BackgroundThe treatment of substance use disorders is a public health priority, particularly in South Africa where the prevalence of these disorders is high. We tested two peer-counsellor delivered brief interventions (BIs) for risky substance use among adults presenting to emergency departments (EDs) in South Africa.MethodsIn this randomised controlled trial, we enrolled patients presenting to one of three 24-hour EDs who screened at risk for substance use according to the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Eligible patients were randomly allocated to one of three conditions: Motivational Interviewing (MI), blended MI and Problem Solving Therapy (MI-PST) or a Psycho-educational Control Group (CG). The primary outcome was reduction in ASSIST scores at three months follow-up.ResultsOf the 2736 patients screened, 335 met inclusion criteria, were willing to participate in the intervention and were randomised to one of three conditions: 113 to MI, 112 to MI-PST and 110 to CG. ASSIST scores at three months were lower in the MI-PST group than they were in the MI and CG groups (adjusted mean difference of −1.72, 95 % CI −3.36 - -0.08). We recorded no significant difference in ASSIST scores between the CG and MI group (adjusted mean difference of −0.02, 95 % CI −2.01 - 1.96).ConclusionWith the addition of minimal resources, BIs are feasible to conduct in EDs in a low resourced country. These preliminary findings report that MI-PST appears to be an effective BI for reducing substance use among at risk participants. Further research is required to replicate these findings with effort to limit attrition, to determine whether reductions in substance use are persistent at 6 and 12 month follow-up and whether parallel changes occur in other indications of treatment outcomes, such as injury rates and ED presentations.Trial registrationThis trial registered with the Pan African Clinical Trial Registry (PACTR201308000591418)

BackgroundIn low- and middle-income countries (LMIC), it is uncertain whether a “dedicated” approach to integrating mental health care (wherein a community health worker (CHW) has the sole responsibility of delivering mental health care) or a “designated” approach (wherein a CHW provides this service in addition to usual responsibilities) is most effective and cost-effective. This study aims to compare the effectiveness and cost-effectiveness of these two models of service integration relative to treatment as usual (TAU) for improving mental health and chronic disease outcomes among patients with HIV or diabetes.Methods/DesignThis is a cluster randomised trial. We will randomise 24 primary health care facilities in the Western Cape Province of South Africa to one of three study arms. Within each cluster, we will recruit 25 patients from HIV and 25 from diabetes services for a total sample of 1200 participants. Eligible patients will be aged 18 years or older, take medication for HIV or diabetes, and screen positive on the Alcohol Use Disorder Identification Test for hazardous/harmful alcohol use or depression on the Centre for Epidemiology Scale on Depression. Participants recruited in clinics assigned to the designated or dedicated approach will receive three sessions of motivational interviewing and problem-solving therapy, while those recruited at TAU-assigned clinics will be referred for further assessment. Participants will complete an interviewer-administered questionnaire at baseline, and at 6 and 12 months post-enrolment to assess change in self-reported outcomes. At these end points, we will test HIV RNA viral load for participants with HIV and HbA1c levels for participants with diabetes. Primary outcomes are reductions in self-reported hazardous/harmful alcohol use and risk of depression. Secondary outcomes are improvements in adherence to chronic disease treatment, biomarkers of chronic disease outcomes, and health-related quality of life. Mixed-effect linear regression models will model the effect of the interventions on primary and secondary outcomes. The cost-effectiveness of each approach will be assessed using incremental cost-effectiveness ratios.DiscussionStudy findings will guide decision-making around how best to integrate mental health counselling into chronic disease care in a LMIC setting.Trial registrationPan African Clinical Trials Registry, Trial registration number: ACTR201610001825403. Registered 17 October 2016.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-2568-9) contains supplementary material, which is available to authorized users.

ObjectivesTo examine the feasibility and acceptability of integrating a ‘designated’ approach to community health worker (CHW)-delivered mental health counselling (where existing CHWs deliver counselling in addition to usual duties) and a ‘dedicated’ approach (where additional CHWs have the sole responsibility of delivering mental health counselling) into chronic disease care.DesignA feasibility test of a designated and dedicated approach to CHW-delivered counselling and qualitative interviews of CHWs delivering the counselling.SettingFour primary healthcare clinics in the Western Cape, South Africa allocated to either a designated or dedicated approach and stratified by urban/rural status.ParticipantsForty chronic disease patients (20 with HIV, 20 with diabetes) reporting hazardous alcohol use or depression. Interviews with seven CHWs.InterventionThree sessions of structured mental health counselling.Main outcome measuresWe assessed feasibility by examining the proportion of patients who were willing to be screened, met inclusion criteria, provided consent, completed counselling and were retained in the study. Acceptability of these delivery approaches was assessed through qualitative interviews of CHWs.ResultsRegardless of approach, a fair proportion (67%) of eligible patients were willing to receive mental health counselling. Patients who screened positive for depression were more likely to be interested in counselling than those with hazardous alcohol only. Retention in counselling (85%) and the study (90%) was good and did not differ by approach. Both dedicated and designated CHWs viewed the counselling package as highly acceptable but requested additional training and support to facilitate implementation.ConclusionsDedicated and designated approaches to CHW-delivered mental health counselling were matched in terms of their feasibility and acceptability. A comparative efficacy trial of these approaches is justified, with some adjustments to the training and implementation protocols to provide further support to CHWs.

