Integrated Practice Units
An Integrated Practice Unit (IPU) model5 was utilized to embed mental health screening and counselling services within existing TB treatment healthcare programs. It utilizes a task shifting approach and uses lay counsellors for mental health service delivery.
Integrated practice units (IPU) offering mental health services were developed across public and private hospital settings in Karachi, Pakistan within six TB facilities (Sindh Government Hospital-Korangi, Sindh Government hospital-New Karachi, Jinnah Postgraduate Medical Centre, Indus Hospital-Korangi, Sehadmand Zindagi Centre-Korangi, Sehatmand Zindagi Centre-Malir).
Prior to the operationalization of the IPUs a batch of 10-15 lay health counsellors attended an intensive six-day training on mental health counselling. The training was conducted by a psychologist and focused on signs and symptoms of common mental health disorders, basic cognitive behavioural therapy techniques, stigma reduction, communication skills and mental health screening. The strongest candidates were selected from the training batch based on their pre and post-test scores as well as their participation and performance during the training for placement at the IPU to screen and provide free of cost treatment. Typically, one counsellor was assigned per site.
Additional training focusing on TB and Antenatal care was also was also provided to the selected counsellors equipping them with knowledge related to their disease area and cater holistically to the patients at their facility.
Under the supervision of a psychologist the lay health counsellors screened TB patients for depression and anxiety using the Aga Khan University Anxiety and Depression Scale (AKUADS), a 25 item screening tool that has been developed and validated for local patient populations. All patients received treatment adherence counselling and a baseline session on mental health, those found to be symptomatic for depression/anxiety (AKUADS score >=21) were offered 4-6 mental health counselling sessions. Data collection was initially done via paper forms, however the mHealth application; a bespoke data collection tool was developed to streamline data collection and was implemented across all sites between July-August 2017
Cost-effectivenessTime Driven Activity Based Costing (TDABC)6, a tool used to generate cost estimates through calculating the time required to perform activities in service delivery was conducted at three of the facilities (Indus Hospital-Korangi, Sehatmand Zindagi Centre-Korangi and Sehatmand Zindagi Centre-Malir) to evaluate the cost of incorporating mental health services through the IPU.
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