South Africa Archives - Page 2 of 3 - Implementation Science at UW

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

Authors:

Inge Petersen, Christopher G. Kemp, Deepa Rao, Bradley H. Wagenaar, Max Bachmann, Kenneth Sherr, Tasneem Kathree, Zamasomi Luvuno, André Van Rensburg, Sithabisile Gugulethu Gigaba, Londiwe Mthethwa, Merridy Grant, One Selohilwe, Nikiwe Hongo, Gillian Faris, Christy-Joy Ras, Lara Fairall, Sanah Bucibo, & Arvin Bhana

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: November 2023

Read the full text in the open access journal PLOS Global Public Health

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.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Healthcare worker perceived barriers and facilitators to implementing a tuberculosis preventive therapy program in rural South Africa: a content analysis using the consolidated framework for implementation research

Abstract:

Background

South African national tuberculosis (TB) guidelines, in accordance with the World Health Organization, recommend conducting routine household TB contact investigation with provision of TB preventive therapy (TPT) for those who qualify. However, implementation of TPT has been suboptimal in rural South Africa. We sought to identify barriers and facilitators to TB contact investigations and TPT management in rural Eastern Cape, South Africa, to inform the development of an implementation strategy to launch a comprehensive TB program.

Methods

We collected qualitative data through individual semi-structured interviews with 19 healthcare workers at a district hospital and four surrounding primary-care clinics referring to the hospital. The consolidated framework for implementation research (CFIR) was used to develop interview questions as well as guide deductive content analysis to determine potential drivers of implementation success or failure

Results

A total of 19 healthcare workers were interviewed. Identified common barriers included lack of provider knowledge regarding efficacy of TPT, lack of TPT documentation workflows for clinicians, and widespread community resource constraints. Facilitators identified included healthcare workers high interest to learn more about the effectiveness of TPT, interest in problem-solving logistical barriers in provision of comprehensive TB care (including TPT), and desire for clinic and nurse-led TB prevention efforts.

Conclusion

The use of the CFIR, a validated implementation determinants framework, provided a systematic approach to identify barriers and facilitators to TB household contact investigation, specifically the provision and management of TPT in this rural, high TB burden setting. Specific resources—time, trainings, and evidence—are necessary to ensure healthcare providers feel knowledgeable and competent about TPT prior to prescribing it more broadly. Tangible resources such as improved data systems coupled with political coordination and funding for TPT programming are essential for sustainability.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ ‘I understood the texting process well’ – Participant perspectives on usability and acceptability of SMS-based telehealth follow-up after voluntary medical male circumcision in South Africa

Abstract:

Background

Voluntary medical male circumcision (MC) is a biomedical HIV prevention method that requires post-operative follow-up for healing confirmation. Recent research found that a two-way texting (2wT) app providing SMS-based telehealth for MC patients was safe and reduced provider workload. We evaluated 2wT usability among MC clients in South Africa assigned the 2wT intervention within a larger randomized controlled trial (RCT) of 2wT safety and workload.

Methods

This quantitative usability study is within an RCT where 547 men used 2wT to interact with an MC provider via SMS. The sub-study involved the first 100 men assigned to 2wT who completed a usability survey 14 days after surgery. Acceptability was assessed through 2wT response rates of the 547 men. Regression models analyzed associations between age, wage, location, potential adverse events (AEs), and 2wT responses.

Results

Men assigned to 2wT found it safe, comfortable, and convenient, reporting time and cost savings. High response rates (88%) to daily messages indicated acceptability. Age, wage, and location didn't affect text responses or potential AEs.

Conclusion

2wT for post-MC follow-up was highly usable and acceptable, suggesting its viability as an alternative to in-person visits. It enhanced confidence in wound self-management. This SMS-based telehealth can enhance MC care quality and be adapted to similar contexts for independent healing support, particularly for men.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Management of Depression in Chronic Care Patients Using a Task-Sharing Approach in a Real-World Primary Health Care Setting in South Africa: Outcomes of a Cohort Study

Abstract:

Depressive symptoms are common in South African primary care patients with chronic medical conditions, but are usually unrecognised and untreated. This study evaluated an integrated, task-sharing collaborative approach to management of depression comorbid with chronic diseases in primary health care (PHC) patients in a real-world setting. Existing HIV clinic counsellors provided a manualised depression counselling intervention with stepped-up referral pathways to PHC doctors for initiation of anti-depressant medication and/ or referral to specialist mental health services. Using a comparative group cohort design, adult PHC patients in 10 PHC facilities were screened with the Patient Health Questionnaire-9 with those scoring above the validated cut-off enrolled. PHC nurses independently assessed, diagnosed and referred patients. Referral for treatment was independently associated with substantial improvements in depression symptoms three months later. The study confirms the viability of task-shared stepped-up collaborative care for depression treatment using co-located counselling in underserved real-world PHC settings.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ “They are gaining experience; we are gaining extra hands”: a mixed methods study to assess healthcare worker perceptions of a novel strategy to strengthen human resources for HIV in South Africa

Abstract:

Background

Lay health workers (LHWs) can support the HIV response by bridging gaps in human resources for health. Innovative strategies are needed to expand LHW programs in many low- and middle-income countries. Youth Health Africa (YHA) is a novel LHW approach implemented in South Africa that places young adults needing work experience in one-year non-clinical internships at health facilities to support HIV programs (e.g., as HIV testers, data clerks). While research suggests YHA can increase HIV service delivery, we need to understand healthcare worker perceptions to know if this is an acceptable and appropriate approach to strengthen human resources for health and healthcare delivery.