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Background: In 2007, South Africa made family medicine a new speciality. Family physicians that have trained for this new speciality have been employed in the district health system since 2011. The aim of the present study was to explore the perceptions of district managers on the impact of family physicians on clinical processes, health system performance and health outcomes in the district health system (DHS) of the Western Cape.Methods: Nine in-depth interviews were performed: seven with district managers and two with the chief directors of the metropolitan and rural DHS. Interviews were recorded, transcribed and analysed using the ATLAS-ti and the framework method.Results: There was a positive impact on clinical processes for HIV/AIDS, TB, trauma, non-communicable chronic diseases, mental health, maternal and child health. Health system performance was positively impacted in terms of access, coordination, comprehensiveness and efficiency. An impact on health outcomes was anticipated. The impact was not uniform throughout the province due to different numbers of family physicians and different abilities to function optimally. There was also a perception that the positive impact attributed to family physicians was in the early stages of development. Unanticipated effects included concerns with their roles in management and training of students, as well as tensions with career medical officers.Conclusion: Early feedback from district managers suggests that where family physicians are employed and able to function optimally, they are making a significant impact on health system performance and the quality of clinical processes. In the longer term, this is likely to impact on health outcomes.Evaluation de l'impact des médecins de famille dans le système de santé du district du Western Cape, en Afrique du Sud.Contexte: En 2007, l'Afrique du Sud a institué une nouvelle spécialité, la médecine de famille. Les médecins de famille qui se sont spécialisés dans cette nouvelle discipline sont employés dans le système de santé de district depuis 2011. L'objet de cette étude était d‘étudier les perceptions des gestionnaires de district sur l'impact que les des médecins de famille avaient sur les processus cliniques, la performance du système de santé et les résultats des systèmes de santé des districts (DHS) du Western Cape.Méthodes: On a effectué neuf entrevues approfondies: sept avec les gestionnaires de district et deux avec les directeurs principaux du DHS rural et métropolitain. On a enregistré, transcrit et analysé les entrevues en utilisant ATLAS-ti et la méthode de structure.Résultats: Il y a eu un effet positif sur les processus cliniques du VIH et/ou du SIDA, la Tuberculose, le traumatisme, les maladies chroniques non-contagieuses, la santé mentale, et la santé de la mère et de l'enfant. La performance du système de santé a été positivement affectée en termes d'accès, coordination, exhaustivité et efficacité. On s'attendait à un impact sur les résultats en matière de santé. L'impact n’était pas uniforme dans toute...

PurposeTo describe patient perceptions of the acceptability of integrating mental health counseling within primary care facilities in the Western Cape province of South Africa and their preferences for the way in which this care is delivered.Patients and methodsQualitative interviews with 30 purposively selected patients receiving treatment for HIV or diabetes within primary care facilities who screened positive for depression using the Center for Epidemiological Studies Depression Scale or hazardous alcohol use through the Alcohol Use Disorders Identification Test.ResultsParticipants articulated high levels of unmet need for mental health services and strong associations between poor mental health and the challenges of living with a chronic disease. Consequently, they considered it acceptable to offer screening and mental health counseling within the context of chronic disease care. They thought counseling would be highly relevant if it helped patients develop adaptive strategies for coping with stress and negative emotions. Irrespective of chronic disease, patients indicated a preference for lay counselors rather than existing clinicians as potential delivery agents, supporting a task-shared approach to mental health counseling delivery in primary care settings. Some expressed concern about the feasibility of using lay counselors already present in facilities to deliver this service, suggesting that additional counselors might be needed.ConclusionFindings demonstrate a need for mental health counseling within the context of chronic disease care in South Africa. Task-shared approaches, using lay counselors, seem acceptable to patients – provided counselors are selected to ensure they possess the qualities associated with effective counselors. Findings have informed the design of a task-shared mental health program that is responsive to the preferences of patients with chronic diseases.

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Objective To explore health care providers’ views on the acceptability and feasibility of two models for integrating facility-based counsellor delivered mental health counselling into chronic disease care, and how such an approach could be improved in South Africa. Methods Fourteen focus group discussions and 25 in-depth individual interviews were conducted with 109 health care workers and facility managers from 24 primary health clinics in the Western Cape, South Africa. Results Findings suggested that despite recent efforts to integrate mental health counselling into chronic disease services for common mental disorders, there remains limited availability of psychosocial and psychological counselling. Feedback on the two models of integration suggested equipoise and the potential of a hybrid approach where these approaches may be tailored to the specific needs and available resources of each facility. Participants identified constraints within the health system and broader social context that require consideration for integrating mental health counselling into chronic disease care. Conclusion Although study participants unanimously agreed that counselling for common mental disorders should be integrated into chronic disease services, they had differing views on the type of model that should be adopted. There is a need for further testing of the two models and aspects of the health service that may require strengthening to implement any such model.