Applying learning health systems thinking in codeveloping integrated tuberculosis interventions in the contexts of COVID-19.

The COVID-19 pandemic reversed much of global progress made in combatting tuberculosis, with South Africa experiencing one of the largest impacts on tuberculosis detection. The aim of this paper is to share our experiences in applying learning health systems (LHS) thinking to the codevelopment of an intervention improving an integrated response to COVID-19 and tuberculosis in a South African district. A sequential partially mixed-methods study was undertaken between 2018 and 2021 in the district of Amajuba in KwaZulu-Natal. Here, we report on the formulation of a Theory of Change, codesigning and refining proposed interventions, and piloting and evaluating codesigned interventions in primary healthcare facilities, through an LHS lens. Following the establishment and formalisation of a district Learning Community, diagnostic work and a codevelopment of a theory of change, intervention packages tailored according to pandemic lockdowns were developed, piloted and scaled up. This process illustrates how a community of learning can generate more responsive, localised interventions, and suggests that the establishment of a shared space of research governance can provide a degree of resilience to facilitate adaption to external shocks. Four main lessons have been gleaned from our experience in adopting an LHS approach in a South African district, which are (1) the importance of building and sustaining relationships, (2) the utility of colearning, coproduction and adaptive capacity, (3) the centrality of theory-driven systems strengthening and (4) reflections on LHS as a framework.

Identifying multilevel and multisectoral strategies to develop a Theory of Change for improving child and adolescent mental health services in a case-study district in South Africa.

BACKGROUND: The lack of child and adolescent mental health (CAMH) policies and implementation plans constitute major barriers to CAMH services in low resource settings. Engaging with on-the-ground stakeholders to identify possible contextually appropriate strategies for developing a CAMH collaborative system and inform CAMH plans and policies is important to ensure that resultant policies and plans are feasible and appropriate. Together with key stakeholders across multiple sectors, this study aims to (i) co-identify causal factors and potential strategies to overcome bottlenecks in one district in SA as a case study; and (ii) Co-develop a Theory of Change (ToC) for increasing access to CAMH services within the resource constraints of a remote resource-scarce district as a case study. METHODS: A participatory workshop was held with key stakeholders (n = 40) from the Departments of Health (DoH), Basic Education (DBE), and Social Development (DSD) and three community-based organisations offering CAMH services in the district. The stakeholders identified context-specific causal factors and possible strategies to address the bottlenecks in the workshop. All the factors identified in the workshop were compared and consolidated. A ToC map was developed based on the data obtained from the workshop. The ToC was further refined by conducting a follow-up virtual workshop with stakeholders (n = 15). RESULTS: Mapping out the strategies identified in the workshop facilitated the development of a ToC model for the resource-scarce context. Key multilevel and multisectoral task-sharing strategies emerged in support of the development of a collaborative system of care that includes the development of (i) community awareness programs and user-friendly CAMH psychoeducation and screening tools to strengthen mental health literacy and facilitate early identification at the community level; (ii) an intersectoral working group to facilitate intersectoral collaboration (iii) a functional district CAMH referral system, (iv) youth-friendly CAMH care packages. CONCLUSIONS: In scarce-resource contexts, it is feasible to work collaboratively with key stakeholders across multiple sectors to identify feasible multilevel and multisectoral strategies that can be used to develop a ToC for improved access to CAMH services within a task-sharing approach.

How the 'HIV/TB co-epidemic-HIV stigma-TB stigma' syndemic impacts on the use of occupational health services for TB in South African hospitals: a structural equation modelling analysis of the baseline data from the HaTSaH Study (cluster RCT).

INTRODUCTION: Tuberculosis (TB) has become an occupational health hazard in South African hospitals where healthcare workers (HCWs) are additionally confronted daily with HIV and its associated stigma, causing a syndemic. Early TB diagnosis and treatment are vital, but the uptake of these services through occupational healthcare units (OHUs) is low. The current study hypothesises that (1) the link between HIV and TB and (2) the perceived HIV stigmatisation by colleagues create (3) a double HIV-TB stigma which increases (4) internalised TB stigma and leads to (5) a lower willingness to use OHU services for TB screening and treatment. DESIGN: A cross-sectional study using the baseline data from the HIV and TB Stigma among Healthcare workers Study (HaTSaH Study). SETTING: Six hospitals in the Free State province of South Africa. PARTICIPANTS: 820 HCWs of the six selected hospitals. RESULTS: The study results demonstrate that the co-epidemic (ß=0.399 (screening model) and ß=0.345 (treatment model)) combined (interaction effect: ß=0.133 (screening) and ß=0.132 (treatment)) with the persistent stigmatisation of HIV is altering the attitudes towards TB (ß=0.345 (screening) and ß=0.400 (treatment)), where the stigmatising views of HIV are transferred to TB-illustrating the syndemic impact. Our model demonstrated that this syndemic not only leads to higher levels of internal TB stigma (ß=0.421 (screening) and ß=0.426 (treatment)), but also to a lower willingness to use the OHU for TB screening (probit coefficient=-0.216) and treatment (probit coefficient=-0.160). Confidentiality consistently emerged as a contextual correlate of OHU use. CONCLUSIONS: Theoretically, our results confirm HIV as a 'syndemic generator' which changes the social meaning of TB in the hospital context. Practically, the study demonstrated that the syndemic of TB and HIV in a highly endemic context with stigma impacts the intended use of occupational TB services. TRIAL REGISTRATION NUMBER: Pre-results of the trial registered at the South African National Clinical Trials Register, registration ID: DOH-27-1115-5204.

