Strengthening South Africa's health system through integrating treatment for mental illness into chronic disease care (Project MIND)

将精神卫生保健纳入初级卫生保健服务可以减少慢性传染病和非传染性疾病（NCD）的影响。与许多低收入和中等收入国家 (LMIC) 一样，南非 (SA) 面临着如何在可提供的服务有限的情况下减少传染病和非传染性疾病（包括精神障碍）的高患病率和影响的挑战。慢性病患者的精神障碍很重要，因为这些问题与治疗依从性差、疾病进展更快和治疗失败有关。由于治疗失败会增加卫生服务的使用和卫生服务成本，中低收入国家的慢性病护理必须扩大到包括精神卫生保健。事实证明，综合提供精神卫生服务和慢性病护理不仅可以改善获得精神卫生保健的机会，而且可以改善慢性病患者的心理健康。 。然而，对于如何以患者和提供者可接受的方式将精神卫生保健纳入慢性病服务以及如何在资源匮乏的情况下实施的方式了解有限，导致南澳服务的整合被推迟。综合心理健康和慢性病服务的提供也因服务应纵向整合还是横向整合的问题而被推迟。纵向一体化服务在同一地点提供，但精神卫生和慢性病服务由不同的卫生工作者骨干提供。横向综合服务由负责心理健康和慢性病护理的同一工作人员在同一地点提供。该项目的目标是通过评估当前将精神卫生服务纳入慢性病护理的能力和障碍，并比较南澳开普敦接受艾滋病毒或糖尿病治疗以及面临治疗失败风险的患者的纵向和横向一体化服务整合模式的有效性和成本效益，来回答这些问题。通过这个项目，我们希望找到一个可行、可接受和有效的模式，将心理健康服务纳入慢性病护理，并适用于其他中低收入国家。鉴于南澳和其他中低收入国家的疾病负担、治疗人群和治疗系统之间的相似性，这项研究的结果可能与其他中低收入国家的使用高度相关。该研究将分为两个阶段。在第一阶段，我们将与一系列艾滋病毒和糖尿病服务的医疗保健提供者进行深入访谈，以评估整合的障碍以及我们提出的服务整合模式的可行性和可接受性（目标 1）。这一阶段的研究结果将用于调整我们基于证据的心理健康服务包，以最佳地融入慢性病服务。在第二阶段，将进行整群随机对照试验。我们将选择 24 个 HIV 诊所和 24 个糖尿病诊所，随机分为垂直整合组、水平整合组或照常治疗（不整合）。我们将从每个诊所招募 25 名有治疗失败风险的患者（总共 1200 名患者）。研究注册后，现场工作人员将完成基线评估。从随机分配到垂直整合组或水平整合组的诊所招募的参与者将接受干预课程。所有参与者，无论其干预部门如何，都将被跟踪进行 6 个月和 12 个月的后续访谈。在这些访谈中，对干预措施不知情的现场工作人员将重新进行基线评估，并收集生物样本以评估慢性病的结果。此阶段的调查结果将用于评估我们提出的服务集成模型（目标 2-3）的相对有效性和成本效益。

Integrating mental health care into primary health care services could reduce the impact of both chronic communicable and non-communicable diseases (NCDs). Like many low- and middle-income countries (LMICs), South Africa (SA) faces the challenge of how to reduce the high prevalence and impact of communicable diseases and NCDs, including mental disorders where limited services are available. Mental disorders are important to address among patients with chronic diseases as these problems are associated with poor adherence to treatment, more rapid disease progression and treatment failure. As treatment failure increases the use of health services and health service costs, chronic disease care in LMICs must be expanded to include mental health care. The integrated delivery of mental health services and chronic disease care has been shown to not only improve access to mental health care but also the mental health of patients living with a chronic disease. . Yet, limited knowledge of how mental health care can be integrated into chronic disease services in ways that are acceptable to patients and providers and feasible to implement with few resources has delayed the integration of services in SA. The provision of integrated mental health and chronic disease services has also been delayed by questions about whether services should be vertically or horizontally integrated. Vertically integrated services are delivered at the same location, but mental health and chronic disease services are provided by separate cadres of health workers. Horizontally integrated services are delivered at the same location by the same staff are responsible for mental health and chronic disease care. The goal of this project is to answer these questions by assessing current capacity and barriers to integrating mental health services into chronic disease care and by comparing the effectiveness and cost-effectiveness of a vertically and horizontally integrated model of service integration among patients receiving treatment for HIV or diabetes and who are at risk for treatment failure in Cape Town, SA. Through this project we hope to identify a feasible, acceptable and effective model for integrating mental health services into chronic disease care that is applicable to other LMICs. Findings from this study are likely to be highly relevant for use in other LMICs given similarities between the burden of disease, treatment populations, and treatment systems in SA and other LMICs.The study will comprise two phases. In the first phase, we will conduct in-depth interviews with a range of healthcare providers in HIV and diabetes services to assess barriers to integration and the feasibility and acceptability of our proposed models of service integration (Aim 1). Findings from this phase will be used to adapt our evidence-based mental health service package for optimal integration into chronic disease services. In phase two, a clustered randomised controlled trial will be conducted. We will select 24 HIV and 24 diabetes clinics to randomise to a vertically integrated arm, horizontally integrated arm, or treatment as usual (no integration). We will recruit 25 patients at risk for treatment failure from each of these clinics (total 1200 patients). After study enrollment, a baseline assessment will be completed by a fieldworker. Participants recruited from clinics randomised to either the vertically integrated or horizontally integrated arm will then receive their intervention sessions. All participants, irrespective of their intervention arm, will be tracked for 6- and 12-month follow-up interviews. At these interviews, fieldworkers blinded to their intervention arm will re-administer the baseline assessment and biological specimens will be collected to assess for chronic disease outcomes. Findings from this phase will be used to evaluate the relative effectiveness and cost-effectiveness of our proposed models of service integration (Aims 2-3).