Article Text
Abstract
Background The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme’s Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC.
Methods We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5.
Results The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers . Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities.
Conclusions Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.
- theory of change
- qualitative comparative analysis
- routine longitudinal data
- programme theory
- mental health
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Footnotes
Handling editor Valery Ridde
Contributors EB was responsible for the conception and design of the study with substantial contributions from MDS, CL and BM. EB, CL, MDS, NL and MJ contributed to the design of the data collection instruments. The data were collected as part of the PRIME consortium evaluation in Nepal led by MJ and NL and assisted by PS. PS, NL and MJ assisted with the interpretation of the data and gave information about the context. EB conducted the analysis with support from CL and wrote the first draft of the paper. All authors were involved in the interpretation of the results, revising the manuscript critically for important intellectual content and reviewing the manuscript prior to submission.
Funding This study is an output of the PRogramme for Improving Mental health carE (PRIME). This work was supported by the UK Department for International Development (201446).
Disclaimer The views expressed do not necessarily reflect the UK Government’s official policies.
Competing interests None declared.
Patient consent Not required.
Ethics approval Permission was obtained from the managers of all 10 facilities to obtain facility-level data. This study was approved by Faculty of Health Sciences Human Research Ethics Committee, University of Cape Town (HREC 412/2011 and 247/2013) and the Nepal Health Research Council (NHRC 10/2013) and conformed to the principles embodied in the Declaration of Helsinki.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The raw data used during the current study are available from the corresponding author on reasonable request. The calibrated data analysed during this study is included in the online supplementary files. Additional data from PRIME can be accessed on request from www.prime.uct.ac.za in line with PRIME’s data sharing policies.