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health.

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

Stakeholders' perceptions of child and adolescent mental health services in a South African district: a qualitative study.

BACKGROUND: In order to develop a district child and adolescent mental health (CAMH) plan, it is vital to engage with a range of stakeholders involved in providing CAMH services, given the complexities associated with delivering such services. Hence this study sought to explore multisectoral dynamics in providing CAMH care in one resource-constrained South African district as a case study, towards informing the development of a model for district mental health plan and generating lessons for mental health systems strengthening to support CAMH services using the Health Systems Dynamics (HSD) framework. HSD provides a suitable structure for analysing interactions between different elements within the health system and other sectors. METHODS: Purposive sampling of 60 key informants was conducted to obtain an in-depth understanding of various stakeholders' experiences and perceptions of the available CAMH services in the district. The participants include stakeholders from the Departments of Health (DoH), Basic Education (DBE), community-based/non-governmental organizations and caregivers of children receiving CAMH care. The data was categorized according to the elements of the HSD framework. RESULTS: The HSD framework helped in identifying the components of the health systems that are necessary for CAMH service delivery. At a district level, the shortage of human resources, un-coordinated CAMH management system, lack of intersectoral collaboration and the low priority given to the CAMH system negatively impacts on the service providers' experiences of providing CAMH services. Services users' experiences of access to available CAMH services was negatively impacted by financial restrictions, low mental health literacy and stigmatization. Nevertheless, the study participants perceived the available CAMH specialists to be competent and dedicated to delivering quality services but will benefit from systems strengthening initiatives that can expand the workforce and equip non-specialists with the required skills, resources and adequate coordination. CONCLUSIONS: The need to develop the capacity of all the involved stakeholders in relation to CAMH services was imperative in the district. The need to create a mental health outreach team and equip teachers and caregivers with skills required to promote mental wellbeing, promptly identify CAMH conditions, refer appropriately and adhere to a management regimen was emphasized.

Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers.

BACKGROUND: HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. METHODS: Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. RESULTS: The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. CONCLUSIONS: This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences. TRIAL REGISTRATION: South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Tuberculosis prevention knowledge, attitudes, and practices of primary health care nurses.

AIM: Tuberculosis (TB) continues to challenge global health systems, especially in South Africa. Nurses are especially vulnerable to TB exposure, because of their prolonged front-line contact with infected patients-especially in primary health care (PHC) clinics. Their infection control practices, influenced by key factors such as knowledge and attitudes towards TB prevention, become an important consideration. The aim of the study was to (1) describe the TB prevention knowledge, attitudes, and practices of PHC nurses in a South African district and (2) explore moderating factors on TB prevention practices. METHODS: A cross-sectional survey was undertaken at all 41 PHC facilities in Mangaung Metropolitan district, Free State province, South Africa, using self-administered questionnaires. Captured data were analysed to yield descriptive and multivariate statistics. RESULTS: Results suggest several instances of inadequate TB prevention knowledge, attitudes, and practices. Good TB practice was predicted by TB attitudes and knowledge, and the relationship between TB prevention knowledge and practices was not moderated by training, attitudes, or nurse category. CONCLUSION: Results echo previous indications that nurses often do not exhibit the desired knowledge, attitudes, and practices required to adequately protect themselves and others against TB and suggest further exploration towards understanding the influences on TB prevention practice among nurses.

Fighting stigma, promoting care: a study on the use of occupationally-based HIV services in the Free State Province of South Africa.

Fear of breaches in confidentiality and HIV-related stigma in the workplace have been shown to be primary concerns and potential barriers to uptake of HIV testing and treatment by health care workers (HCWs) at the Occupational Health Unit (OHU). In a context of human resource shortages, it is essential to investigate potential ways of reducing HIV-related stigma and promoting confidentially in the workplace. Using Structural Equation Modelling (SEM), baseline data of the "HIV and TB Stigma among Health Care Workers Study" (HaTSaH Study) for 818 respondents has been analysed to investigate (1) whether bottom-up stigma-reduction activities already occur; and (2) whether such grassroots actions can reduce the fear of breaches in confidentiality and HIV-related stigma - and thus indirectly stimulate the uptake of HIV services at the OHU. Results (aim 1) illustrate the occurrence of existing activities aiming to reduce HIV-related stigma, such as HCWs giving extra support to HIV positive co-workers and educating co-workers who stigmatise HIV. Furthermore, results of the SEM analysis (aim 2) show that the Fighting-stigma factor has a significant negative effect on HIV-related stigma and a significant positive effect on Confidentiality. Results show that the latent fighting-stigma factor has a significant positive total indirect effect on the use of HIV testing, CD4 cell count and HIV-treatment at the OHU. The findings reveal that the fear of breaches in confidentiality and HIV-related stigma can be potential barriers to the uptake of occupationally-based HIV services. However, results also show that a bottom-up climate of fighting HIV-related stigma can stimulate confidentiality in the workplace and diminish the negative effect of HIV-related stigma - resulting in an overall positive effect on the reported willingness to access occupationally-based HIV services.

