Sample characteristics
Participants who took part in the study were aged between 26 to 35 years, they were 32.5% (n=65) and 25% were 25 or younger. The minority were 17.5% (n=35) were aged 36 to 45 and about 25% (n=50) were aged 46 and above. Females total up to 65% (n=130) while 35% (n=70) were males.
Number of years of experience of the participants was also taken into consideration, it was checked how many years as healthcare professionals, working in mental healthcare, PHC and HIV services, findings show that 40% (n=80) of participants had 2 to 5 years of experience while 22.5% (n=45) of the participants had 6 to 10 years of experience, and 15% (n=30) of the participants had 11 to 15 years of experience. A lesser number, 7.5% (n=15), had 16 to 20 years and a limited had 20 or more years of experience.
Then two to five years of experience were 50% (n=100), 14.5% (n=29) had six to ten years of experience, 7.5% (n=15) had 11 to 15 years of experience, and 5% (n=10) had 16 to 20 years of experience, in HIV services. Of the participants, 32.5% (n=65) had 2 to 5 years of experience while 26% (n=52) of the participants had 6 to 10 years of experience. 14% (n=28) of the participants had 11 to 15 years of experience, 22.5% (n=45) had 16 to 20 years of experience, and a mere 5% (n=10) had 20 or more years of experience.
The results obtained showed that, majority of participants, which was 71% (n=142), were mental health, primary health care, HIV trained nurses while 0.5% (n=1) of participants were psychiatrists, and 21.5% (n=43) were medical doctors. Only 11 (5.5) were psychologists.
When asked about the availability of guidelines for the implementation of a national mental health policy framework, 72.5% (n=145) agreed that there were guidelines available for the implementation of a national mental health policy framework. Regardless of the majority of the participants having been agreed on the availability of guidelines needed for implementation of a national mental health policy framework, 15% (n=30) disagreed that there were guidelines for the implementation of the national mental health policy framework existed for the implementation of the national mental health policy framework, they were claiming that it was all new to them there were such guidelines. 5% (n=10) remained neutral on the statement.
Participants were further asked by the researcher using statement “guidelines on the implementation of a national mental health policy framework were read and explained to me using simple language”, results revealed that most of the participants accepted that the guidelines on the implementation of a national mental health policy framework were read and explained to them,72.5% (n=145) of the participants agreed. However, 20% (n=40) disagreed, while 7.5% (n=15) remained neutral on the statement.
Participants responses to the question “I was given the opportunity to seek clarity on the guidelines or the available document for the implementation of a national mental health policy framework” results shows that 50% (n=100) agreed, 40% (n=80) disagreed, and 10% (n=20) refrained from responding to the statement.
The researcher further, asked the participants if the district personnel visited their facility to provide guidance on the available documentation for the implementation of a national mental health policy framework on the integration of mental healthcare services into HIV services. From the participants’ responses, it was congregated that 42.5% (n=85) agreed that the district personnel had visited in order to provide guidance on the available documentation for the implementation of a mental policy framework. However,40% (n=80), disagreed, stating that the district personnel have not visited to provide guidance on a mental health policy framework implementation.
When the participants about the organisation of workshops or in-service education to enlighten the participants about the implementation of a national mental health policy framework, 27.5% (n=55) remained neutral and did not respond to the statement. 40% (n=80) agreed that workshops or in-service training were conducted by employers to inform employees on the implementation of a national mental health policy framework. 32.5% (n=65) disagreed, stating that there were no workshops or in-service training that were run or in place to assist health professionals with the implementation of a national mental health policy framework.
All the health professionals that participated in this study, were asked were asked if the district and immediate supervisors did test and evaluations of the national mental health policy framework. The results obtained showed that there was almost a balance between the participants who responded positively and negatively. 37.5% (n=75) agreed, 17.5% (n=35) of the participants abstained from responding, and 40% (n=80) disagreed that testing and evaluation of the national mental health policy framework was done by the district and immediate supervisors.
Finally, participants were asked if there was a need to implement a national mental health policy framework on the integration of mental healthcare services into HIV services and the majority of the health professionals believed that there was a need to implement a national policy framework that integrates mental healthcare services into HIV services. 80% (n=160) agreed that there was a need for the integration of mental healthcare services into HIV services, 20% (n=40) disagreed.