Methods

We conducted a convergent mixed methods study to assess healthcare worker acceptance and perceived appropriateness of YHA as implemented in Gauteng and North West provinces, South Africa and identify issues promoting or hindering high acceptability and perceived appropriateness. To do this, we adapted the Johns Hopkins Measure of Acceptability and Appropriateness to survey healthcare workers who supervised interns, which we analyzed descriptively. In parallel, we interviewed frontline healthcare workers who worked alongside YHA interns and conducted an inductive, thematic analysis. We merged quantitative and qualitative results using the Theoretical Framework of Acceptability to understand what promotes or hinders high acceptance and appropriateness of YHA.

Results

Sixty intern supervisors responded to the survey (91% response rate), reporting an average score of 3.5 for acceptability and 3.6 for appropriateness, on a four-point scale. Almost all 33 frontline healthcare workers interviewed reported the program to be highly acceptable and appropriate. Perceptions that YHA was mutually beneficial, easy to integrate into facilities, and helped facilities be more successful promoted a strong sense of acceptability/appropriateness amongst healthcare workers, but this was tempered by the burden of training interns and limited program communication. Overall, healthcare workers were drawn to the altruistic nature of YHA.

Conclusion

Healthcare workers in South Africa believed YHA was an acceptable and appropriate LHW program to support HIV service delivery because its benefits outweighed its costs. This may be an effective, innovative approach to strengthen human resources for HIV services and the broader health sector.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Implementation of a Psychosocial Support Intervention for Adolescents on Antiretroviral Treatment: Challenges and Experiences from Ehlanzeni District, South Africa

Abstract:

Adolescents living with HIV (ALHIV) need support from family, peers and health workers to remain on antiretroviral therapy and achieve and sustain viral suppression. This paper qualitatively explores the implementation of a psychosocial support intervention (PSS) in five primary health care facilities in the Ehlanzeni district, South Africa. Data were collected through key informant interviews and focus group discussions with ALHIV on ART. Data analysis employed inductive thematic analysis. Informed consent was obtained prior to all data collection. The PSS intervention facilitated full disclosure of HIV status to adolescents, supported treatment adherence through health education, peer support, health care provider- and client relations, and quick access to health service delivery. However, COVID-19 restrictions and regulations challenged the implementation of the intervention. The PSS intervention showed promise to support adolescent’s adherence and retention in care. We recommend innovative approaches to account for systemic disruptions, as evidenced by the COVID-19 pandemic.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Comparing Patients’ Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa

Abstract:

Differentiated service delivery for HIV treatment seeks to enhance medication adherence while respecting the preferences of people living with HIV. Nevertheless, patients’ experiences of using these differentiated service delivery models or approaches have not been qualitatively compared. Underpinned by the tenets of descriptive phenomenology, we explored and compared the experiences of patients in three differentiated service delivery models using the National Health Services’ Patient Experience Framework. Data were collected from 68 purposively selected people living with HIV receiving care in facility adherence clubs, community adherence clubs, and quick pharmacy pick-up. Using the constant comparative thematic analysis approach, we compared themes identified across the different participant groups. Compared to facility adherence clubs and community adherence clubs, patients in the quick pharmacy pick-up model experienced less information sharing; communication and education; and emotional/psychological support. Patients’ positive experience with a differentiated service delivery model is based on how well the model fits into their HIV disease self-management goals.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Adolescent girls and young women’s PrEP-user journey during an implementation science study in South Africa and Kenya

Abstract:

Successful scale-up of PrEP for HIV prevention in African adolescent girls and young women (AGYW) requires integration of PrEP into young women’s everyday lives. We conducted interviews and focus group discussions with 137 AGYW PrEP users aged 16–25 from South Africa and Kenya. Individual and relational enablers and disablers were explored at key moments during their PrEP-user journey from awareness, initiation and early use through persistence, including PrEP pauses, restarts, and discontinuation. PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service, but hampered by low awareness, stigma and misconceptions about PrEP in the community. Daily pill-taking was challenging for AGYW due to individual, relational and structural factors and PrEP interruptions (intended or unintended) were described as part of AGYW’s PrEP-user journey. Disclosure, social support, adolescent-friendly health counseling, and convenient access to PrEP were reported as key enablers for PrEP persistence.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

Implementation and Scale-Up of Integrated Depression Care in South Africa: An Observational Implementation Research Protocol

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

Authors:

John A.Naslund, Jasmine Kalha, Juliana L. Restivo, Ishmael Amarreh, Tamora Callands, Hongtu Chen, Carlos Gomez-Restrepo, Hesham M. Hamoda, Arjun Kapoor, Sue Levkoff, Jones Masiye, Maria A. Oquendo, Vikram Patel, Inge Petersen, Ozge Sensoy Bahar, Laura Shields-Zeeman, Fred M. Ssewamala, Deepak Tugnawat, José Miguel Uribe-Restrepo, Lakshmi Vijayakumar, Bradley H. Wagenaar, Milton L.Wainberg, Larry Wissow, Haja Ramatulai Wurie, Chifundo Zimba, & Soumitra Pathare

^{University of Washington affiliated authors are displayed in bold.}

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Published: January 2021

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Read the full text in the open access journal PLOS Global Public Health

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Read the full text in the open access journal Implementation Science Communications

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Background

Methods

Results

Conclusion

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Read the full text in the open access journal Digital Health

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Read the full text in the open access journal Community Mental Health Journal

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Read the full text in the open access journal BMC Health Services Research

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Methods

Results

Conclusion

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Read the full text in the open access journal Journal of the International Association of Providers of AIDS Care

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Read the full text in the open access journal Qualitative Health Research

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Read the full text in the open access journal PLOS ONE

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Read the full text in the subscription access journal Psychiatric Services

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Read the full text in the subscription access journal Asian Journal of Psychiatry