Adaptation of the Texas Christian University organisational readiness for change short form (TCU-ORC-SF) for use in primary health facilities in South Africa

Objectives The Texas Christian University Organisational Readiness for Change Scale (TCU-ORC) assesses factors influencing adoption of evidence-based practices. It has not been validated in low-income and middle-income countries (LMIC). This study assessed its psychometric properties in a South African setting with the aim of adapting it into a shorter measure. Methods This study was conducted in 24 South African primary healthcare clinics in the Western Cape Province. The TCU-ORC and two other measures, the Organisational Readiness to Change Assessment (ORCA) and the Checklist for Assessing Readiness for Implementation (CARI) were administered. The questionnaire was readministered after 2 weeks to obtain data on test–retest reliability. Three hundred and ninety-five surveys were completed: 281 participants completed the first survey, and 118 recompleted the assessments. Results We used exploratory factor analysis (EFA) to identify latent dimensions represented in the data. Cronbach’s alpha for each subscale was assessed and we examined the extent to which the subscales and total scale scores for the first and retest surveys correlated. Convergent validity was assessed by the correlation coefficient between the TCU-ORC, ORCA and CARI total scale scores. EFA resulted in a three-factor solution. The three subscales proposed are Clinic Organisational Climate (8 items), Motivational Readiness for Change (13 items) and Individual Change Efficacy (5 items) (26 items total). Cronbach’s alpha for each subscale was >0.80. The overall shortened scale had a test–retest correlation of r=0.80, p<0.01, acceptable convergent validity with the ORCA scale (r=0.56, p<0.05), moderate convergence with the CARI (r=39, p<0.05) and strong correlation with the original scale (r=0.79, p<0.05). Conclusions This study presents the first psychometric data on the TCU-ORC from an LMIC. The proposed shortened tool may be more feasible for use in LMICs. Trial registration number Results stage. Project MIND trial. Pan-African Clinical Trials Registry

Systematic review of feasibility and acceptability of psychosocial interventions for schizophrenia in low and middle income countries

Abstract Background In low and middle income countries there is evidence to suggest effectiveness of community-based psychosocial interventions for schizophrenia. Many psychosocial interventions have however been conceptualized in high income countries and assessing their feasibility and acceptability in low and middle income countries is pertinent and the objective of this review. Methods Six databases were searched using search terms (i) “Schizophrenia”; (ii) “Low and middle income or developing countries” and (iii) “Psychosocial interventions”. Abstracts identified were extracted to an EndNote Database. Two authors independently reviewed abstracts according to defined inclusion and exclusion criteria. Full papers were accessed of studies meeting these criteria, or for which more information was needed to include or exclude them. Data were extracted from included studies using a predesigned data extraction form. Qualitative synthesis of qualitative and quantitative data was conducted. Results 14 037 abstracts were identified through searches. 196 full articles were reviewed with 17 articles meeting the inclusion criteria. Little data emerged on feasibility. Barriers to feasibility were noted including low education levels of participants, unavailability of caregivers, and logistical issues such as difficulty in follow up of participants. Evidence of acceptability was noted in high participation rates and levels of satisfaction with interventions. Conclusions While there is preliminary evidence to suggest acceptability of community-based psychosocial interventions for schizophrenia in low and middle income countries, evidence for overall feasibility is currently lacking. Well-designed intervention studies incorporating specific measures of acceptability and feasibility are needed

COVID-19 experience of people with severe mental health conditions and families in South Africa

Background: People with severe mental health conditions, such as schizophrenia, and their family caregivers are underserved in low- and middle-income countries where structured psychosocial support in the community is often lacking. This can present challenges to recovery and for coping with additional strains, such as a pandemic.Aim: This study explored the experiences and coping strategies of people with lived experience of a severe mental health condition, and family caregivers, in South Africa during the initial stages of the coronavirus disease 2019 (COVID-19) pandemic.Setting: This qualitative study was conducted in the Nelson Mandela Bay District, Eastern Cape, South Africa, in the most restrictive period of the COVID-19 lockdown.Methods: Telephonic qualitative interviews were conducted with people with lived experience (n = 14) and caregivers (n = 15). Audio recordings were transcribed and translated to English from isiXhosa. Thematic analysis was conducted with NVivo 12.Results: Participants described negative impacts including increased material hardship, intensified social isolation and heightened anxiety, particularly among caregivers who had multiple caregiving responsibilities. Coping strategies included finding ways to not only get support from others but also give support, engaging in productive activities and taking care of physical health. The main limitation was inclusion only of people with access to a telephone.Conclusion: Support needs for people with severe mental health conditions and their families should include opportunities for social interaction and sharing coping strategies as well as bolstering financial security.Contribution: These findings indicate that current support for this vulnerable group is inadequate, and resource allocation for implementation of additional community-based, recovery-focused services for families must be prioritised

