Barriers to and Facilitators of Integrated Primary Mental Health Care in South Africa

Thesis (Ph.D.)--University of Washington, 2019South Africa faces a staggering burden of syndemic HIV and chronic disease compounded by untreated mental illness. However, only one quarter of South Africans experiencing mental disorder have access to mental health treatment. Integration of mental health treatment into primary care may be an effective way to deliver essential services and improve health outcomes. Primary integration has been shown to cost-effectively improve health outcomes in high-resource settings, though in lower-resource settings the barriers to mental health integration remain largely undefined. Our objective was to identify determinants and potential cost-savings of successful integrated mental health service delivery in South Africa. The first study used data from patients with at least moderate depressive symptoms receiving care for chronic disease at primary health care facilities in Amajuba District, KwaZulu-Natal, South Africa. We observed whether nurses successfully detected the depressive symptoms and whether they made appropriate referrals. Nurses successfully detected depressive symptoms about half the time and referred under half of patients whose depression they detected. More depressed patients were more likely to be detected but not more likely to be referred once detected. The second study was guided by the Consolidated Framework for Implementation Research and combined data from interviews and questionnaires with professional nurses at primary health care facilities in Amajuba District, KwaZulu-Natal, South Africa. We used crisp set qualitative comparative analysis to determine whether factors like training and competency were necessary for successful service delivery. Nurses face significant staff shortages, demanding targets, and the expansion of PHC services. Competency was critical for appropriate care. We suggest several strategies to improve service delivery. The third study analyzed data from a trial of an integrated care model in North West Province, South Africa. Participants were adult patients living with HIV and at least moderate depression. We estimated health care use and expenditure over one year. We found that depressive symptom severity may drive use and cost in this context, and that patients with HIV and depression may be especially likely to suffer catastrophic out-of-pocket medical expense. Integrated care may eventually save health system and patient costs in this setting