Strengthening integrated depression services within routine primary health care using the RE-AIM framework in South Africa.
Strengthening integrated depression services within routine primary health care using the RE-AIM framework in South Africa.
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DOI：
10.1371/journal.pgph.0002604
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发表时间：
2023
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在低收入和中等收入国家，将心理健康纳入常规初级卫生保健（PHC）服务是全球公认的，以改善其他疾病的健康结果，缩小心理健康治疗差距。然而，执行工作仍然是一项挑战。本研究的目的是确定实施策略，提高实施结果的循证抑郁症护理合作实施模式与常规PHC诊所服务在南非。一个迭代的，准实验性的，观察性的实施研究设计，结合达到，有效性，采用，实施和维护（RE-AIM）的框架，应用于评估实施结果的一个加强的一揽子实施战略（第二阶段）相比，初步评估的模型（第一阶段）。在南非夸祖鲁-纳塔尔省一个资源匮乏地区的10个初级保健诊所实施和评价了第一阶段一揽子计划，在19个初级保健诊所（包括最初的10个诊所）实施和评价了第二阶段强化一揽子计划。与第一阶段相比，诊断的服务使用者更有可能在第二阶段被转介接受咨询治疗（OR 23.15，SE = 18.03，z = 4.04，95%CI [5.03-106.49]，p < .001）。培训和使用经过验证的强制性心理健康筛查工具，包括现场教育推广和技术支持访问，是护士级诊断率的重要促进因素（OR 3.75，95% CI [1.19，11.80]，p = 0.02）。认为综合护理模式可接受的护士也更有可能成功诊断患者（OR 2.57，95%CI [1.03-6.40]，p = 0.043）。诊所咨询师的持续可用性与更大的转诊概率相关（OR 5.9，95%CI [1.29-27.75]，p = 0.022）。在这两个阶段，转诊服务使用者接受治疗的情况仍然令人关切，不一致的同地咨询服务与接受治疗的情况不佳有关。实施研究的重要性，为加强实施战略沿着级联的护理抑郁症护理整合在常规的初级保健服务中突出。
Integration of mental health into routine primary health care (PHC) services in low-and middle-income countries is globally accepted to improve health outcomes of other conditions and narrow the mental health treatment gap. Yet implementation remains a challenge. The aim of this study was to identify implementation strategies that improve implementation outcomes of an evidence-based depression care collaborative implementation model integrated with routine PHC clinic services in South Africa. An iterative, quasi-experimental, observational implementation research design, incorporating the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, was applied to evaluate implementation outcomes of a strengthened package of implementation strategies (stage two) compared with an initial evaluation of the model (stage one). The first stage package was implemented and evaluated in 10 PHC clinics and the second stage strengthened package in 19 PHC clinics (inclusive of the initial 10 clinics) in one resource-scarce district in the province of KwaZulu-Natal, South Africa. Diagnosed service users were more likely to be referred for counselling treatment in the second stage compared with stage one (OR 23.15, SE = 18.03, z = 4.04, 95%CI [5.03–106.49], p < .001). Training in and use of a validated, mandated mental health screening tool, including on-site educational outreach and technical support visits, was an important promoter of nurse-level diagnosis rates (OR 3.75, 95% CI [1.19, 11.80], p = 0.02). Nurses who perceived the integrated care model as acceptable were also more likely to successfully diagnose patients (OR 2.57, 95% CI [1.03–6.40], p = 0.043). Consistent availability of a clinic counsellor was associated with a greater probability of referral (OR 5.9, 95%CI [1.29–27.75], p = 0.022). Treatment uptake among referred service users remained a concern across both stages, with inconsistent co-located counselling services associated with poor uptake. The importance of implementation research for strengthening implementation strategies along the cascade of care for integrating depression care within routine PHC services is highlighted.