This section presents Phase three of the research which comprises health system stakeholder engagements. Following the brief introduction below, a description of multiple stakeholder engagements is provided, along with a discussion of the main outcomes thereof in terms of health system needs.
4.3.1 Introduction
Evidence suggests that health systems, described by the WHO as resources, institutions, and organisations aimed at improving health through responsive, affordable, and quality healthcare, play an important role in making health service interventions more accessible to low-resourced communities in LMICs (Semrau et al., 2015). Therefore, a sustainable and scalable mental health intervention needs to form part of routine primary health care services. Cuipers et al., (2016) corroborate the importance of a thorough
investigation of health system processes to understand how best to integrate an intervention into primary health care. In the current study, multi-sector stakeholder meetings formed a critical part of the intervention development. This process involved iterative engagements at district, facility, and community levels. A breakdown of these processes is detailed in the following section.
4.3.2 Description of multiple stakeholder engagements
District-level decision makers included senior managers that represented the four sub- districts, with knowledge of facility and community health policies, processes, and challenges.
Meeting discussions and feedback confirmed the lack of, and need for, standardised routine maternal mental health counselling care. From these engagements, it emerged that a prominent primary health care challenge is the scarcity of professional human resources to deliver mental health counselling and the high workloads of lay health workers. In turn, senior managers indicated that primary healthcare systems were moving towards a community-based approach and that this involved phasing out facility-based lay health workers. In line with this approach, the National Department of Health introduced a new community-based programme to extend basic health services from the facility to the community. This initiative involved the rollout of the first national community health worker programme called “ward-based outreach teams”
(WBOTs). These teams consisted of CHWs trained by the Department of Health training centres to deliver integrated community-based health programmes, under the guidance of a professional nurse, called an “outreach team lead” (OTL).
Facility-level engagements involved various staff members responsible for the implementation of policies, procedures, and operations, such as facility managers, antenatal nurses, and lay counsellors. Feedback at this level suggested that depression and anxiety was a common occurrence amongst perinatal mothers, mainly due to contextual challenges associated with lowsocio-economic communities. In turn, the high workload of professional and lay health workers remained a common concern. Although some felt that the new initiative to introduce integrated care at house-hold level will require more time to get used to, offering counselling support at community-level was strongly supported and viewed as an opportunity to decant supportive services, and in this way, support facility-based functions.
Community-level collaborations involved managers and OTLs from NPOs linked to the respective facilities. Engagements with community organisations and service delivery role- players clarified the implementation details of the WBOTs and identified community-based
health counselling component to enhance existing integrated community-based treatment programmes. While the WBOT programmes include maternal mental health psychoeducation and a direct referral to the clinic, they lack an evidence-based counselling component. High workloads of non-specialist health workers were emphasised as an ongoing concern and careful thought had to be given to the type of evidence-intervention (difficulty level), training requirements, and length of the intervention design and duration of a session (Aitken, 2013).
Role-players, on all respective levels, considered the newly introduced community health worker programme as a suitable platform to introduce a mental health component and CHWs from WBOTs as the best suited delivery agent. The main drivers that supported these recommendations were as follows: The introduction of a brief task-sharing evidence-based counselling intervention can help to: (1) supplement the skills of CHWs already in contact with perinatal mothers through home-based visits, and (2) promote access to maternal mental health treatment for mild to moderate symptoms of perinatal depression and anxiety as part of routine care. The community health worker programme involves the delivery of integrated care programmes which include TB/HIV, hypertension, diabetes, and maternal and child health care (e.g., postnatal care and keeping track of clinic visits). To deliver these programmes, CHWs receive training that involves seven core community-based service delivery skills:
confidentiality and ethical work, health promotion, communication skills, screening, tracing and psychosocial support (empathic listening, containing, and referral). These skills set a firm foundation for developing further counselling skills, and therefore, could serve as a prerequisite for counselling training. The counselling intervention served to complement the WBOT in- service programme psychosocial component.
4.3.3 Main outcomes of stakeholder engagement and health system needs
While stakeholder recommendations on all three levels predicted the best suited delivery agent and setting, the duration of the intervention design had to be negotiated and adapted to align with health system needs. Informed by findings from the manual review and two evidence-based task-sharing study-led problem-solving interventions, an initial six-session intervention design was proposed as a suitable framework to integrate psychoeducation and behavioural activation components, as well as three problem-solving sessions and one termination session. However, all stakeholders expressed concern over the high workload of both professional and lay health workers. For example, facility-based health workers, such as Antenatal Care (ANC) nurses, expressed concern about their heavy workload and felt that large patient numbers allowed them limited time with each patient. Therefore, the integration of a
counselling component to the ANC portfolio was not feasible. CHWs were best suited, and motivated, to offer counselling support as part of their portfolio, however, on condition that the counselling programme complement the WBOTs community health worker portfolio and not extended their existing workload.
In addition to informing the overall intervention design collaborations with the relevant role-players promoted stakeholder buy-in and provided insights into health system management processes that could potentially support or challenge the integration of a maternal mental health counselling intervention into routine health care.
This concludes the introduction and discussion of Phases one (section 4.1), two (section 4.2) and three (section 4.3) and their related themes that emerged from the analysis of the data.
Building on the findings of these three phases, a pilot counselling intervention and training manual was developed. This is described in more detail in the sections that follow.