Partners In Health, Boston, MA, United States of America.
Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, United States of America.
PLoS One. 2020 Feb 21;15(2):e0228854. doi: 10.1371/journal.pone.0228854. eCollection 2020.
To address the know-do gap in the integration of mental health care into primary care in resource-limited settings, a multi-faceted implementation program initially designed to integrate HIV/AIDS care into primary care was adapted for severe mental disorders and epilepsy in Burera District, Rwanda. The Mentoring and Enhanced Supervision at Health Centers (MESH MH) program supported primary care-delivered mental health service delivery scale-up from 6 to 19 government-run health centers over two years. This quasi-experimental study assessed implementation reach, fidelity, and clinical outcomes at health centers supported by MESH MH during the scale up period.
MESH MH consisted of four strategies to ensure the delivery of the priority care packages at health centers: training; supervision and mentorship; audit and feedback; and systems-based quality improvement (QI). Implementation reach (service use) across the 19 health centers supported by MESH MH during the two year scale-up period was described using routine service data. Implementation fidelity was measured at four select health centers by comparing total clinical supervisory visits and checklists to target goals, and by tracking clinical observation checklist item completion rates over a nine month period. A prospective before and after evaluation measured clinical outcomes in consecutive adults presenting to four select health centers over a nine month period. Primary outcome assessments at baseline, 2 and 6 months included symptoms and functioning, measured by the General Health Questionnaire (GHQ-12) and the World Health Organization Disability Assessment Scale (WHO-DAS Brief), respectively. Secondary outcome assessments included engagement in income generating work and caregiver burden using a quantitative scale adapted to context.
A total of 2239 mental health service users completed 15,744 visits during the scale up period. MESH MH facilitated 70% and 76% of supervisory visit and clinical checklist utilization target goals, respectively. Checklist item completion rates significantly improved overall, and for three of five checklist item subgroups examined. 121 of 146 consecutive service users completed outcome measurements six months after entry into care. Scores improved significantly over six months on both the GHQ-12, with median score improving from 26 to 10 (mean within-person change 12.5 [95% CI: 10.9-14.0] p< 0.0001), and the WHO-DAS Brief, with median score improving from 26.5 to 7 (mean within-person change 16.9 [95% CI: 14.9-18.8] p< 0.0001). Over the same period, the percentage of surveyed service users reporting an inability to work decreased significantly (51% to 6% (p < 0.001)), and the proportion of households reporting that a caregiver had left income-generating work decreased significantly (41% to 4% (p < 0.001)).
MESH MH was associated with high service use, improvements in mental health care delivery by primary care nurses, and significant improvements in clinical symptoms and functional disability of service users receiving care at health centers supported by the program. Multifaceted implementation programs such as MESH MH can reduce the evidence to practice gap for mental health care delivery by nonspecialists in resource-limited settings. The primary limitation of this study is the lack of a control condition, consistent with the implementation science approach of the study.
ISRCTN #37231.
为了解决资源有限环境下精神卫生保健融入初级保健方面的知行差距问题，最初设计的一种多方面实施计划被用来将艾滋病毒/艾滋病护理融入卢旺达布鲁拉地区初级保健，该计划随后被调整用于严重精神障碍和癫痫。“卫生中心辅导和强化监督（MESH MH）”项目在两年期间支持了从 6 家政府运营的卫生中心扩展到 19 家的精神卫生保健服务。这项准实验研究评估了在扩大规模期间 MESH MH 支持的卫生中心的实施范围、保真度和临床结果。
MESH MH 由四项策略组成，以确保在卫生中心提供优先护理包：培训；监督和辅导；审计和反馈；以及基于系统的质量改进（QI）。在两年的扩大规模期间，通过使用常规服务数据描述了 19 家由 MESH MH 支持的卫生中心的实施范围（服务使用情况）。在四个选定的卫生中心，通过比较总临床监督访问和检查表与目标目标，以及通过跟踪九个月期间临床观察检查表项目完成率，衡量了实施保真度。前瞻性的前后评估在九个月期间连续评估了四个选定卫生中心的成年患者的临床结果。在基线、2 个月和 6 个月的主要结果评估包括症状和功能，使用一般健康问卷（GHQ-12）和世界卫生组织残疾评估量表（WHO-DAS 简介）进行评估。次要结果评估包括使用适应背景的定量量表评估获得收入的工作和照顾者负担。
在扩大规模期间，共有 2239 名精神卫生服务使用者完成了 15744 次就诊。MESH MH 分别实现了 70%和 76%的监督访问和临床检查表利用率目标。检查表项目完成率总体上显著提高，并且在五个检查表项目子组中的三个中也是如此。在进入护理后六个月，146 名连续服务使用者中有 121 名完成了结果测量。在 GHQ-12 上的评分在六个月内显著提高，中位数从 26 分提高到 10 分（个体内变化 12.5 [95%CI：10.9-14.0]，p<0.0001），在 WHO-DAS 简介上的评分也显著提高，中位数从 26.5 分提高到 7 分（个体内变化 16.9 [95%CI：14.9-18.8]，p<0.0001）。在同一时期，报告无法工作的服务使用者比例显著下降（51%降至 6%（p<0.001）），报告照顾者离开收入来源工作的家庭比例也显著下降（41%降至 4%（p<0.001））。
MESH MH 与高服务利用率相关，通过初级保健护士改善了精神卫生保健的提供，并且显著改善了接受项目支持的卫生中心服务使用者的临床症状和功能残疾。像 MESH MH 这样的多方面实施计划可以减少资源有限环境中精神卫生保健提供方面的证据到实践差距。本研究的主要限制是缺乏对照条件，这符合研究的实施科学方法。
ISRCTN #37231。
