Services Flashcards
What is task-shifting?
When circumscribed components of care are delegated to existing or new cadres of worker who either have less training OR more narrowly focused training than specialists
What is task-sharing?
When task-shifting is done with ongoing support and input from specialist mental health care
What is the predominant benefit of task-sharing?
Addressing the treatment gap
- between need for mh care in community and availability of care
What is the treatment gap for people with severe mental disorders in many low-income countries?
Treatment gap of 90%
- fewer than 10% receive evidence-based treatment
Why should specialist mental health care be shared with generalist health workers?
- Generalist health workers are much more numerous than specialists
AND they’re located in more accessible health facilities - there will never be enough specialists to meet the need of the community
What are four potential benefits of task-sharing?
- Increase access to care
- Cheaper and more efficient use of human resources
- More acceptable care
- Integrate both mental and physical health services
How would task-sharing result in more acceptable care?
Trained primary healthcare workers will keep people closer to their existing supports and social world
What is the limit of the evidence base of the mhGAP intervention guide treatments?
The evidence base is for the clinical guidelines
NOT for effectiveness of task-sharing service model
Who can be the targets of mental health task-sharing?
- Generalist health worker
- Community members
- Family members
- Peers
- Traditional and religious healers
What are the general findings of the systematic review of Van Ginneken et al. (2013) on the task-sharing model of care?
> Low quality of evidence on task-sharing
- especially for service interventions (mhGAP, collaborative care models)
- limited evidence of symptom reduction for PTSD
- small effects on outcomes for dementia
- good quality evidence for reduced symptom severity in maternal depression
> Absence of evidence for severe mental disorders (e.g. psychosis)
Why may psychosis most benefit from task-shared care?
In psychosis:
- high level of disability and vulnerability to human rights violations
What are the reasons for the lack of research into task-sharing models for people with severe mental disorders?
Severe mental disorders:
- Need for clinical assessment (diagnosis, symptoms)
- Increased cost of the study (screening scale administered by lay interviewer)
- Scarcity of clinical researchers
- Controversy on patient’s capacity to consent (to treatment of participation to study)
- Stigmatising attitudes
What are the two main challenges with task-sharing?
Acceptability and feasibility
What did Padmanathan and De Silva (2013) find about the acceptability and feasibility of task-sharing for mental healthcare in LMICs?
- Task-sharing welcomed but not seen as easy fix
- Service users appreciated interventions but reported unmet needs
perhaps from narrow focus of interventions
Which challenges could there be with task-sharing (besides acceptability and feasibility)?
- Emotional burden on providers who have little support
- Lack of confidence in skills
- Need for ongoing supervision
- Need for incentivisation
- Limited resources
- Neglect of ongoing specialist support (because it’s expensive)
- Quality of care (with only short-term training for low-level PHWs)
- Fidelity to original intervention (task-shared cared that respects evidence-based version of therapy)
- Sustainability (ongoing enthusiasm depict routine practice)
- System barriers (e.g. staff turnover, medication supply, weak leadership, …)
What is the most significant challenge with task-sharing (besides acceptability and feasibility)?
System barriers
- e.g. staff turnover, medication supply, weak leadership, …
What is the Programme for Improving Mental health carE (PRIME)?
mhGAP implementation and study in 5 countries
South Africa, Uganda, Ethiopia, India, Nepal
Who are the stakeholders of the PRIME study?
- Ministry of Health
- WHO
- 3 NGOs
- KCL
- others
How is the mhGAP implemented in the PRIME study?
- Implementation in one district in each country
- Each country undertook an intensive period of formative work resulting in a mental healthcare plan
What are the three aims of the packages implemented in the PRIME study?
- Enable the health system
- Enable specialist mental health workers
- to provide appropriate supervision and support - Stimulate demand for the new service
What is particular about the packages’ implementation in the PRIME study?
The 5 countries don’t receive the same packages (from mhGAP)
- i.e some packages concern all 5, while other packages concern 1 or 2 countries
How is implementation evaluated in the PRIME study?
It uses different study designs:
- examining impact at different levels
- using pre- and post- intervention community survey
- facility detection survey
In PRIME, what would successful integrated services result in?
It should improve contact coverage between those in need and the service
What is contact coverage?
The % of people in need in the community who have contact with the service
In PRIME, what does the facility detection survey examine?
- How well practitioners (primary care workers) detect new cases of people with depression or alcohol problems
- Examine appropriateness of the initiated treatment
- > quality of care
What are the two types of evaluations in the PRIME study?
- Cohort study
2. Case study
What is the purpose of the cohort study in PRIME?
- Treatment of MNS disorders
- Examines individual benefits AND impact on functioning and economic status
What is the purpose of the case study in PRIME?
> For:
- processing data
- qualitative exploration
- documentation of contextual factors
> Examines:
- what did and didn’t work
- key drivers of success
- reasons for contextual variation across PRIME countries
What is the Task Sharing for the Care of Severe mental disorders in a low-income country (TaSCS) (Hanlon et al., 2016)?
RCT (non-inferiority trial) on integrating care for people with severe mental disorder in Butajira (Ethiopia)
- Change mental health care to the health centre (n = 162)
vs. - Continue having follow-up with psychiatric nurse (n = 162)
- Primary outcomes: 12 months
- Follow-up: 18 months
What is the disadvantage of the randomised controlled trial in the TaSCS study?
Less information on how to optimise implementation
Why was the participatory consultation with relevant stakeholders needed in TaSCS?
- To develop the model of task-sharing
- To guide the researchers in how to carry out the RCT
What were the findings of the participatory consultation with the relevant stakeholders in TaSCS?
Strong preference for primary care side of the RCT because of concern regarding transport costs
What is the shared premise of PRIME and TaSCS?
Integrate mental health into primary care for people with severe mental disorders
What were the shared aims of PRIME and TaSCS?
- Continuing care
- Physical health monitoring
- Family support
What were the differing characteristics between PRIME and TaSCS?
> PRIME:
- more ambitious approach
- includes community awareness programmes
- primary care workers take on role of diagnosis, assessment and initiation of care
> TaSCS:
- more conservative approach
- back-referral from specialist care
- potentially less accessible than PRIME model
- more potential to be long-term sustainable and achieve better quality of care
