most relevant concepts and models of integrated care for people with chronic (or recurring) mental illness and comorbid physical health conditions, provide a conceptual overview and a narrative review of the strength of the evidence base for these models in high-income countries and in low-income and middle-income countries, and identify opportunities to test the feasibility and effects of such integrated care models. We discuss the rationale for integrating care for people with mental disorders into chronic care; the models of integrated care; the evidence of the effects of integrating care in high-income countries and in low-income and middle-income countries; the key organisational challenges to implementing integrated chronic care in low-income and middle-income countries; and the practical steps to realising a vision of integrated care in the future.
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Affiliation(s)
- Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Shalini Ahuja
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Public Health Foundation of India, New Delhi, India
| | - Sarah Barber
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daniel Chisholm
- Division for Non-Communicable Diseases and Promoting Health through the Life-Course, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Pamela Y Collins
- Department of Psychiatry and Behavioral Sciences, and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Sumaiyah Docrat
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Heidi Lempp
- School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Unaiza Niaz
- University of Health Sciences, Lahore, Pakistan; Dow University of Health Sciences, Karachi, Pakistan
| | - Vicky Ngo
- RAND Corporation, Santa Monica, CA, USA
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Cambridge, MA, USA; London School of Hygiene & Tropical Medicine, London, UK; Sangath, Porvorim, Goa, India; Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Martin Prince
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maya Semrau
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Global Health and Infection Department, Brighton and Sussex Medical School, Brighton, UK
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Huang Yueqin
- Peking University Sixth Hospital, Key Laboratory of Mental Health, Ministry of Health (Peking University), National Clinical Research Centre for Mental Disorders, Beijing, China
| | - Shuo Zhang
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Fairall L, Cornick R, Bateman E. Empowering frontline providers to deliver universal primary healthcare using the Practical and Approach to care kit. BMJ Glob Health 2018; 3:bmjgh-2018-k4451rep. [PMID: 30538824 PMCID: PMC6266967 DOI: 10.1136/bmjgh-2018-k4451rep] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Feyissa YM, Hanlon C, Emyu S, Cornick RV, Fairall L, Gebremichael D, Teka T, Shiferaw S, Walelgne W, Mamo Y, Segni H, Ayehu T, Wale M, Eastman T, Awotiwon A, Wattrus C, Picken SC, Ras CJ, Anderson L, Doherty T, Prince MJ, Tegabu D. Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Ethiopia. BMJ Glob Health 2018; 3:e001108. [PMID: 30498596 PMCID: PMC6241984 DOI: 10.1136/bmjgh-2018-001108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 11/04/2022] Open
Abstract
The Federal Ministry of Health, Ethiopia, recognised the potential of the Practical Approach to Care Kit (PACK) programme to promote integrated, comprehensive and evidence-informed primary care as a means to achieving universal health coverage. Localisation of the PACK guide to become the 'Ethiopian Primary Health Care Clinical Guidelines' (PHCG) was spearheaded by a core team of Ethiopian policy and technical experts, mentored by the Knowledge Translation Unit, University of Cape Town. A research collaboration, ASSET (heAlth Systems StrEngThening in sub-Saharan Africa), has brought together policy-makers from the Ministry of Health and health systems researchers from Ethiopia (Addis Ababa University) and overseas partners for the PACK localisation process, and will develop, implement and evaluate health systems strengthening interventions needed for a successful scale-up of the Ethiopian PHCG. Localisation of PACK for Ethiopia included expanding the guide to include a wider range of infectious diseases and an expanded age range (from 5 to 15 years). Early feedback from front-line primary healthcare (PHC) workers is positive: the guide gives them greater confidence and is easy to understand and use. A training cascade has been initiated, with a view to implementing in 400 PHC facilities in phase 1, followed by scale-up to all 3724 health centres in Ethiopia during 2019. Monitoring and evaluation of the Ministry of Health implementation at scale will be complemented by indepth evaluation by ASSET in demonstration districts. Anticipated challenges include availability of essential medications and laboratory investigations and the need for additional training and supervisory support to deliver care for non-communicable diseases and mental health. The strong leadership from the Ministry of Health of Ethiopia combined with a productive collaboration with health systems research partners can help to ensure that Ethiopian PHCG achieves standardisation of clinical practice at the primary care level and quality healthcare for all.
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Affiliation(s)
| | - Charlotte Hanlon
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King’s College London, London, UK
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Emyu
- Technical Assistant to the Clinical Services Directorate, Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Ruth Vania Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Telahun Teka
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Solomon Shiferaw
- Department of Reproductive Health and Health Service Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wubaye Walelgne
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Yoseph Mamo
- Institute of Palliative Care, Kozhikode, Kerala, India
- Tropical Health Education Trust and Jimma University Chronic Disease Project, Jimma, Ethiopia
| | | | - Temesgen Ayehu
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Meseret Wale
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Tracy Eastman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- BMJ Knowledge Centre Department, BMA House, London, UK
| | - Ajibola Awotiwon
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Camilla Wattrus
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Sandy Claire Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Christy-Joy Ras
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Lauren Anderson
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Martin James Prince
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King’s College London, London, UK
- King’s Global Health Research Institute, King’s College London, London, UK
| | - Desalegn Tegabu
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
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Fairall L, Cornick R, Bateman E. Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit. BMJ 2018; 363:k4451. [PMID: 30355721 PMCID: PMC6200083 DOI: 10.1136/bmj.k4451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
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