Breuer Erica, Subba Prasansa, Luitel Nagendra, Jordans Mark, De Silva Mary, Marchal Bruno, Lund Crick
Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
TPO Nepal, Kathmandu, Nepal.
BMJ Glob Health. 2018 Dec 30;3(6):e001023. doi: 10.1136/bmjgh-2018-001023. eCollection 2018.
The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme's Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC.
We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5.
The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers. Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities.
Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.
将精神卫生服务纳入初级保健对于提高资源匮乏地区精神卫生服务的覆盖范围至关重要，但对此进行评估仍具有挑战性。我们使用一个项目的变革理论（ToC）作为概念框架，以确定在尼泊尔奇旺实施的地区精神卫生保健计划（MHCP）后，设施和社区层面的哪些条件组合影响了精神卫生服务的利用情况。此外，我们展示了如何使用定性比较分析来对来自变革理论的数据进行综合分析。
我们对实施MHCP的10个卫生设施进行了纵向案例研究。我们在基线时（2013年10月至12月）从所有设施收集数据，并在干预实施后每季度（2014年3月至2016年11月）收集一次。使用fsQCA V.2.5中的汇总定性比较分析对数据进行分析。
高精神卫生服务利用率需要以下条件：具备基本和高级社会心理护理、循证识别和治疗指南（世卫组织mhGAP）、转诊至三级服务以及有经过培训的女性社区卫生志愿者。还确定了另外两种条件组合对于高精神卫生服务利用率也足够：高药物供应、经过培训的设施工作人员以及使用社区信息检测工具或有较大比例的社区居民参加社区宣传活动。
供应方干预措施（卫生工作者检测和治疗的正规方法、卫生工作者培训、监督）和需求方干预措施（社区宣传和病例发现）对于将精神卫生纳入初级保健都很重要。变革理论可用于对来自变革理论的数据进行综合分析，从而有助于揭示复杂多层次干预措施的黑箱。
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