Strategies for supporting the implementation of a task-shared psychological intervention in South Africa's chronic disease services: qualitative insights from health managers' experiences of project MIND

BACKGROUND: Although evidence indicates that task-shared psychological interventions can reduce mental health treatment gaps in resource-constrained settings, systemic barriers have limited their widespread implementation. Evidence on how to sustain and scale such approaches is scant. This study responds to this gap by examining the experiences of South African health managers involved in the implementation of a task-shared counselling service for Project MIND. OBJECTIVES: To qualitatively describe managers' experiences of implementing the MIND programme and their insights into potential strategies for supporting sustained implementation. METHODS: Two focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with managers of urban and rural primary care facilities in the Western Cape province. All managers were female and 30-50 years old. FGDs and IDIs used an identical semi-structured topic guide to explore the experiences of the MIND programme and perceived barriers to sustained implementation. Normalisation process theory (NPT) guided the thematic analysis. RESULTS: Four themes emerged that mapped onto the NPT constructs. First, managers noted that their relational work with staff to promote support for the intervention and reduce resistance was key to facilitating implementation. Second, managers emphasised the need for staff reorientation and upskilling to foster openness to mental health practice and for adequate time for quality counselling. Third, managers underscored the importance of strengthening linkages between the health and social service sectors to facilitate delivery of comprehensive mental health services. Finally, managers recommended ongoing monitoring of the service and communication about its impacts as strategies for supporting integration into routine practice. CONCLUSIONS: Findings contribute to the emerging literature on strategies to support implementation of task-shared interventions in low- and middle-income countries. The findings highlight the leadership role of managers in identifying and actioning these strategies. Investing in managers' capacity to support implementation of psychological interventions is critical for scale-up of these mental health innovations

Peer-led recovery groups for people with psychosis in South Africa (PRIZE): protocol for a randomized controlled feasibility trial

BackgroundThe available care for people with psychosis in South Africa is inadequate to support personal recovery. Group peer support interventions are a promising approach to foster recovery, but little is known about the preferences of service users, or the practical application of this care model, in low and middle-income countries (LMIC). This study aims to assess the acceptability and feasibility of integrating peer-led recovery groups for people with psychosis and their caregivers in South Africa into existing systems of care, and to determine key parameters in preparation for a definitive trial.MethodsThe study is set in Nelson Mandela Bay Metropolitan district of the Eastern Cape Province, South Africa. The design is an individually randomised parallel group feasibility trial comparing recovery groups in addition to treatment as usual (TAU) with TAU alone in a 1:1 allocation ratio. We aim to recruit 100 isiXhosa-speaking people with psychosis and 100 linked caregivers. TAU comprises anti-psychotic medication-focused outpatient care. The intervention arm will comprise seven recovery groups, including service users and caregiver participants. Recovery groups will be delivered in two phases: a 2-month phase facilitated by an auxiliary social worker, then a 3-month peer led phase. We will use mixed methods to evaluate the process and outcomes of the study. Intervention acceptability and feasibility (primary outcomes) will be assessed at 5 months post-intervention start using qualitative data collected from service users, caregivers and auxiliary social workers, along with quantitative process indicators. Facilitator competence will be assessed with the GroupACT observational rating tool. Trial procedures will be assessed, including recruitment and retention rates, contamination, and validity of quantitative outcome measures. To explore potential effectiveness, quantitative outcome data (functioning, unmet needs, personal recovery, internalised stigma, health service use, medication adherence and caregiver burden) will be collected at baseline, 2 months and 5 months post-intervention start. DiscussionThis study will contribute to the sparse evidence on the acceptability and feasibility of peer-led and recovery-oriented interventions for people with psychosis in LMIC when integrated into existing care systems. Results from this feasibility trial will inform preparations for a definitive trial and subsequent larger scale implementation.Trial registrationRegistered at Pan-African Clinical Trials Register on 28th February 2022. PACTR202202482587686. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2149

“It’s all about asking from those who have walked the path”: Patient and stakeholder perspectives on how peers may shift substance use stigma in HIV care in South Africa

