Background
Methods
Setting
Dr Kenneth Kaunda District | Bojanala Platinum District | ||
---|---|---|---|
Population | 742 821 | 1 657 148 | |
Unemployment rate | 29.7% | 25.6% | |
Poverty headcount | 4.9% | 8.8% | |
NHI pilot site | Yes | No | |
ICSM pilot site | Yes | No | |
Number of clinics | 60 | 115 | |
Leading causes of mortality | HIV & TB burden | 28% | 22% |
NCDs | 47% | 47% |
Approach
Control condition
Intervention condition
Professional nurses
PHC doctors
Lay-counsellors
District and PHC facility managers
Provider | Intervention | Implementation Strategies |
---|---|---|
Intervention and Control Condition | ||
Professional PHC nurses | Capacitated to use the Department of Health Basic APC guidelines to identify, provide brief psycho-education and refer patients with depression | Dr KK and Bojanala Use of Department of Health Basic APC guidelines Department of Health (DoH) cascade model of training was used where APC Master Trainers provide onsite training in Basic APC guidelines using case scenarios (n = 27) over 12 weekly sessions to capacitate Professional PHC nurses to use the APC guidelines to identify and manage common chronic diseases, including communicable diseases, NCDs, women’s health and mental health (3 of the 27 cases over 2 of the 12 sessions). Mental health components draw on the WHO’s mhGAP guidelines and adopt a syndromic approach to mental health symptoms (such as stress, insomnia, suicidal thinking) with diagnostic algorithms and treatment checklists for depression. A cascade model of training was used where district APC Master Trainers train Facility Trainers who train PHC nurses at the facilities |
Intervention Condition only | ||
Professional PHC nurses | Strengthened capacity to use Department of Health Basic APC guidelines to identify, provide brief psycho-education, refer to facility-based lay counsellors in addition to existing referral pathways and provide case management | Dr KK and Bojanala The DoH cascade model of training was emulated where APC Master Trainers trained Facility Trainers who trained Professional PHC nurses to use additional case scenario material of chronic patients with comorbid mental health conditions at the facilities. The scenarios covered the following: i) Detection of depression and anxiety, psychoeducation and referral to lay-counsellors and/or doctors for consideration of psychotropic medication in the case of moderate to severe depression ii) Detection of risky alcohol use and brief intervention for harmful/hazardous drinking. Detoxification and referral to specialist rehabilitation programmes for dependency as per the mhGAP guidelines1 iii) Assessment of suicide intent iv) Patient review after 8 weeks of lay counselling services to assess response to treatment and onward referral for specialist care if necessary following a treatment-to-target approach as contained in the collaborative care model. Treatment to target involves tracking a patient’s symptom severity and adjusting or intensifying treatment should patients not show an improvement in symptoms following initial treatment Bojanala only Additional project support was provided for facility-based training. The use of the counsellor referral forms were also integrated into the APC training in Bojanala |
Professional PHC nurses | Orientation to Integrated Clinical Services Management model & Clinical Communication skills training | Dr KK and Bojanala Clinical Communication Skills Workshops Four 2-h interactive workshops at PHC facilities/regional training centres facilitated by Clinical Communication Skills experts covering the following: i) Overview of the system changes being made by the DoH in South Africa to accommodate the demands of integrated chronic care; their role as case managers within the collaborative care model for depression; ii) Orientation to person-centred care and clinical communication skills necessary to implement person-centred care; iii) Skills to manage patient emotions within the consultation; self-care including how to cope with their own emotions and burn-out; iv) Motivational interviewing skills to promote patient self-management Bojanala only APC clinical training included signposting the different clinical communication skills |
PHC doctors | Strengthened capacity to diagnose, initiate and monitor response to psychotropic medication | Dr KK and Bojanala Two-day face-to-face workshops facilitated by psychiatrists and physicians were held to: i) Orientate PHC doctors to the importance of treating comorbid depression ii) Upskill PHC doctors in the use of APC in managing depression and anxiety using case scenarios Dr KK only Training in mhGAP guidelines for other conditions besides depression and anxiety |
Lay counsellors | Introduced into facilities and capacitated to provide manualized counselling for patients with depression, drawing on problem solving and cognitive behavioural techniques to address the common triggers of depression and anxiety. An additional adherence counselling session. | Dr KK and Bojanala One week of off-site training in the use of a manualized 8-session counselling intervention for depression with an additional adherence counselling session facilitated by the project employed clinical psychologist and psychological counsellors with a Bachelor in Psychology using adult education principles; one week of peer to peer mentoring of lay-counsellors in the clinics in the use of the manual; supervision by a psychologist/B.Psych counsellor assisted by a bespoke fidelity checklist of each session—either in-vivo or of recorded sessions; weekly follow up group supervisory sessions (face to face or online), augmented by ad hoc individual supervision/mentoring sessions The training was organized accordingly to mirror the counsellors’ activities when delivering the intervention using the intervention materials and covered the following sections: i. A psychoeducation session on depression offered to all patients referred to the lay counsellor during their first meeting which took place on the day of the referral ii. Using the step-by-step intervention manual to address the identified triggers and issues that maintain depressive cycles (poverty; interpersonal conflict; social isolation/ avoidance; grief and bereavement; internalized and externalized stigma) iii. The closure session iv. Facilitating adherence counselling and providing accurate information on chronic conditions and patients’ prescribed treatment where needed through the use chronic conditions educational pamphlets |
District and facility operational managers | Support implementation of collaborative care model in facilities and district | Dr KK and Bojanala Once-off half day workshops facilitated by project employed intervention coordinators to orientate district and PHC facility managers to the PRIME/CobALT collaborative model of care and the task-shared counselling intervention Bojanala only Individual orientation for each facility manager |