Using Quality Improvement To Implement Substance Use Disorders Services In Primary Health Care In Kenya: Impact And Experiences Of A Blended Course Among Health Workers Using The NextGenU Online Model

Background: Worldwide, mental and substance use disorders (SUD) account for over 183.9 million disability adjusted life years. While interventions do exist they are not readily implemented, especially in low- and middle-income countries, due to a lack of available human resources, monetary resources, stigma, and difficulties in changing practice patterns. Quality Improvement (QI) has been reported in literature to successfully improve health services and systems through small-scale, iterative change cycles. Objectives: This study assessed the impact of the NextGenU.org online blended course in terms of integrating, improving and sustaining mental health services using quality improvement methods in primary health care in Kenya. It also analyzed the experience of participants who completed the NextGenU.org online blended course. Method: A mixed-methods study was conducted, incorporating both qualitative focus groups (FGD) and key informant interviews (KII), and quantitative statistical measures. Data came from the Computer-Based and Alcohol Training Assessment in Kenya (eDATA K), which was implemented in collaboration with the University of British Columbia (UBC) and African Mental Health Foundation (AMHF). FGDs and KIIs were analyzed using NVivo through a constant-comparison method, to identify themes emerging from the data. A second coder analyzed the data to ensure reliability and validity. Quantitative analysis was conducted to analyze the course completion rates. Additionally, the researcher incorporated their own notes from observations made during fieldwork over the course of a 12-week practicum with AMHF to triangulate the results. Results: Overall, 27 screeners and clinicians completed the NextGenU.org online blended course. There were two FGDS and two KIIs conducted in Makueni county during July - September 2015. In terms of the staff’s experience in completing the online course many participants noted strong facilitators such as: the certificates, desire for knowledge, personal motivations, relevant material, and case studies. The limited amount of space, computers, and restrictions on Internet access acted as barriers. Participants perceived their knowledge of QI methods, leadership, and time management to have increased from completing the course. Perceived self-efficacy also increased, as staff believed their ability to be a leader, manage time and deal with errors and mistakes within the workplace improved. There was also a positive shift in stigma associated with SUD. Most importantly, the integration and improvement in mental health services was maintained even though staff discussed common challenges, such as heavy workload and limited time. Some participants reported that some people in management roles should have been more supportive, as their limited involvement acts as a barrier to greater integration of services, while other where thankful of the management support. Conclusion: This is one of the first studies of using QI methods to integrate, improve and sustain mental health services in the primary health care system in Kenya. Based upon the experiences described in the FGDs and KIIs, the blended online course was perceived to be acceptable, feasible and successful. The results indicate that quality improvement continues to be integrated in Makueni overall improving mental health services

Primary care, public health and the intersectoral management of health determinants : a realist inquiry

Problem: International bodies such as the World Health Organization call on nation-states to more adequately address health determinants (HD) and strengthen primary healthcare through intersectoral action for health (IAH). Despite many leaders expressing the desire to strengthen IAH, in many countries, practitioners and policy-makers struggle to succeed. This study aims to deepen the understanding of how to maximize the impact on health and HD through collaborations between primary care providers (PCP), public health professionals (PHP), and representatives of sectors other than the health sector (ROS). Method: This research includes a supplementary analysis of a mixed-methods case study on Cuban IAH to clarify and compare the roles of the various actors of interest (PCP, PHP, ROS) in managing HD, including the contexts, mechanisms, and outcomes (CMO) in which IAH occurs in Cuba when involving those particular actors. This is followed by a knowledge synthesis of IAH interventions internationally, providing a variety of different contexts, which enables systematic comparison of the various CMO configurations extracted from those interventions, following a method inspired by realist synthesis. Data for the final CMO analysis and demi-regularity are drawn from both the Cuban case study and the other examples of IAH from around the world that involved PCP, PHP, and ROS. Conclusions: IAH involving PHP, PCP, and ROS can lead to significant, positive health outcomes through the management of HD. A key context in which significant improvement in HD and health outcome occurs is when the IAH are carefully planned based on prior evidence and best practices related to partnership building and public health. Key mechanisms of those interventions include: 1) systematic attention to infrastructures, and activities that successfully increase social capital; 2) which in turn supports the negotiation of complementary and synergistic roles between PCP, PHP and ROS, and 3) using cycles of adjustment based on best practices of quality improvement which enable cumulative and reinforcing synergies over time (years and decades), as projects unfold in complex changing policy and practice environments, and as the multiple actors increase their social capital and experience in dealing with health determinants.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat