The development and feasibility of a community mental health education and detection (CMED) tool in the Amajuba District, KwaZulu-Natal, South Africa.

Abstract

Background Poor mental health literacy, misinformation about treatment and stigma result in low demand for mental health services in low-and middle-income countries. Community-based interventions that raise mental health awareness and facilitate detection of mental health conditions, are instrumental in increasing demand of available mental health services. The CMED tool was developed to provide psychoeducation on mental health conditions and identify people with potential mental health problems at a household level who may benefit from available mental health interventions.

Aims/Objectives Objectives of the study were 1) To develop the CMED Tool for adults for use by Ward-based Primary Health Care Outreach Teams (WBPHCOTs) in South Africa aligned with their roles of health promotion, screening and linkage to care; 2) To assess the accuracy of the CMED in identifying patients with a mental health problem and 3) to assess the feasibility of the CMED for use by WBPHCOTs and community members.

Methods The research was made up of three sub-studies 1) Formative study, 2) an Accuracy study 3) and a Feasibility study. The Formative study (Objective 1) involved engagement with the KwaZulu-Natal Department of Health (KZN DoH) to ensure co-creation of the CMED tool and alignment with routine WBPHCOT activities; adaptation of the CMED tool; review of the CMED vignettes and illustrations by a panel of local and international mental health care experts to establish contextual and cultural relevance; and process mapping and focus group discussions with WBPHCOTs in one district to establish cultural and contextual appropriateness as well as coherence and compatibility with existing community-based services. The Accuracy study (Objective 2) involved assessing the accuracy of the newly developed CMED against the validated Brief Mental Health screening tool as the gold standard in identifying individuals in households with possible mental health conditions at a community level. The Feasibility study (Objective 3) was assessed using Bowen et al.’s (2009) framework which informed the study design, interview tools and analysis. The feasibility study involved four phases: (1) observations of the CMED consultation to evaluate the administration of the tool; (2) semi-structured interviews with household member/s after the CMED was administered to explore experiences of the visit; (3) follow-up interviews of household members referred using the CMED tool to assess uptake of referrals; (4) and weekly focus group discussions with the community health team to explore experiences of using the tool. Framework analysis was used to inform a priori themes and allow inductive themes to emerge from the data.

Results The formative study resulted in a co-produced CMED tool consisting of five case vignettes and related illustrations to facilitate psychoeducation and detection of possible depression, anxiety, psychosis, harmful alcohol and drug use by WBPHCOTs. The tool was found to be culturally and contextually appropriate and aligned to the services provided by WBPHCOTs. The accuracy study found the CMED to perform at an acceptable level having a 79% sensitivity and 67% specificity. The feasibility study found the CMED to be acceptable to both community health teams and household members, demand for the tool was evident, implementation, practicality and integration within the existing health system were also indicated.

Conclusion Collectively, the formative, accuracy and feasibility studies that make up this thesis, provide a valid and feasible tool that enables community health workers to perform their functions at a household level of health promotion, screening and linkage to care in relation to mental health. It enables mental health to be practically integrated at a community level as part of primary health care services through a people-centered, task sharing approach. This approach is aligned to international guidelines (Sustainable Development Goals) and National policy (South African Mental Health Act and the National Mental Health Framework and Strategic Plan) which call for the integration of mental health into primary health care), as well as the South African District Health System model through the PHC re-engineering strategy and the community-oriented primary care model where care extends from primary health care facilities into the community.