Scale-Up Study

  • This scale up study evaluates the scale-up of a collaborative care model for the integration of mental health into the care provided for chronic care patients at primary health care (PHC) level called the Mental Health Integration Project (MhINT) in the Newcastle sub-district of Amajuba in KwaZulu-Natal, South Africa.

  • Adopting a learning health system approach, this study uses an in-site, iterative observational implementation science design.

  • The first stage comprises assessment of the original MhINT model under real-world conditions in a single sub-district in KwaZulu-Natal, South Africa, in order to inform refinement of the model and its implementation strategies. The second stage comprises assessment of the refined model across additional contexts.

  • In both stages, impact is assessed using the RE-AIM (Reach-Effectiveness-Adoption-Implementation-Maintenance) evaluation framework, and the Consolidated Framework for Implementation Research (CFIR) is used to understand multi-level determinants of the RE-AIM outcomes. Participatory concept mapping is used to identify adaptations to the initial scale-up package needed to address key multi-level determinants; as well as at the end of the second phase to inform adaptation for wider scale-up.

  • The Scale-Up Study is the primary research focus of the SMhINT Project.

Progress

  • There have been tremendous learnings from the examination of the multi-level factors influencing implementation and engagement of key stakeholders in the first cohort.

 

  • Our close collaboration with the KwaZulu-Natal Department of Health (KZN DoH), our implementation research approach including the continuous quality improvement process as part of the MHINT project has meant that we have been able to respond to the health system needs:
  • Development and Validation of the Brief Mental Health (BMH) Screening tool: The CQI process along with the close engagement with the KZN Provincial Department of Health (DoH) identified the need to increase levels of identification of common mental disorders at a PHC level. This led to the development and validation of the Brief Mental Health Screening Tool (BMH) (Bhana et al., 2019).

  • The BMH assesses for positive symptoms of common mental disorders (depression, anxiety and substance abuse) and it was developed against a nurse-initiated assessment using the Adult Primary Care (APC) Manual. The BMH is a 7-item screening tool comprised of brief versions of the AUDIT, PHQ-9 and GAD-7, and is designed to be used by enrolled nurses at a PHC facility level.

  • Having completed the validation of the Brief Mental Health (BMH) screening tool our findings show that the tool is effective in screening for common mental disorders.

  • We have also worked closely with the KZN DoH to investigate how best the tool should be used at facility level to inform a standard operating procedure for the tool.

  • Following the continuous quality improvement process that we have engaged with to strengthen the system to enable integrated care, we were requested by the KwaZulu-Natal provincial Department of Health to expand the MhINT intervention package to develop and include a community mental health screening tool that would assist the existing Ward Based Primary Health Care Outreach Teams (WPHCBOTs) to identify community members with possible mental health conditions during their routine household visits and to strengthen demand for services. We have thus been working on the following:

i) A Community Mental Health Education and Detection (CMED) tool that will assist the existing ward-based PHC outreach teams (WPHCBOTS) comprised of community health workers (CHWs) to identify chronic care patients with comorbid mental health disorders on their household visits. The feasibility and validity of this tool will be established before it is introduced into routine care. Adding a community layer should contribute to increased demand for mental health care services.

ii) Strengthening processes to enable timely follow-up of chronic patients lost to care and patient re-engagement, especially of chronic patients with HIV and/or TB with comorbid CMDs and tracking of health improvement via routine data such as blood pressure in hypertensive patients, viral load suppression rates in HIV patients and sputum conversion rates in TB patients

iii) We will start our second cohort in 2021 where we will assess whether the strengthened MhINT intervention (that incorporates screening at a PHC facility level using the BMH, as well as a community package that comprises strengthened processes for retention in care of chronic patients with comorbid CMDs) as well as other lessons emerging from the first phase of evaluation results in improved uptake and outcomes of the MhINT integration package.

Broader provincial scale-up: The MhINT model for integrated primary mental health care has been adopted by the King Cetswayo district in KwaZulu-Natal and currently being scaled up by the Department of Health in this district.

Updates

Development and Validation of the Brief Mental Health (BMH) Screening Tool

The need for a validated standardized screening tool at facility level as well as strengthening of the mental health component of the ward-based primary health care outreach teams (WBPHCOTS) to facilitate detection of mental health problems at a community level as well as tracing of non-adherent patients have been identified through the ongoing continuous quality improvement process as well as national, provincial and district Department of Health collaborators. As a result we developed and validated a Brief Mental Health (BMH) screening tool that has since been published in the South African Medical Journal (Bhana et al, 2019). The BMH assesses

Read More

Development and Validation of the Brief Mental Health (BMH) Screening Tool

The need for a validated standardized screening tool at facility level as well as strengthening of the mental health component of the ward-based primary health care outreach teams (WBPHCOTS) to facilitate detection of mental health problems at a community level as well as tracing of non-adherent patients have been identified through the ongoing continuous quality improvement process as well as national, provincial and district Department of Health collaborators. As a result we developed and validated a Brief Mental Health (BMH) screening tool that has since been published in the South African Medical Journal (Bhana et al, 2019). The BMH assesses

Read More