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Table 2 Comparison of training provided to control and intervention clinics

From: Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial

Provider

Role

Training

Content of training

Method and timeframe

Control and intervention facilities

PHC nurses

Identifies, provides brief interventions and refers

Basic onsite PC101 training

Case scenarios used for training in the identification and management of common chronic diseases, including communicable diseases, NCDs (including hypertension), women’s health and mental health. Mental health components draw on the WHO’s mhGAP guidelines [67] and adopt a syndromic approach to mental health symptoms (such as stress, insomnia, suicidal thinking) with diagnostic algorithms and treatment checklists for depression

(1) PC101 master trainers train facility trainers who train PHC nurses at the facilities

(2) 12 weekly sessions over 12 weeks at facilities (2 of which are on mental disorders)

(3) Training uses case-scenario material of patients with chronic conditions, including co-morbid conditions

Intervention facilities

PHC nurses

Identifies, provides brief interventions and refers

Orientation and clinical communication skills training

(1) Overview of the system changes being made by the DoH in South Africa to accommodate the demands of integrated chronic care; their role as case managers within the collaborative-care model for depression

4 2-h interactive workshops at PHC facilities/regional training centre

(2) Orientation to patient-centred care and clinical communication skills necessary to implement patient-centred care

(3) Skills to manage patient emotions within the consultation; self-care including how to cope with their own emotions and burn-out

(4) Motivational interviewing skills to promote patient self-management

PC101 supplementary training in mental health

(1) Detection of depression and anxiety, psychoeducation and referral to counsellors and/or physician for consideration of psychotropic medication in the case of moderate to severe depression

(1) PC101 master trainers train facility trainers (2-day workshop) who train PHC nurses at the facilities

(2) Detection of risky alcohol use and brief intervention for harmful/hazardous drinking and for detoxification and referral to specialist rehabilitation programmes for dependency as per the mhGAP guidelines [68]

(2) 3 weekly sessions over 3 weeks at facilities, with an additional follow-up session 1 month later

(3) Assessment of suicide intent

 

(4) Patient review after 8 weeks to assess response to treatment and onward referral for specialist care as indicated by the mhGAP evidence-based guidelines for LMICs [68] if necessary following a treatment-to-target approach as contained in the collaborative-care model (see Fig. 3). Treatment to target involves tracking a patient’s symptom severity and adjusting or intensifying treatment should patients not show an improvement in symptoms following initial treatment [69]

(3) Training uses case scenarios case scenario material of chronic patients with co-morbid mental disorders

PHC physicians

Diagnoses, initiates and monitors response to psychotropic medication

Orientation and training in mhGAP/PC101

(1) Orientation to the importance of treating co-morbid depression

3 1-day workshops spread over 6 months

(2) Training in mhGAP guidelines

(3) Follow-up using case studies of patients

Behavioural health counsellors

Provides evidence-based counselling

Counselling training

(1) Manualised counselling package comprising 8 sessions (delivered individually or in groups)

1 week of off-site training; 1 week of peer-to-peer mentoring; in-vivo supervision by a psychologist of each session; weekly follow-up group supervisory sessions, augmented where possible by weekly individual supervision sessions

(2) Session 1: psychoeducation session on depression; the last session is a closure session; sessions 2-7 draw on problem solving and cognitive behavioural techniques, including behavioural activation to address the common triggers of depression and anxiety which, in this population, include poverty, interpersonal conflict, social isolation and avoidance, grief and loss, and stigma that emerged from qualitative interviews held with service users with depression during the formative phase of the PRIME project in South Africa in 2 provinces [70]. A prototype had been field tested in KwaZulu-Natal and positive results demonstrated in an individually randomised pilot trial [42, 71]; adherence session provides information on the chronic condition/s and chronic medication/s the patients may have as well as helping patients with adherence difficulties

(3) While developed to treat depression, the intervention has been found to promote improvements in global psychological functioning as well [42, 71], thus having the potential for trans-diagnostic effects, in line with evidence that diagnosis-specific cognitive-behavioural therapy has beneficial effects on untargeted co-morbid emotional disorders [72]

Specialists (psychologist/psychiatrist)

Training, supervision of counsellors

Orientation to task sharing

Psychologists (including interns and community service psychologists) orientated to their roles

One-off workshops

  1. NCD noncommunicable diseases, PHC primary health care, WHO World Health Organisation