Gigaba Sithabisile Gugulethu, Luvuno Zamasomi, Bhana Arvin, Janse van Rensburg Andre, Mthethwa Londiwe, Rao Deepa, Hongo Nikiwe, Petersen Inge
University of KwaZulu-Natal Centre for Rural Health School of Nursing and Public Health Durban South Africa.
Psychology Department KwaZulu-Natal Department of Health Durban South Africa.
Learn Health Syst. 2023 Oct 2;8(2):e10389. doi: 10.1002/lrh2.10389. eCollection 2024 Apr.
The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of task-sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC).
The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas.
Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%.
The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.
尽管有大量证据表明任务分担式心理健康干预措施具有有效性，但低收入和中等收入国家在心理健康障碍治疗方面的差距依然存在。采用这些创新措施的主要障碍包括缺乏支持实施的政策，以及在本就不堪重负的卫生系统中，工作人员被从日常工作中抽调出来。南非拥有有利的政策环境；然而，将政策理想转化为实际行动的策略却很缺乏。本文介绍了心理健康整合项目（MhINT），该项目采用了加强卫生系统的方法，将基于证据的抑郁症任务分担式护理包嵌入其中，以便在初级卫生保健（PHC）中将心理健康护理纳入慢性病护理。
MhINT护理包包括心理教育讲座、由护士主导的心理健康评估，以及由非专业咨询师提供的结构化社会心理咨询干预，在夸祖鲁-纳塔尔省的阿马朱巴区实施了两年。采用了学习型卫生系统方法，使用持续质量改进（CQI）策略来促进干预措施的融入。MhINT分五个阶段实施：项目阶段，组建推动实施的团队；诊断阶段，利用常规收集的数据识别综合心理健康护理的系统障碍；干预阶段，包括能力建设并使用计划-执行-研究-行动循环来解决实施障碍；影响和持续改进阶段，评估项目的影响，并启动系统层面的干预措施，以维持并将成功的变革理念制度化。
通过在旨在跟踪非传染性疾病和人类免疫病毒临床项目绩效指标的周会上纳入关键心理健康服务指标，实现了综合规划和监测。心理健康筛查缺乏标准化促使对一种心理健康筛查工具进行验证，并测试其在集中筛查站使用的可行性。通过CQI数据驱动的学习会议，促进了协作解决问题文化的形成。省级筛查率提高了10%，而区级筛查率提高了7%，开始接受心理健康治疗的新患者增加了16%。
CQI方法有望在资源匮乏的环境中促进实现综合心理健康护理。研究人员与卫生系统利益相关者之间的合作关系是促进采用基于证据的创新措施的重要策略。然而，缺乏解决医护人员自身心理健康问题的干预措施，对初级卫生保健中的综合心理健康护理构成了威胁。