Voices from the frontline: barriers and strategies to improve tuberculosis infection control in primary health care facilities in South Africa.

BACKGROUND: Tuberculosis (TB) infection control at primary healthcare (PHC) level remains problematic, especially in South Africa. Improvements are significantly dependent on healthcare workers' (HCWs) behaviours, underwriting an urgent need for behaviour change. This study sought to 1) identify factors influencing TB infection control behaviour at PHC level within a high TB burden district and 2) in a participatory manner elicit recommendations from HCWs for improved TB infection control. METHOD: A qualitative case study was employed. TB nurses and facility managers in the Mangaung Metropolitan District, South Africa, participated in five focus group and nominal group discussions. Data was thematically analysed. RESULTS: Utilising the Information Motivation and Behaviour (IMB) Model, major barriers to TB infection control information included poor training and conflicting policy guidelines. Low levels of motivation were observed among participants, linked to feelings of powerlessness, negative attitudes of HCWs, poor district health support, and general health system challenges. With a few exceptions, most behaviours necessary to achieve TB risk-reduction, were generally regarded as easy to accomplish. CONCLUSIONS: Strategies for improved TB infection control included: training for comprehensive TB infection control for all HCWs; clarity on TB infection control policy guidelines; improved patient education and awareness of TB infection control measures; emphasis on the active role HCWs can play in infection control as change agents; improved social support; practical, hands-on training or role playing to improve behavioural skills; and the destigmatisation of TB/HIV among HCWs and patients.

Health policy and integrated mental health care in the SADC region: strategic clarification using the Rainbow Model.

BACKGROUND: Mental illness is a well-known challenge to global development, particularly in low-to-middle income countries. A key health systems response to mental illness is different models of integrated health care, especially popular in the South African Development Community (SADC) region. This complex construct is often not well-defined in health policy, hampering implementation efforts. A key development in this vein has been the Rainbow Model of integrated care, a comprehensive framework and taxonomy of integrated care based on the integrative functions of primary care. The purpose of this study was to explore the nature and strategic forms of integrated mental health care in selected SADC countries, specifically how integrated care is outlined in state-driven policies. METHODS: Health policies from five SADC countries were analysed using the Rainbow Model as framework. Electronic copies of policy documents were transferred into NVivo 10, which aided in the framework analysis on the different types of integrated mental health care promoted in the countries assessed. RESULTS: Several Rainbow Model components were emphasised. Clinical integration strategies (coordination of person-focused care) such as centrality of client needs, case management and continuity were central considerations, while others such as patient education and client satisfaction were largely lacking. Professional integration (inter-professional partnerships) was mentioned in terms of agreements on interdisciplinary collaboration and performance management, while organisational integration (inter-organisational relationships) emerged under the guise of inter-organisational governance, population needs and interest management. Among others, available resources, population management and stakeholder management fed into system integration strategies (horizontally and vertically integrated systems), while functional integration strategies (financial, management and information system functions) included human resource, information and resource management. Normative integration (a common frame of reference) included collective attitude, sense of urgency, and linking cultures, though aspects such as conflict management, quality features of the informal collaboration, and trust were largely lacking. CONCLUSIONS: Most countries stressed the importance of integrating mental health on primary healthcare level, though an absence of supporting strategies could prove to bar implementation. Inter-service collaboration emerged as a significant goal, though a lack of (especially) normative integration dimensions could prove to be a key omission. Despite the usefulness of the Rainbow Model, it failed to adequately frame regional governance aspects of integration, as the SADC Secretariat could play an important role in coordinating and supporting the development and strengthening of better mental health systems.

Power and Integrated Health Care: Shifting from Governance to Governmentality.

Integrated care occurs within micro, meso and macro levels of governance structures, which are shaped by complex power dynamics. Yet theoretically-led notions of power, and scrutiny of its meanings and its functioning, are neglected in the literature on integrated care. We explore an alternative approach. Following a discussion on governance, two streams of theorising power are presented: mainstream and second-stream. Mainstream concepts are based on the notion of power-as-capacity, of one agent having the capacity to influence another-so the overall idea is 'power over?'. Studies on integrated care typically employ mainstream ideas, which yield rather limited analyses. Second-stream concepts focus on strategies and relations of power-how it is channelled, negotiated and (re)produced. These notions align well with the contemporary shift away from the idea that power is centralised, towards more fluid ideas of power as dispersed and (re)negotiated throughout a range of societal structures, networks and actors. Accompanying this shift, the notion of governance is slowly being eclipsed by that of governmentality. We propose governmentality as a valuable perspective for analysing and understanding power in integrated care. Our contribution aims to address the need for more finely tuned theoretical frameworks that can be used to guide empirical work.