Scaling up an integrated primary mental health screening programme in South Africa through co-development and continuous quality improvement.

backgroundDespite global progress in developing integrated mental healthcare on primary healthcare level, particularly in low-and-middle income countries, descriptions of scaling-up efforts remain scarce. The aim of this study was two-fold. First, to describe a collaborative approach to embed a common mental health conditions screening tool and process within district primary health care systems in KwaZulu-Natal, South Africa. Second, to explore perceptions of participating frontline workers and policy makers of the barriers and facilitators to embedding the tool using this collaborative approach as part of a scale-up process.

methodsFollowing a participatory action research approach, a learning collaborative was established that involved (1) mental health service coordinators from each district of the province of KwaZulu-Natal (n = 11), (2) provincial managers and policymakers (n = 4), and (3) members of the local research team. The capacity building programme was co-developed during a series of participatory workshops, and the common mental health conditions screening tool and associated processes were implemented and workshopped iteratively. The development and implementation of this programme as part of scaling up the screening intervention was assessed drawing from workshop proceedings, individual interviews with district coordinators (n = 11), and a focus group discussion (n = 8). Data were transcribed verbatim and thematically analysed guided by the Consolidated Framework for advancing Implementation Research.

resultsThe participatory development and implementation process resulted in consensus building, curriculum development, situational analyses, training, and continuous quality improvement. The collaborative and co-development approach to the capacity building curriculum was broadly favoured. Outer Settings emerged in terms of a lack of formal guidance documents for district mental health services, limited intersectoral collaboration, and limited community mental health literacy. In terms of Inner Settings, mental health continued to be under-prioritised in district services, with a lack of ring-fenced funding and data monitoring systems. Regarding Individuals, PHC staff were less well-trained and did not always want to engage in mental healthcare, with limited opportunity for capacity development. In terms of Implementation Processes, the flexibility of programme was particularly well illustrated during the disruptions of COVID-19, and adaptations were added to the programme to help address mental health and containing leadership among primary healthcare workers. While this period resulted in virtual workshops, face-to-face meetings were favoured.

conclusionsThe scaling-up of an integrated primary mental health screening innovation requires capacity building among mid-level management, and a co-developed, collaborative programme built on continuous quality improvement provides promise in providing flexibility and communal problem-solving for more sustained implementation.