Many Southern African countries are confronted with the challenge of having to adapt their health systems to respond to a changing disease profile characterized by a rise in multiple chronic comorbidities. HIV, which is now considered a chronic condition, and tuberculosis are increasingly co-occurring with a rising burden of non-communicable diseases (NCDs). Included in this mix are Common Mental Disorders (CMDs), which interfere with adherence and self-care, compromising global investments in vaccines, medications and other treatments. The proposed scale-up study responds to the urgent need to generate knowledge of how best to scale up integrated evidence-based practices for CMDs into real- world primary health care (PHC) platforms for multiple chronic diseases in resource- constrained settings. Our proposed study will be layered onto the ongoing scale-up of our task-shared, evidence-based package for integrating care for CMDs into this integrated chronic care system in PHC facilities with the following specific aims:
Aim 1 : Utilize the RE- AIM framework to examine the reach, effectiveness, adoption, implementation and maintenance of scale-up in the two different real-world district contexts.
Aim 1. 1: Track RE- AIM outcomes in implementing facilities;
Aim 1. 2: Engage in continuous quality improvement at facility and district levels. We will examine indicators of mental health screening, referral, treatment uptake, adherence, quality of care; health care worker training, knowledge, attitudes and satisfaction; patient outcomes and satisfaction; cost impact; and organizational integration.
Aim 2 : Utilize the Consolidated Framework for Implementation Research (CFIR) framework to examine and adapt to multi-level factors that influence implementation in the two different real-world district contexts.
Aim 2. 1: Identify and assess multi-level factors affecting package implementation;
Aim 2. 2: Engage health system managers and planners at district, provincial and national levels in a participatory process to propose adaptations for continued efficient implementation. We will conduct key informant interviews in high-, medium- and low-performing clinics to identify multi-level factors and engage stakeholders in a participatory process.
