An exploration of multilevel factors influencing the uptake of strengthened integrated depression care as part of routine primary health care services in KwaZulu-Natal, South Africa

In the context of a large treatment gap for depression in South Africa, integration of depression care into routine primary health care (PHC) using task sharing provides a potential strategy to enhance access to mental health care. The aim of this study was to understand multilevel factors that contributed to increased nurse referrals for depression counselling, but not increased adoption of the non-specialist clinic-based referral counselling service offered as part of routine PHC services in the KwaZulu-Natal province of South Africa. Guided by the Consolidated Framework for Implementation Research (CFIR), semi-structured key informant interviews (SSI) were conducted with a purposive sample of PHC providers non-specialist-counsellors and nurse practitioners and service users in receipt of non-specialist counselling services. A total of 45 interviews exploring health care providers’ and service users’ experiences of the strengthened MhINT intervention at a facility level were conducted. Factors that contributed to an increase in nurse referrals, included waiting room educational talks, linking service users directly to professional nurses (PNs) after screening positive on a Brief Mental Health (BMH) screening tool, and using the BMH in conjunction with the Adult Primary Care clinical guideline for diagnostic support. The limited adoption of the non-specialist counselling service observed was attributed to, inter alia , mental health counselling not being formally included in the scope of practice and reporting indicators of non-specialist counsellor responsibilities; lack of information provided to service users on the benefits of counselling; lack of appointments made for follow-up sessions; and inconsistent availability of the counselling service. Multilevel interventions are necessary to improve uptake of integrated mental health services within PHC. These include improving mental health literacy and utilisation of mental health screening tools. Formal inclusion of counselling services as a treatment for depression within the existing roles of PHC providers and provision of resources enabling such services is also recommended.