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

Abstract

Background: Integrating mental health services into primary healthcare platforms is an established health systems strategy in low-to-middle-income countries. In South Africa, this was pursued through the Programme for Improving Mental Health Care (PRIME), a multicountry initiative that relied on task-sharing as a principle implementation strategy. Towards better describing the implementation processes, qualitative comparative analysis was adopted to explore causal pathways in the intervention. Objective: This study aimed to explore factors that could have influenced key outcomes of an integrated mental healthcare intervention in South Africa. Methods: Drawing from an embedded multiple case study design, the analysis used qualitative comparative analysis. Focusing on nine PHC clinics in the Dr Kenneth Kaunda District as cases, with depression reduction scores set as outcome measures, trial data variables were modelled in a hypothetical causal process. A fuzzy-set qualitative comparative analysis was performed by 1) developing the research questions, 2) developing the fuzzy set, 3) testing necessity and 4) testing sufficiency. These steps were undertaken collaboratively among the research team. Results: The data were calibrated during several meetings among team members to gain a degree of consensus. Necessity analyses suggested that none of the causal conditions exceeded the threshold of necessity and triviality, and confirmed the inclusion of relevant variables in line with the proposed models. Sufficiency analyses produced two configurations, which were subjected to standard and specific analyses. Ultimately, the results suggested that none of the causal conditions were necessary for a reduction in depression scores to occur, while programme fidelity was identified as a sufficient condition for a reduction in scores to occur. Conclusions:The study highlights the importance of understanding implementation pathways to enable better integration of mental health services within primary healthcare in lowto-middle-income settings. It underlines the importance of programme fidelity in achieving the goals of implementation.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa

“…Grant funding support is an essential element of fulfilling the complex needs of people with severe conditions but it can risk becoming part of a system that ranks the investment value of vulnerable populations, determined by global auditing firms. In the almost complete absence of community-based psychosocial support services and almost no prospects to generate income, people with severe mental health conditions risk being rendered as one-dimensional income-generating bodies with little agency within neo-liberal contexts [ 61 , 80 ]. Instead, a more comprehensive package of psychosocial support services alongside disability payments would better serve people to break the cycle of dependence.…”

Strengthening integrated depression services within routine primary health care using the RE-AIM framework in South Africa

“…We assessed counselling fidelity using a bespoke counselling fidelity rating checklist adapted from ENACT and previously used as part of the evaluation of the original package [ 27 ].…”

Scaling up alcohol prevention in primary health care

“…Fuzzy set qualitative comparative analysis is a social science methodology that combines case-oriented and variable-oriented quantitative analysis. It is similar to qualitative comparative analysis in terms of identifying configurations of conditions that can explain the selected outcome, however, unlike the qualitative comparative analysis the conditions do not have to belong to dichotomous categories (0 or 1), but can exist on a continuous scale between 0 and 1 (Janse van Rensburg et al, 2021). This would allow us to quantify the qualitative data and have a more robust insight into combinations of conditions leading to the outcome.…”

“…In-depth examination of the organizational factors and their impact on provider screening: while research in this thesis briefly focused on the organizational level factors through the providers" perspective (captured in the provider questionnaire), more objective indicators could be sought to explain the number of providers screening and patient coverage on the level on primary health care centre level. An approach such as fuzzy set qualitative comparative analysis could be suitable for this purpose, with an examination of which combination of organizational factors (such as the size of the centre, the proportion of providers participating in the project out of all providers, leadership support, leadership changes, structural changes during the implementation period) led to higher patient coverage in the centre (an example of similar approach done in South Africa (Janse van Rensburg et al, 2021))…”