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

ENhancing Assessment of Common Therapeutic factors (ENACT) tool: adaptation and psychometric properties in South Africa

BACKGROUND: The ENhancing Assessment of Common Therapeutic factors (ENACT) tool measures a set of therapeutic competencies required for the effective psychological intervention, including delivery by non-specialists. This paper describes the systematic adaptation of the ENACT for the South African (SA) context and presents the tool's initial psychometric properties. METHODS: We employed a four-step process: (1) Item generation: 204 therapeutic factors were generated by SA psychologists and drawn from the original ENACT as potential items; (2) Item relevance: SA therapists identified 96 items that were thematically coded according to their relationship to one another and were assigned to six domains; (3) Item utility: The ENACT-SA scale was piloted by rating recordings of psychological therapy sessions and stakeholder input; and (4) Psychometric properties: Internal consistency and inter-rater reliability of the final 12-item ENACT-SA were explored using Cronbach's alpha and intraclass correlation co-efficient (ICC) for both clinical psychologists and registered counsellors. RESULTS: Although the original ENACT provided a framework for developing a tool for use in SA, several modifications were made to improve the applicability of the tool for the SA context, and optimise its adaptability other contexts. The adapted 12-item tool's internal consistency was good, while the inter-rater reliability was acceptable for both clinical psychologists and registered counsellors. CONCLUSION: The ENACT-SA is a reliable tool to assess common factors in psychological treatments. It is recommended that the tool be used in conjunction with assessment protocols and treatment-specific competency measures to fully assess implementation fidelity and potential mechanisms of therapeutic change

Prevalence of hypertension and its associated risk factors in a rural black population of Mthatha town,South Africa

The occurrence of hypertension has been increasing alarmingly in both low and middle-income countries. Despite acknowledging hypertension as the most common life-threatening risk factor for cardiovascular disease (CVD), a dearth of data is available on the prevalence, awareness, and determinants of hypertension in rural parts of South Africa. The principal aim of the current study is to determine the prevalence and associated risk factors of hypertension among a black rural African population from the Mtatha town of Eastern Cape Province. Methods: This was a cross-sectional study, and individuals over 18 years of age were randomly screened using a World Health Organization stepwise questionnaire. Sociodemographic information, anthropometric measurements, fasting blood glucose levels, and three independent blood pressure (BP) readings were measured. Blood pressure measurements were classified according to the American Heart Association guidelines. Univariate and multivariate analyses were performed to determine the significant predictors of hypertension. Results: Of the total participants (n = 556), 71% of individuals had BP scores in the hypertensive range. In univariate analysis, age, westernized diet, education, income, and diabetic status, as well as overweight/obese status were positively associated with the prevalence of hypertension

Barriers to alcohol and other drug treatment use among Black African and Coloured South Africans

Background: There are racial disparities in the use of alcohol and other drug (AOD) treatment services in South Africa but little is known about the factors contributing to these disparities. This study aimed to redress this gap through identifying differences in barriers to AOD treatment use among Black African and Coloured persons from Cape Town, South Africa. The Behavioral Model of Health Services Utilization was used as an analytic framework. Methods. A case-control design was used to compare 434 individuals with AOD problems who had accessed treatment with 555 controls who had not accessed treatment on a range of variables. Logistic regression procedures were employed to examine the unique profile of variables associated with treatment utilization for Black African and Coloured participants. Results: After controlling for the influence of treatment need and predisposing factors on treatment use, several barriers to treatment were identified. Greater awareness of treatment options and fewer geographic access and affordability barriers were strongly associated with an increased likelihood of AOD treatment use for both race groups. However, Black African persons were more vulnerable to the effects of awareness and geographic access barriers on treatment use. Stigma consciousness was only associated with AOD treatment utilization for Coloured participants. Conclusion: Differences in barriers to AOD treatment use were found among Black African and Coloured South Africans. Targeted interventions that address the unique profile of barriers experienced by each race group are needed to improve AOD treatment use by these underserved groups. Several strategies for improving the likelihood of treatment entry are suggested. © 2013 Myers; licensee BioMed Central Ltd

