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

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Abstract

Integration of mental health into routine primary health care (PHC) services in low-and middle-income countries is globally accepted to improve health outcomes of other conditions and narrow the mental health treatment gap. Yet implementation remains a challenge. The aim of this study was to identify implementation strategies that improve implementation outcomes of an evidence-based depression care collaborative implementation model integrated with routine PHC clinic services in South Africa. An iterative, quasi-experimental, observational implementation research design, incorporating the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, was applied to evaluate implementation outcomes of a strengthened package of implementation strategies (stage two) compared with an initial evaluation of the model (stage one). The first stage package was implemented and evaluated in 10 PHC clinics and the second stage strengthened package in 19 PHC clinics (inclusive of the initial 10 clinics) in one resource-scarce district in the province of KwaZulu-Natal, South Africa. Diagnosed service users were more likely to be referred for counselling treatment in the second stage compared with stage one (OR 23.15, SE = 18.03, z = 4.04, 95%CI [5.03–106.49], p < .001). Training in and use of a validated, mandated mental health screening tool, including on-site educational outreach and technical support visits, was an important promoter of nurse-level diagnosis rates (OR 3.75, 95% CI [1.19, 11.80], p = 0.02). Nurses who perceived the integrated care model as acceptable were also more likely to successfully diagnose patients (OR 2.57, 95% CI [1.03–6.40], p = 0.043). Consistent availability of a clinic counsellor was associated with a greater probability of referral (OR 5.9, 95%CI [1.29–27.75], p = 0.022). Treatment uptake among referred service users remained a concern across both stages, with inconsistent co-located counselling services associated with poor uptake. The importance of implementation research for strengthening implementation strategies along the cascade of care for integrating depression care within routine PHC services is highlighted.

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A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project

Byron J. Powell, Thomas Waltz, Matthew J Chinman … (2015)

Background Identifying, developing, and testing implementation strategies are important goals of implementation science. However, these efforts have been complicated by the use of inconsistent language and inadequate descriptions of implementation strategies in the literature. The Expert Recommendations for Implementing Change (ERIC) study aimed to refine a published compilation of implementation strategy terms and definitions by systematically gathering input from a wide range of stakeholders with expertise in implementation science and clinical practice. Methods Purposive sampling was used to recruit a panel of experts in implementation and clinical practice who engaged in three rounds of a modified Delphi process to generate consensus on implementation strategies and definitions. The first and second rounds involved Web-based surveys soliciting comments on implementation strategy terms and definitions. After each round, iterative refinements were made based upon participant feedback. The third round involved a live polling and consensus process via a Web-based platform and conference call. Results Participants identified substantial concerns with 31% of the terms and/or definitions and suggested five additional strategies. Seventy-five percent of definitions from the originally published compilation of strategies were retained after voting. Ultimately, the expert panel reached consensus on a final compilation of 73 implementation strategies. Conclusions This research advances the field by improving the conceptual clarity, relevance, and comprehensiveness of implementation strategies that can be used in isolation or combination in implementation research and practice. Future phases of ERIC will focus on developing conceptually distinct categories of strategies as well as ratings for each strategy’s importance and feasibility. Next, the expert panel will recommend multifaceted strategies for hypothetical yet real-world scenarios that vary by sites’ endorsement of evidence-based programs and practices and the strength of contextual supports that surround the effort. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0209-1) contains supplementary material, which is available to authorized users.

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Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

(2022)

Summary Background The mental disorders included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were depressive disorders, anxiety disorders, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, eating disorders, idiopathic developmental intellectual disability, and a residual category of other mental disorders. We aimed to measure the global, regional, and national prevalence, disability-adjusted life-years (DALYS), years lived with disability (YLDs), and years of life lost (YLLs) for mental disorders from 1990 to 2019. Methods In this study, we assessed prevalence and burden estimates from GBD 2019 for 12 mental disorders, males and females, 23 age groups, 204 countries and territories, between 1990 and 2019. DALYs were estimated as the sum of YLDs and YLLs to premature mortality. We systematically reviewed PsycINFO, Embase, PubMed, and the Global Health Data Exchange to obtain data on prevalence, incidence, remission, duration, severity, and excess mortality for each mental disorder. These data informed a Bayesian meta-regression analysis to estimate prevalence by disorder, age, sex, year, and location. Prevalence was multiplied by corresponding disability weights to estimate YLDs. Cause-specific deaths were compiled from mortality surveillance databases. The Cause of Death Ensemble modelling strategy was used to estimate death rate by age, sex, year, and location. The death rates were multiplied by the years of life expected to be remaining at death based on a normative life expectancy to estimate YLLs. Deaths and YLLs could be calculated only for anorexia nervosa and bulimia nervosa, since these were the only mental disorders identified as underlying causes of death in GBD 2019. Findings Between 1990 and 2019, the global number of DALYs due to mental disorders increased from 80·8 million (95% uncertainty interval [UI] 59·5–105·9) to 125·3 million (93·0–163·2), and the proportion of global DALYs attributed to mental disorders increased from 3·1% (95% UI 2·4–3·9) to 4·9% (3·9–6·1). Age-standardised DALY rates remained largely consistent between 1990 (1581·2 DALYs [1170·9–2061·4] per 100 000 people) and 2019 (1566·2 DALYs [1160·1–2042·8] per 100 000 people). YLDs contributed to most of the mental disorder burden, with 125·3 million YLDs (95% UI 93·0–163·2; 14·6% [12·2–16·8] of global YLDs) in 2019 attributable to mental disorders. Eating disorders accounted for 17 361·5 YLLs (95% UI 15 518·5–21 459·8). Globally, the age-standardised DALY rate for mental disorders was 1426·5 (95% UI 1056·4–1869·5) per 100 000 population among males and 1703·3 (1261·5–2237·8) per 100 000 population among females. Age-standardised DALY rates were highest in Australasia, Tropical Latin America, and high-income North America. Interpretation GBD 2019 showed that mental disorders remained among the top ten leading causes of burden worldwide, with no evidence of global reduction in the burden since 1990. The estimated YLLs for mental disorders were extremely low and do not reflect premature mortality in individuals with mental disorders. Research to establish causal pathways between mental disorders and other fatal health outcomes is recommended so that this may be addressed within the GBD study. To reduce the burden of mental disorders, coordinated delivery of effective prevention and treatment programmes by governments and the global health community is imperative. Funding Bill & Melinda Gates Foundation, Australian National Health and Medical Research Council, Queensland Department of Health, Australia.

