Lovero Kathryn L, Lammie Samantha L, van Zyl André, Paul Sharon N, Ngwepe Phuti, Mootz Jennifer J, Carlson Catherine, Sweetland Annika C, Shelton Rachel C, Wainberg Milton L, Medina-Marino Andrew
New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 1051 Riverside Drive #24, New York, NY, 10032, USA.
Emory University School of Medicine, 1648 Pierce Dr NE, Atlanta, GA, 30307, USA.
BMC Health Serv Res. 2019 Jan 31;19(1):83. doi: 10.1186/s12913-019-3912-9.
The South African National Mental Health Policy Framework and Strategic Plan 2013-2020 was adopted to address the country's substantial burden and inadequate treatment of mental illness. It outlines measures toward the goal of full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, we conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of four districts in South Africa.
Forty clinics (ten per district) were purposively selected to represent both urban and rural locations. District-level program managers (DPMs) for mental health, tuberculosis, and maternal-child healthcare were qualitatively interviewed about district policy and procedures for management of mental illness and challenges in integrating mental health services into primary care. Clinic nurses and mental health practitioners (MHPs) completed a quantitative questionnaire to assess their engagement with stepped care for patients with mental illness. Qualitative and quantitative data were collected concurrently and compared to triangulate progress in implementation of integrated services.
A total of 59 nurses and 17 MHPs completed questionnaires, and nine DPMs were interviewed (total n = 85). DPMs indicated that nurses should screen for mental illness at every patient visit, although only 43 (73%) nurses reported conducting universal screening and 26 (44%) reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialized care. However, only 7 (41%) MHPs indicated that they diagnose mental illness and 14 (82%) offer any treatment for mental illness. Addressing challenges to current integration efforts, DPMs highlighted 1) insufficient funding and material resources, 2) poor coordination at the district administrative level, and 3) low mental health awareness in district administration and the general population.
Though some progress has been made toward integration of mental health services into primary care settings, there is a substantial lack of training and clarity of roles for nurses and MHPs. To enhance implementation, increased efforts must be directed toward improving district-level administrative coordination, mental health awareness, and financial and material resources.
《2013 - 2020年南非国家精神卫生政策框架与战略计划》旨在应对该国精神疾病负担沉重且治疗不足的问题。该计划概述了到2020年将精神卫生服务全面纳入初级保健的目标所采取的措施。为评估实施过程中的进展和挑战，我们对南非四个地区结核病及母婴保健服务中的精神卫生服务提供情况进行了混合方法评估。
有目的地选取了40家诊所（每个地区10家），以代表城乡不同地点。对精神卫生、结核病及母婴保健方面的地区级项目管理人员（DPM）进行了定性访谈，了解地区关于精神疾病管理的政策和程序以及将精神卫生服务纳入初级保健的挑战。诊所护士和精神卫生从业者（MHP）完成了一份定量问卷，以评估他们对精神疾病患者分级护理的参与情况。定性和定量数据同时收集，并进行比较以确定综合服务实施过程中的进展情况。
共有59名护士和17名MHP完成了问卷，9名DPM接受了访谈（共85人）。DPM表示护士应在每次患者就诊时筛查精神疾病，尽管只有43名（73%）护士报告进行了普遍筛查，26名（44%）报告使用了特定筛查工具。对于精神疾病筛查呈阳性的患者，DPM描述了一种分级护理方法，即MHP对患者进行诊断，然后进行治疗或转诊至专科护理。然而，只有7名（41%）MHP表示他们会诊断精神疾病，14名（82%）为精神疾病提供任何治疗。在应对当前整合工作的挑战方面，DPM强调了：1）资金和物质资源不足；2）地区行政层面协调不力；3）地区行政部门和普通民众对精神卫生的认识较低。
尽管在将精神卫生服务纳入初级保健机构方面已取得一些进展，但护士和MHP严重缺乏培训且职责不明确。为加强实施，必须加大力度改善地区行政协调、提高精神卫生意识以及增加资金和物质资源。
