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Background: Maternal mental health care is a neglected area in low and middle income countries (LAMIC) such as South Africa, where maternal and child health care priorities are focused on reducing maternal and infant mortality and promoting infant physical health. In the context of a paucity of mental health specialists, the aim of this study was to understand the explanatory models of illness held by women with maternal depression with the view to informing the development of an appropriate counselling intervention using a task sharing approach., Methods: Twenty semi-structured qualitative interviews were conducted with mothers from a poor socio-economic area who were diagnosed with depression at the time of attending a primary health care facility. Follow-up interviews were conducted with 10 participants in their homes., Results: Dimensions of poverty, particularly food and financial insecurity and insecure accommodation; unwanted pregnancy; and interpersonal conflict, particularly partner rejection, infidelity and general lack of support were reported as the causes of depression. Exacerbating factors included negative thoughts and social isolation. Respondents embraced the notion of task sharing, indicating that counselling provided by general health care providers either individually or in groups could be helpful., Conclusion: Counselling interventions drawing on techniques from cognitive behavioural therapy and problem solving therapy within a task sharing approach are recommended to build self-efficacy to address their material conditions and relationship problems in poorly resourced primary health care facilities in South Africa.

Introduction: A task-sharing collaborative care model for integrated depression care for South Africa's burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges. Methods: The Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of 'modifications made' and 'actual implementation' introduced in the 'Getting messier with TIDieR' framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts. Results: In the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger. Conclusion: The need for in-country co-designed collaborative care models, and 'implementation heavy' implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted. [ABSTRACT FROM AUTHOR]

An amendment to this paper has been published and can be accessed via the original article. [ABSTRACT FROM AUTHOR]

Background: In the context of a large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists in low- and middle-income countries, there is increasing evidence of the effectiveness of task sharing of counselling interventions to increase access to mental health care for CMDs at primary health care level. This study evaluated the relationship between levels of exposure to a task-shared counselling intervention and psychosocial outcomes (depression, functional disability, internalised stigma and social support) in chronic care service users with comorbid depression in South Africa guided by the Medical Research Council process evaluation framework. Implementation and participant-level factors that promote greater exposure were also investigated. Method: The study design was a cohort study comprising of 173 participants referred by primary health care nurses for the task-shared counselling intervention. The study site comprised four primary health care facilities in a sub-district of the Dr. Kenneth Kaunda district in the North West Province of South Africa. The participants were assessed for psychosocial outcomes at three time points: baseline, 3 months and at 12 months. The number of counselling sessions each participant was exposed to was collected for each participant. Linear regression models were used to test the influence of counselling exposure on each of the psychosocial variables between baseline and endline. In-depth qualitative interviews were conducted on 29 randomly selected participants, stratified according to exposure to counselling sessions, and analysed using framework analysis. Findings: Findings from the cohort study indicated a significant reduction in depression severity at 12 months. Internalised stigma and functional disability improved from baseline to endline. Participants receiving 5–8 sessions have the greatest reduction in PHQ9 scores from baseline to endline (β = − 2.46, 95% CI − 5.06 to 0.15) compared to those with 0 sessions (β = − 0.51, 95% CI − 3.62 to 2.60, p = 0.064). The WHODAS scores decreased significantly more from baseline to endline among those who received 5–8 sessions (β = − 10.73, 95% CI − 19.86 to 1.59) compared to those with 0 sessions (β = 2.25, 95% CI − 8.65 to 13.14, p = 0.021). No significant differences as a function of levels of counselling exposure from baseline to endline was observed for OSS-3 scores. An improvement in ISMI scores from 1–4 sessions to 5–8 sessions was found (β = − 4.05, 95% CI − 7.30 to − 0.80, p = 0.015). The qualitative process evaluation indicated that the service was acceptable and accessible; but that session attendance was hindered by women's' caregiving burden, poor counsellor attributes and poor referral processes. Conclusion: Exposure to a greater number of sessions (5–8 sessions) was found to optimize functional ability, reduce stigma, and potentially reduce depression symptoms. In order to enhance session attendance, lay counsellor delivered psychosocial interventions need to pay attention to (i) counsellor selection criteria, particularly person-centred care qualities; and (ii) strengthening referral processes in contexts where mental health literacy is low. [ABSTRACT FROM AUTHOR]

Background: The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts. Methods: One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy). Discussion: Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders. [ABSTRACT FROM AUTHOR]