Centre for Research in Health systems

About

Globally, people living with severe mental conditions continue to become caught in cycles of acute psychiatric hospitalisation followed by discharge and re-hospitalisation. Evidence-based interventions in low-and-middle income countries (LMICs) that promote positive outcomes during these transitional periods remain limited. The South African context highlights a profound urgency to develop, test and implement effective, sustainable interventions that 1) support people living with severe mental conditions following discharge from acute psychiatric hospitalisation while 2) considering the country’s limited existing resources. By following a human-centred, health system strengthening approach, this study seeks to lay the foundation for a larger effectiveness implementation trial built on the foundations of co-development and sustainable integration.

Research

Overall aim

The overall aim of this research is to determine the feasibility of real-world implementation of a co-produced health system strengthening intervention in reducing hospital re-admission rates related outcomes among people living with severe mental illness following acute psychiatric hospitalisation in South Africa.

The specific study objectives are:

1. To generate understanding of multilevel health system influences on psychiatric re-admission amongst people living with severe mental conditions.
2. To co-develop an integrated, multilevel intervention programme that provides psychosocial, transitional support to people who have been hospitalised and discharged following an acute psychiatric event.
3. To test the feasibility of the co-developed intervention programme in reducing re-hospitalisation rates and improving well-being and functionality amongst people living with severe mental conditions and their families.

Design

A learning site was selected in consultation with the Department of Health (the central district of uMgungundlovu in KwaZulu-Natal). A human-centred design approach is followed, according to which the study has three phases, which unfold iteratively and are driven by a learning collaborative. The learning collaborative was set up between academic and government partners, with systematic inclusion of inputs from service users, their caregivers and families, healthcare providers, and healthcare managers.  

Phase 1: Mapping and exploration

During this phase, the public mental health system was mapped out in terms of service user flows, drawing from multiple data sources. This included focused ethnographies of people living with SMI who have been hospitalised following an acute psychotic event, and then discharged to community settings. Interviews and observations were conducted with participants, their caregivers, families, and community health worker (CHW). Interviews and focus group discussions were conducted with healthcare providers on primary and secondary levels of care, participatory process maps were completed of mental health service processes in different facilities, participatory workshops were conducted with a range of stakeholders, and data audits were undertaken of different hospital service levels. All data was compiled and workshopped within the learning collaborative, leading to the development of a causal loop analysis of health system bottlenecks across community, primary, secondary and tertiary levels.

Phase 2: Intervention co-development

Different elements of the intervention package, focused on key identified system challenges, were co-developed with relevant stakeholders during a series of workshops. Workshop proceedings were used to develop prototypes which were recurrently workshopped with stakeholders through the learning collaborative, until a mature package with broad consensus could be generated. Additional formative research was undertaken where needed.

The final intervention package includes tools, training, supervision and service quality improvement on hospital, primary healthcare, and community levels (illustrated below). On hospital level, a psychosocial rehabilitation toolkit and training for healthcare workers will be implemented to enhance in-hospital care and discharge readiness. Referral and linkage standard operating guidelines for SMIs will be integrated with an existing provincial referral policy, including improved discharge processes.

On PHC level, a training package will be implemented that focuses on the management of SMI, particularly psychotic episodes. The referral and linkage intervention will also be implemented. Within community health centres (CHCs), medication prescription processes will be strengthened in order to relieve pressure on hospitals.

On community level, a CHW will provide structured routine visits to the households, guided by a six-session programme that aims to improve mental health literacy and management skills through the use of culturally-appropriate illustrated vignettes. This is based on the Community Mental Health Education and Detection toolkit which in already being rolled out in the province, and allows for on-going monitoring of the mental state of a person, with detailed guidelines on further steps when necessary. Further, a self-directed toolkit will be used to empower caregivers in day-to-day management.