Innovation summary

Chronic conditions like diabetes are associated with common mental disorders (especially depression and alcohol misuse). Yet in low- and middle-income countries, common mental disorders often go undetected and untreated.1 The goal of Primary Care 101 PLUS (PC 101+) is to close this gap by:

  • Equipping primary health care (PHC) practitioners to diagnose and treat comorbid common mental disorders within chronic care
  • Equipping lay health workers to counsel people with comorbid depression and chronic conditions

In order to meet these goals, pragmatic randomized control trials are measuring the effects of PC101+ on health outcomes for patients accessing anti-retroviral treatment (ART) and non-communicable disease care at 40 primary care clinics in South Africa.

Impact summary

  • PC101+ will be evaluated at 40 clinics in South Africa from 2015 to 2016

"When I began coming to the group knowing that I was HIV-positive, I looked down upon myself and I felt worthless and that I was not of value in life… I am now free again, and I have gained back confidence in myself."

 

Group Counseling Participant

 

Innovation details

PC 101+ brings together two task-sharing innovations:

  • Enhanced integrated chronic care guidelines and training for PHC practitioners (PC101)
  • Depression counseling guidelines for lay counselors

Enhanced PC101 integrated chronic care guidelines and training

PC101 is a nationally endorsed set of guidelines for treating common mental disorders and other chronic conditions within primary care. The guidelines and accompanying training are currently being rolled out in a number of pilot districts by the national Department of Health in South Africa.

In PC101+, the original PC101 guidelines and training have been strengthened:

  • Additional case studies demonstrate how depression and alcohol misuse can manifest in patients with other common chronic conditions (e.g. hypertension, diabetes, HIV/AIDS, tuberculosis)
  • Guidelines help practitioners manage stressed patients and identify and treat comorbid depression and alcohol misuse
  • Depression and alcohol misuse guidelines incorporate mhGAP guidelines
  • Guidelines include appropriate referral pathways for depression and alcohol misuse
  • Take-home pamphlets have been developed to promote mental health literacy
  • Training sessions for mental health have been extended from 1 to 4 sessions

Depression counselling guidelines and training for lay counselors

These guidelines have been adapted from a lay counselor interpersonal therapy (IPT) manual originally developed for group-based counseling in Uganda2. Adaptation took place over several phases:

  • Initial adaptation for the South African context
  • Testing among patients attending primary health care facilities in rural KwaZulu-Natal3
  • Further adaptation following formative work by PRIME on triggers of depression in chronic care patients and initial piloting4

The guidelines provide lay counselors with a stepped structure for each session and can be used in an individual or group context. The accompanying training is divided into two phases:

  • Phase 1: Lay counselors are equipped with basic counseling skills that have been shown to be effective within a task-shifting approach5:
    • Micro-counseling skills
    • Problem management (a lay-delivered version of problem-solving therapy)
    • Getting active (a lay-deliveredversion of behavioral activation used in cognitive behavioral therapy)
    • Healthy thinking (a lay-delivered version of cognitive behavior therapy)
  • Phase 2: Lay counselors are equipped with a structure and steps for each group or individual counseling session, as follows:
    • Initial referral session
    • Running an initial opening session
    • Psychoeducation
    • Identifying triggers
    • Assessment for further group vs. individual counseling
    • Running ongoing sessions, including closing sessions
    • Dealing with specific triggers of depression, drawing on problem management, healthy thinking and getting active strategies.

Key drivers

Integration with the policies, implementation structures, and priorities of the South African Department of Health

  • Department of Health has prioritized the implementation of integrated chronic disease management given the rising burden of chronic diseases in South Africa
  • PC101+ strengthens existing PC101 chronic care guidelines adopted by the Department of Health and leverages an existing cadre of HIV lay counselors to provide counselling for common mental disorders that are co-morbid with other chronic conditions, in alignment with South Africa’s shift from vertical disease management to integrated chronic disease management
  • Adoption of cascade method of training (whereby existing facility-level trainers employed by Department of Health are trained to further train facility-level staff) embeds the innovation within routine dissemination practices of the Department of Health

Use of evidence-based psychological interventions appropriate for delivery by lay workers

  • The guidelines provide counselors with a simple step-by-step guide for each session. Strong guidelines are particularly important given evidence suggesting that lay counselors in South Africa are prone to resorting to advice-giving6

Engagement of service users and providers

  • The innovation has the support of both service providers and service users at the district level, forming part of the district mental health care plan that has been developed through a consultative process with both service providers and service users at a district level

Challenges

Structural challenges

  • Limited time for clinical consultations and lack of adequate counseling space for the implementation of the adjunct counseling intervention have emerged as challenges during piloting

Mental health literacy and stigma

  • Stigma associated with mental conditions and poor mental health literacy may also be an obstacle to the identification and referral of service users with common mental disorders, as well as service users following up on referrals for counseling

Continuation

Future plans include the adoption of PC101+ by the Department of Health in South Africa as the strategy for integrating mental health care into the integrated chronic disease service delivery platform. Given that PC101 is being adopted by other African countries (e.g., Botswana), the strengthened PC101+ guidelines and adjunct lay counselor guidelines and support materials will be made available to other countries as well. Scale-up of the innovation is further planned through the PRIME project.

Partners

Funders

The development and evaluation of the innovation is being funded by two sources:

Department for International Development (DFID)

DFID provides funding through the PRIME (Programme for Improving Mental Health Care) research consortium, which has contributed to the development of the innovation and will assist in the evaluation of the health outcomes for non-communicable diseases.

National Institutes of Health (NIH)

NIH provides funding through COBALT (Comorbid Affective Disorders, AIDS/HIV and Long Term Health), a pragmatic cluster randomized control trial to evaluate the health outcomes for HIV+ patients on anti-retroviral treatment (ART).

Evaluation methods

The impact of the innovation will be assessed through pragmatic randomized control trials measuring health outcomes for ART patients (COBALT) and NCD patients (PRIME) in 2015-2016.

Cost of implementation

PC 101+ is currently costing the intervention and will evaluate its cost effectiveness.

Impact details

The trials will affect 40 clinics and 2,000 ART patients through COBALT and over 20 clinics and over 1,000 ART patients through PRIME.

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Country

South Africa

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