Effectiveness of early interventions for substance-using adolescents: Findings from a systematic review and meta-analysis

Background: Information on the impact of available interventions that address adolescent substance use and delinquency can inform investment choices. This article aims to identify and evaluate early interventions that target adolescent substance use as a primary outcome, and criminal or delinquent behaviours as a secondary outcome. Method: A systematic review of early interventions for adolescent substance use and behavioural outcomes was conducted. Results: We identified nine studies using specific search strategies. All but one of the studies reported the use of brief intervention strategies. Only seven studies contained information which allowed for the calculation of an effect size, and were therefore included in the meta-analysis. The overall effect size for all outcomes combined was small but significant (g = 0.25, p < 0.001). The overall outcome for substance use was also small but significant (g = 0.24, p < 0.001). For studies with behavioural outcomes, the overall effect size reached significance (g = 0.28, p < 0.001). In general, subgroup analysis showed that individual interventions with more than one session had a stronger effect on the outcomes of interest. Conclusions: Early interventions for adolescent substance use do hold benefits for reducing substance use and associated behavioural outcomes. Interventions are most promising if delivered in an individual format and over multiple sessions. One intervention in particular had large effect sizes. As all the interventions were tested in developed countries, further testing is needed in low- and middle-income countries where there is a lack of research on evidence-based interventions for adolescent risk behaviours. Additional recommendations for policy and practice are provided in this paper. © 2012 Carney and Myers; licensee BioMed Central Ltd

Feasibility and Acceptability of Screening and Brief Interventions to Address Alcohol and Other Drug Use among Patients Presenting for Emergency Services in Cape Town, South Africa.

Despite evidence from high income countries, it is not known whether screening and brief interventions (SBI) for alcohol and other drug (AOD) use are feasible to implement in low and middle income countries. This paper describes the feasibility and acceptability of a peer-led SBI for AOD-using patients presenting with injuries at emergency services in Cape Town, South Africa. Data were extracted from program records on the number of eligible patients screened and the number of program refusals. A questionnaire examined preliminary responses to the intervention for 30 patients who had completed the program and 10 emergency personnel. Peer counselors were also interviewed to identify barriers to implementation. Of the 1458 patients screened, 21% (305) met inclusion criteria, of which 74% (225) were enrolled in the intervention. Of the 30 patients interviewed, most (83%) found the program useful. Emergency personnel were supportive of the program but felt that visibility and reach could improve. Peer counselors identified the need for better integration of the program into emergency services and for additional training and support. In conclusion, with limited additional resources, peer-led SBIs for AOD use are feasible to conduct in South African emergency services and are acceptable to patients and emergency personnel

Social service offices as a point of entry into substance abuse treatment for poor South Africans

Background: In South Africa, district social service offices are often the first point of entry into the substance abuse treatment system. Despite this, little is known about the profile of people presenting with substance-related problems at these service points. This has a negative impact on treatment service planning. This paper begins to redress this gap through describing patterns of substance use and service needs among people using general social services in the Western Cape and comparing findings against the profile of persons attending specialist substance abuse treatment facilities in the region. Methods: As part of a standard client information system, an electronic questionnaire was completed for each person seeking social assistance. Data on socio-demographic characteristics, the range of presenting problems, patterns of substance use, perceived consequences of substance use, as well as types of services provided were analysed for the 691 social welfare clients who reported substance use between 2007 and 2009. These data were compared against clients attending substance abuse treatment centres during the same time period. Results: Findings indicate that social services offices are used as a way of accessing specialist services but are also used as a service point, especially by groups under-represented in the specialist treatment sector. Women, people from rural communities and people with alcohol-related problems are more likely to seek assistance at social service offices providing low threshold intervention services than from the specialist treatment sector. Conclusions: The study provides evidence that social services are a point of entry and intervention for people from underserved communities in the Western Cape. If these low-threshold services can be supported to provide good quality services, they may be an effective and efficient way of improving access to treatment in a context of limited service availability. © 2012 Harker Burnhams et al.; licensee BioMed Central Ltd

A task-sharing intervention for prepartum common mental disorders: Feasibility, acceptability and responses in a South African sample

