Effectiveness of a task-sharing collaborative care model for identification and management of depressive symptoms in patients with hypertension attending public sector primary care clinics in South Africa: pragmatic parallel cluster randomised controlled trial.

Fuzzy-set qualitative comparative analysis of implementation outcomes in an integrated mental healthcare trial in South Africa

“…A possibly important implementation condition that could have affected the trial outcome was the rate of referrals for counselling. It was previously reported that, while 1 400 referrals were made to lay counsellors during the trial period, only 11.3% of trial intervention group participants were referred to lay counsellors, and only 5% were referred to mental health specialists -this represents relatively low rates of referral, which could have had an influence on other conditions in the analysis [12]. A well-functioning referral structure is critical to achieve a continuum of care on PHC level [49], and nurses' referral rates have been suggested to be higher in cases where pathways were set within the healthcare facility, where referral processes are explicit and well-described [50].…”

“…This can lead to improved quality through improved decisionmaking, by sensitising nurses to the knowledge and skills of counsellors [61]. The fact that CCS and APC training were not uniformly attended by nurses across the trial clinics could further contribute to low referrals, and may in turn be attributed to a relatively low priority given to mental health in PHC training contexts in South Africa [12].…”

“…The number of referrals were derived from capturing and counting referral forms, and transformed to percentage scores out of patient headcounts per facility. Stigma and depression symptoms were measured in a pre-post patient survey, respectively, drawing from the Mental Illness Clinicians' Attitudes scale and the PHQ9, described more fully elsewhere [9,11,12]. Finally, the Quality of Clinic Management was drawn from the Department of Health's Ideal Clinic assessment, a routine quality assessment conducted of PHC clinics in South Africa.…”

“…Process data from the initial pilot sites also suggested a correlation between the amount of counselling sessions received and a reduction of depressive symptoms, as well as improved health and mental functionality at endline, and found that the intervention package was acceptable and accessible [11]. However, the effectiveness analysis of the main trial outcome, which was defined as at least a 50% improvement in PHQ-9 score at 6 months from baseline, showed no difference between the intervention and control arms [12].…”

“…These methodological considerations have been taken up by multi-country mental health strengthening programmes, such as PRIME, that aims to develop, implement and scale-up integrated mental healthcare models, considerations that are applied in order to speed up knowledge translation of mental healthcare interventions and increase their relevance and adaptability to other contexts [16,17]. The results of the PRIME South Africa trial require further scrutiny in order to better understand what elements of the intervention process require attention in order to improve identification and referral pathways [12].…”