South Africa has the highest number of people with HIV (PWH) globally and a significant burden of co-occurring substance use disorder (SUD). Health care worker (HCW) stigma towards SUD is a key barrier to HIV care engagement among PWH with SUD. Support from peers—individuals with lived experience of SUD—may be a promising solution for addressing SUD stigma, while also improving engagement in HIV care. We evaluated the perceived acceptability of integrating a peer role into community-based HIV care teams as a strategy to address SUD stigma at multiple levels and improve patient engagement in HIV care. Patients and stakeholders (N = 40) were recruited from publicly-funded HIV and SUD organizations in Cape Town, South Africa. We conducted a quantitative assessment of stigma among stakeholders using an adapted Social Distance Scale (SDS) and patient perceptions of working with a peer, as well as semi-structured interviews focused on experiences of SUD stigma, acceptability of a peer model integrated into community-based HIV care, and potential peer roles. On the SDS, 75% of stakeholders had high stigma towards a patient with SUD, yet 90% had low stigma when in recovery for at least 2 years. All patients endorsed feeling comfortable talking to someone in recovery and wanting them on their HIV care team. Three main themes emerged from the qualitative data: (1) patient-reported experiences of enacted SUD and HIV stigmas were common and impacted HIV care engagement; (2) both patients and stakeholders considered a peer model highly acceptable for integration into HIV care to support engagement and address SUD stigma; and (3) patients and stakeholders identified both individual-level and systems-level roles for peers, how peers could work alongside other providers to improve patient care, and key characteristics that peers would need to be successful in these roles. Findings from this formative work point to the promise of a peer model for reducing SUD stigma among patients and HCWs within community-based HIV care teams in SA.https://doi.org/10.1186/s13722-022-00330-

Perceptions of psychosocial disability amongst psychiatric service users and caregivers in South Africa

Background: In many parts of South Africa there is little support for people with psychosocial disability caused by schizophrenia, beyond provision of psychotropic medications. Appropriate community-based psychosocial rehabilitation interventions are a crucial element of mental health service development. Objectives: This study aimed to use an explanatory model of illness framework to document experiences of illness, disability and recovery amongst service users with schizophrenia and their caregivers in a poorly resourced area in the North West Province. Data were used to provide recommendations for a contextually appropriate non-specialist facilitated group psychosocial rehabilitation intervention. Method: Eighteen in-depth individual interviews were conducted: nine with schizophrenia service users and nine with caregivers. Interviews were conducted by two trained field researchers; both clinical psychologists fluent in the first language of participants. All interviews were recorded, translated and transcribed. Data were thematically analysed using NVivo 9. Results: Participants linked the illness to witchcraft, poverty and stress. Family conflict was recognised in the course of the illness, causing stress and challenges for emotional well-being. Knowledge of diagnosis and biomedical treatment was minimal. Key factors recognised by service users as promoting recovery were the ability to work, and the support of traditional healers and religious structures. Conclusion: Based on the findings of this study, a group psychosocial rehabilitation intervention emerged as a recommendation, with the incorporation of psycho-education, adherence support, coping skills, and opportunities for income generation and productive activity. The importance of also enlisting the support of religious leaders and traditional healers in supporting recovery is emphasised

Bridging the gap: investigating challenges and way forward for intersectoral provision of psychosocial rehabilitation in South Africa

Background: Intersectoral collaboration between government sectors such as Health and Social Development and nongovernmental organisations (NGOs) in communities is crucial for provision of psychosocial rehabilitation (PSR) for those with severe mental illness. This study aims to provide recommendations for strengthening such intersectoral collaboration in South Africa and with relevance to other low and middle income countries (LMIC), particularly African countries. Methods: Twenty-four in-depth semi-structured interviews were conducted with 16 key informants from the South African Department of Health, two key informants from the Department of Social Development, four key informants from the NGO sector and one key informant from a service user organisation at national level. Framework analysis was conducted with NVivo 10 software. Results: Challenges to intersectoral work identified were lack of communication between sectors, problems delin eating roles, and each sector’s perception of lack of support from other sectors. Participant-identified strategies for addressing these challenges included improving communication between sectors, promoting leadership from all levels and formalising intersectoral relationships through appropriate written agreements; as well as ensuring that the available resources for PSR are effectively re-directed to district level. Conclusions: This study has outlined several directions for progress to address challenges for intersectoral working for PSR in South Africa. These may be of relevance to other LMIC, particularly those in Africa. Political will and a longterm view will be necessary to realise these strategies