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Implementation strategies: recommendations for specifying and reporting

Enola K. Proctor, Byron J. Powell, J. McMillen (2013)

Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and ‘reproducibility.’ We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

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Author and article information

Contributors

Inge Petersen: Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing

Christopher G. Kemp: Role: Formal analysisRole: Writing – review & editing

Deepa Rao: Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing

Bradley H. Wagenaar:

ORCID: https://orcid.org/0000-0002-3351-7175

Role: MethodologyRole: Writing – review & editing

Max Bachmann: Role: Formal analysisRole: MethodologyRole: Writing – review & editing

Kenneth Sherr:

ORCID: https://orcid.org/0000-0002-2963-0829

Role: MethodologyRole: Writing – review & editing

Tasneem Kathree:

ORCID: https://orcid.org/0000-0002-8451-9197

Role: Project administrationRole: SupervisionRole: Writing – review & editing

Zamasomi Luvuno: Role: InvestigationRole: Writing – review & editing

André Van Rensburg: Role: InvestigationRole: Writing – review & editing

Sithabisile Gugulethu Gigaba: Role: InvestigationRole: Writing – review & editing

Londiwe Mthethwa: Role: Data curationRole: Writing – review & editing

Merridy Grant:

ORCID: https://orcid.org/0000-0002-7790-5102

Role: InvestigationRole: Project administrationRole: SupervisionRole: Writing – review & editing

One Selohilwe: Role: SupervisionRole: Writing – review & editing

Nikiwe Hongo: Role: Writing – review & editing

Gillian Faris: Role: ResourcesRole: Writing – review & editing

Christy-Joy Ras: Role: ResourcesRole: Writing – review & editing

Lara Fairall: Role: ResourcesRole: Writing – review & editing

Sanah Bucibo: Role: InvestigationRole: Writing – review & editing

Arvin Bhana:

ORCID: https://orcid.org/0000-0003-4235-0108

Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing

Ahmed Waqas: Role: Editor

Journal

Journal ID (nlm-ta): PLOS Glob Public Health

Journal ID (iso-abbrev): PLOS Glob Public Health

Journal ID (publisher-id): plos

Title: PLOS Global Public Health

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 2767-3375

Publication date (Electronic): 13 November 2023

Publication date Collection: 2023

Volume: 3

Issue: 11

Electronic Location Identifier: e0002604

Affiliations

[1 ] Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

[2 ] Institute for Global Health, University College London, London, United Kingdom

[3 ] Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America

[4 ] Department of Global Health, University of Washington, Seattle, WA, United States of America

[5 ] Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom

[6 ] Curtin University, Perth, Australia

[7 ] Mental Health Directorate, KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa

[8 ] Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa

[9 ] SA Medical Research Council, Health Systems Research Unit, Durban, South Africa

University of Liverpool, UNITED KINGDOM

Author notes

The authors have declared that no competing interests exist.

* E-mail: PETERSENI@ 123456ukzn.ac.za

Author information

Bradley H. Wagenaar https://orcid.org/0000-0002-3351-7175

Kenneth Sherr https://orcid.org/0000-0002-2963-0829

Tasneem Kathree https://orcid.org/0000-0002-8451-9197

Merridy Grant https://orcid.org/0000-0002-7790-5102

Arvin Bhana https://orcid.org/0000-0003-4235-0108

Article

Publisher ID: PGPH-D-23-01047

DOI: 10.1371/journal.pgph.0002604

PMC ID: 10642780

PubMed ID: 37956110

SO-VID: 3479e2d7-954a-4e98-9b21-289fcd2bacee

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 6 June 2023

Date accepted : 21 October 2023