Innovation summary

With an estimated 510,000 new tuberculosis (TB) cases each year, Pakistan is ranked fifth among the highest burden countries for TB worldwide1. Tuberculosis control is a prominent public health priority within the country. In line with WHO’s ‘End TB Strategy’2, a focus on more innovative methodologies and integrative treatment approaches are needed to address the public health challenge. Generating more evidence to understand the relationship between TB treatment non-adherence and co-morbid mental conditions can inform new approaches to more effective and holistic care of TB-affected populations.

Existing literature on the relationship between TB and mental health suggests that patients with TB are at a higher risk for depression and anxiety, with prevalence estimates ranging between 42% - 52%3-4. The evidence for elevated rates of mental distress in populations with chronic conditions indicates a dire need to provide mental health care services to these patients.

This project’s primary goal was to develop and evaluate a practical and replicable model for integrating mental health screening and treatment services within healthcare settings in Karachi, Pakistan. As part of our objectives, the project:

  1. Established and evaluated the performance of an Integrated Practice Unit (IPU) for mental health services embedded within existing TB, diabetes and antenatal care programs in both public and private local provider settings
  2. Assessed perceptions and barriers to seeking mental health care among patients by undertaking qualitative research and engaging communities in improving awareness and decreasing stigma around mental health
Evaluating the process of integration is essential in generating evidence on best-practice techniques to improve mental health service uptake and effectiveness as well as treatment outcomes for chronic conditions in Pakistani healthcare settings.

Impact summary

  • A total of 3,500 patients with TB were screened for depression and anxiety received baseline treatment adherence counselling 
  • 1,057 (30%) of the total patients had symptoms of depression/anxiety, received a baseline session for mental health and were offered counselling services
  • 522 (49%) completed the mental health intervention and were no longer found symptomatic for depression and anxiety after re-screening

“This work highlights the importance of providing mental health care services to chronically ill patients, in order to have a positive impact on treatment outcomes” – Aneeta Pasha, PI.

Innovation details

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).

Capacity Building

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.

Screening

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-effectiveness

Time 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.   

Key drivers

Acceptability

  • As mental health screening was incorporated into the treatment plan for TB/ANC, patients were overall receptive to being screened for mental health and forthcoming about their issues
  • Moreover, adherence counselling pertaining to treatment plan helped develop rapport between the counsellor and the patient allowing for an easier transition to mental health screening 

Alignment of treatment plan

  • Aligning counselling sessions with TB treatment visits facilitated higher completion rates for the mental health intervention

Challenges

Management of patients at high flow facilities

  • Certain tertiary care facilities engaged for the program were high volume sites. A large number of patients visiting the facility combined with the relative complexity of the process flow made it challenging for the counsellor to track and deliver services to all the patients visiting the facility.

Lack of cooperation from facility staff

  • In certain instances, the existing staff at some facilities was uncooperative and would not direct patients towards the mental health counsellor as mandated by our protocol. This was eventually resolved by repeated meetings with the facility staff and reinforcement of standard operating procedures.

Management of paper-based database

  • Data was initially collected via paper forms making the maintenance and management of a large quantity of forms unwieldy and the monitoring of records difficult. This was eventually mitigated by the development of an mHealth application.       

Continuation

This innovation is in the process of scale up in partnership with the Global Health Directorate of the Indus Health Network (Karachi, Pakistan).

As part of the move to increase coverage, the programme’s mental health services are being integrated within primary health care clinics across the county and within priority public healthcare care programs for HIV, Diabetes and Antenatal Care.

Partners

Evaluation methods

The impact of the IPU was evaluated through:

  1. The value created for patients as measured through improved outcomes and well-being indicators
  2. The cost and time effectiveness for the program using Time Driven Activity Based Costing (TDABC)

Training and Supervision:

  • The program also evaluated lay health counsellors performance and retention of material after training through pre- and post-tests and role-playing exercises.
  • Periodic refresher trainings were provided to reinforce training content and techniques. The frequency of refresher trainings was determined by counsellor performance at the site and gaps highlighted during monthly meetings (e.g. If a counsellor’s performance evaluation indicated a score below 70%)
  • Fidelity and quality of the mental health intervention was ensured via weekly case discussion and supervisory visits by a Clinical Psychologist
  • Team meetings were held every month to provide a platform to discuss overarching issues and highlight gaps

Quality Control and Fidelity:

  • Standard of Procedures (SOPs) and performance checklists were developed for counselling, data collection and management prior to implementation
  • Adherence to the SOPs was ensured by weekly spot-checks by the programmatic team and monthly performance evaluations based on the checklist
  • Data reports were compiled and reviewed twice a week by the program team to track progress
  • Patient progress was closely monitored and they were reassessed on the AKUADS at the 4th and 6th session to evaluate the effectiveness of the intervention.

Cost of implementation

The administration of Time-Driven Activity-Based Costing (TDABC) estimated the operational cost of providing mental health treatment (4-6 counselling sessions per patient) as less than $USD 10 per patient. 

Impact details

  • 3,500 patients with TB were screened for Depression and Anxiety using the AKUADS-25 and given baseline treatment adherence counselling 
  • 1,057 (30%) were symptomatic (indicated by a score of 21 or higher on the AKUADS-25) and received a baseline session for mental health. All patients who screened positive for depression and anxiety were offered counselling services
  • 522 TB patients with Depression and Anxiety symptomology were administered 4-6 sessions.
    • 100% of these patients attended and completed the mental health intervention and experienced a reduction in their AKUADS score, indicating that they were no longer symptomatic for Depression and Anxiety  
  • 94% of the patients with depression and anxiety who completed the mental health intervention completed TB treatment
    • This was in contrast to the 69% TB treatment completion rate in the patients who did not complete the mental health intervention
Preliminary findings from the project suggest some evidence for a positive relationship between mental health counselling for depression and anxiety and improved TB treatment outcomes. More conclusive results are expected after the final evaluation of the programme additionally including health centres for diabetes and antenatal care. 

References

  1. Munir M K et al. (2018) Meeting the Challenge, Making a Difference: Multidrug Resistance Tuberculosis in Pakistan. Pakistan Journal of Medical Research, 57(1):1-2 [Link]
  2. World Health Organization (2015). The End TB Strategy [Link]
  3. Walker I F et al. (2018) Depression among multidrug-resistant tuberculosis patients in Punjab, Pakistan: a large cross-sectional study, The International Journal of Tuberculosis and Lung Disease, Volume 22 (7): 773-778 [Link]
  4. Ambaw F et al. (2017) Burden and presentation of depression among newly diagnosed individuals with TB in primary care settings in Ethiopia. BMC Psychiatry, 17 (57) [Link]
  5. Van Harten WH (2018) Turning teams and pathways into integrated practice units: Appearance characteristics and added value. International journal of care coordination, 21(4):113-6 [Link]
  6. Keel G et al. (2017) Time-driven activity-based costing in health care: A systematic review of the literature. Health Policy, 121(7):755-63 [Link]

Research

Tools

Associates

Aneeta Pasha PI

Comments

Submitted by Norman Gustavson on Wednesday, 6th February 2019
I am trying to find measures of treatment progress for the client to fill out. Like the PHQ-9 for depression might work for depression. looking for a more general measure of progress in mental health treatment. Any suggestions much appreciated. working in Afghanistan.
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