Practice facilitation and supervision to strengthen depression treatment in primary care in Zimbabwe

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PROJECT SUMMARY Background: Worldwide, the majority of people with depression receive no treatment, despite the existence of evidence-based, low-cost treatments. In Zimbabwe, at least a third of people presenting to primary care screen positive for depression, but most cases go unrecognized and untreated. Research strategy: This study includes the development and pilot testing of an implementation strategy to improve uptake of clinical guidelines for depression diagnosis and treatment in primary care. It has three phases: 1) Assessment of current practice: In a sample of patients presenting to routine primary care (n=200), determine what percent of patients with probable depression are recognized by primary care nurses and offered treatment, 2) Adaptation of an implementation strategy: Using a human-centered design (HCD) approach, conduct qualitative interviews and hold focus groups with nurses to iteratively adapt a implementation strategy that combines in-person practice facilitation with mobile phone-based clinical supervision, 3) Pilot trial of the implementation strategy: In order to evaluate whether the implementation strategy is feasible and acceptable and to inform a future cluster randomized trial of the strategy, pilot test the strategy in two clinics (n=12 nurses, n=30 patients), comparing outcomes to two control clinics (n=12 nurses, n=30 patients). Outcomes include a) feasibility and acceptability of the implementation strategy (qualitative interviews, surveys, and program data), b) exploratory implementation outcomes (e.g. depression screening, recognition, treatment receipt), c) exploratory clinical outcomes: PHQ-9 score of patients at 6 and 12 weeks after initial visit, and d) feasibility of data collection strategy. Training plan: To conduct the proposed research and transition to being an independent investigator, Dr. Jack will receive mentorship and training in the following areas: 1) foundational understanding of methods for the design and analysis of clustered clinical trials, 2) implementation science with a focus on mixed methods, and 3) human-centered design. Mentorship: Dr. Jack’s primary mentor (Rao) brings expertise in implementation science and global mental health in primary care, which is complemented by her co-mentors who are experts in depression research in Zimbabwe (Chibanda) and mental health treatment guidelines and clinical trials in low and middle income-countries (Thornicroft). She also has a scientific advisory team (Dorsey, Hallgren, and Lyon) who will support her training and research in implementation science, clustered trial design, and HCD, respectively. Candidate: Dr. Jack combines clinical training in Internal Medicine with a research background that has focused on global mental health and the integration of behavioral health into primary care (42 publications, 15 as first author). This K23 builds on her eight years of prior research in Zimbabwe and will allow her the dedicated time for research and training required to become an independent, NIH-funded investigator in implementation science to address the behavioral health treatment gap worldwide.