Background: Peripartum common mental disorders (CMD) are highly prevalent in low- and middle-income countries (LMIC) such as South Africa. With limited public mental health resources, task sharing approaches to treatment are showing promise. However, little is known about the feasibility and acceptability of, as well as responses associated with problem-solving therapy (PST) for the treatment of prepartum CMD symptoms in South African public health settings. Aim: To investigate participants’ preliminary responses to a task sharing PST intervention, and to evaluate the feasibility and acceptability of the intervention. Setting: A Midwife and Obstetrics Unit attached to a Community Health Centre in a Western Cape district. Methods: Using mixed methods, 38 participants’ responses to a PST intervention, and their perceptions of its feasibility and acceptability, were explored. Primary outcomes included psychological distress (Self Reporting Questionnaire; SRQ-20) and depression symptoms (Edinborough Postnatal Depression Scale; EPDS). Semi-structured interviews were conducted three after the last session. Six stakeholders were also interviewed. Results: Significant reductions were seen on EPDS (Cohen's d = 0.61; Hedges g = 0.60) and SRQ-20 (Cohen's d = 0.68; Hedges g = 0.67) scores. The intervention's acceptability lay in the opportunity for confidential disclosure of problems; and in relieving staff of the burden of managing of patients’ distress. Barriers included lack of transport and work commitments. Conclusion: Results support task sharing PST to Registered Counsellors to treat antenatal CMDs in perinatal primary health care settings. Research is needed on how such programmes might be integrated into public health settings, incorporating other non-specialists

Service Providers Perspectives on Personal Recovery from Severe Mental Illness in Cape Town, South Africa: A Qualitative Study.

Severe mental illnesses (SMI) contribute significantly to the global burden of disease. In low-and-middle-income countries (LMICs), the treatment gap impacts the clinical and personal recovery of people living with an SMI. The drive to reduce this treatment gap in LMICs makes it pertinent to understand service providers’ views on recovery from SMI. Semi-structured interviews and focus groups with service providers from health services and non-profit organisations in the Western Cape Province, South Africa, were conducted in this qualitative study. Seventeen participants were purposively selected, and data were thematically analysed. Three major themes emerged: delineating recovery, available services supporting recovery from SMI, and facilitators and barriers to recovery at the service level. Health services favoured clinical over personal recovery. Participants thought that many service users’ personal recovery from SMI was hindered by intersecting social, economic, cultural, and political inequalities that extended beyond the influence of the health sector

Development of a trauma-informed substance use and sexual risk reduction intervention for young South African women

Purpose: To develop a trauma-informed substance use and sexual risk reduction intervention for young South African women at risk of HIV. Patients and methods: Guided by the ADAPT-ITT framework for intervention development, we selected four focus groups (n=26) to assess the service needs and preferences of trauma-exposed young women (aged 18–25 years) who use substances. We used findings to develop a needs-based and contextually appropriate intervention. In addition four focus groups (n=30) were selected to explore potential service users’ views of this intervention and recommendations for improving acceptability and appeal. Expert stakeholders were also consulted. Results: Young women described therapeutic, self-care, and social support needs for coping with traumatic experiences and reducing substance-and sexual-related risks for HIV and further trauma. To address these needs, we expanded the Women’s Health Co-Operative (WHC; an evidence-based HIV prevention program) to include trauma-related psychoeducation; cognitive-behavioral strategies for coping with the emotional impact of trauma, stress, and substance use craving; social support strategies; and self-care components to help young women create a life with purpose. This novel and expanded six-session group-based intervention is called the trauma-informed WHC. Focus group participants and expert stakeholders viewed the trauma-informed WHC as highly relevant and acceptable. They provided recommendations for modifications to the intervention structure and reformatting of intervention materials to enhance the intervention’s appeal and the feasibility of reaching and retaining young women in the program. Conclusion: Engaging women as potential service users in the process of developing a trauma-informed substance use and sexual risk reduction intervention helped identify service needs not commonly addressed in trauma-informed substance use interventions but critical for recovery and local relevance. It also enhanced the acceptability and appeal of the intervention. While potentially acceptable, the trauma-informed WHC requires feasibility testing before establishing its efficacy in a larger trial