Mean differences
ANOVA one-way test was run to determine mean differences in knowledge scores between mental health professionals of different years of service, results displayed that there were statistically significant differences between groups, with a p value of 0.000 (p=.00). The one-way ANOVA was then followed- up by running a Tukey’s honestly significant differences (HSD) post hoc test, also known as Tukey, since our data met the homogeneity of variances assumption. The aim was to control the experiment wise error rate (usually alpha=0.05). Post hoc comparisons using the Tukey HSD test indicated that the mean score of knowledge for the MHCPs with service number of years 2-5 and 20 years and above (p=0.00) was significantly different than mean difference between 2-5 and 16-20 (p=0.001). However, there were no differences between the groups of 2-5 and 16-20 years of service (p=0.992).
National Mental Health Policy Framework
The National Mental Health Policy Framework is a policy in line with the values and principles of the Alma Ata Declaration; mental health is an integral element of health.
The policy was developed through a consultative process with relevant stakeholders. All nine provinces held summits to review the state of mental health and mental health services in their province, to identify the best practices and to generate a roadmap for improving mental health. These consultations concluded in a national mental health summit where a draft of this policy framework was discussed and a declaration was made.
Integrating mental health into HIV services is unarguable. Challenges are apparent in implementing this integration that are cost-effective, and of high quality and sway. In LMICs, health systems are usually overreached due to poor mortal and monetary resources, and they are preoccupied with treating critical disorders, resulting in fragmented care and poor sustainability of health systems for mental disorders and HIV (Semrau et al., 2015). Studies reveal that in well developed countries health care systems are better at dealing with the lower overall burden of diseases. In well developed countries the integration of mental health care into HIV services has been initiated successfully with good results in decreasing the non-adherence of antiretroviral therapy as well as depression (Theron et al., 2015). Considering these reasons, it is highly recommended that the integration of mental health into HIV services must be facilitated.
Conceptual framework
Brynard (2009a) identified key factors that influence policy implementation. The key to successful policy implementation is understanding the specific situation where the policy initiative is to be put into practice This includes understanding the environment as well as those intended to implement. Implementation is a dynamic process which is shaped by the behaviours of the political and administrative role-players involved in the implementation (Brynard, 2009a). An extensive list of the factors that influence policy implementation include effective approach, positive commitment, cooperation, effective planning, effective resourcing, enthusiasm, leadership, location of political responsibility, management style, ownership, project team/management dynamic, role delineation, skills and abilities, stakeholders, trust, use of networks, and values or beliefs. Brynard (2009a).
Figure 1.2: Theory of organisational, process, personnel and environmental factors (Brynard, 2009b).
Using relevant literature, the study aimed to develop a model to facilitate a policy information cascade to ensure the integration of mental health into HIV services with a focus on the National Mental Health Policy Framework. The study used the Theory of organisational, process, personnel and environmental factors (Brynard, 2009b), to guide the study and to develop a model.
Model development
It was evident that there were no existing models which adequately address how the National Mental Health Policy Framework can be successfully implemented towards integrating mental health into HIV services at primary health care settings.
During workshops it was evident that health care practitioners had limited awareness about the existence of the National Mental Health Policy Framework.
I am not sure of that because I do not remember anybody talking to us about any that National Mental Health Policy Framework [Participant H].
Another participant said:
Even myself I am not sure of that because I do not remember anybody talking to us about that National Mental Health Policy Framework [Participant I].
Health care practitioners expressed concerns around a lack of communication and the cascading of information regarding the policy framework; they felt that it was the responsibility of their provincial and district managers to communicate the policy to their local level managers who would then cascade to the operational practitioners at the local level.
Communication is the most important thing [Participant K].
Some health practitioners had some doubts regarding the integration of mental health care into HIV services as they felt that they were not appropriately equipped with the skills necessary to manage people with mental health conditions.
How am I expected to attend those mental health care users in HIV services as I don’t have skills or trained in mental health, because I am just a general nurse with midwifery only (Participant C).
The health care practitioners believed that mental health care users should be strictly managed by practitioners trained in mental health. Those that were at primary health care units believed that they were only to attend to general conditions and refer accordingly if a general clients’ conditions complicate and present with strong side effects from antiretroviral therapy and mental health conditions such as psychosis,
As a primary health care professional working at primary health care setting, why am I expected to attend to people that are psychotic instead of referring them to the hospital with a psychiatric ward or mental health institution, … we see so many general patients here per day and we are short staff, …I am the only medical practitioner stationed here as we speak today
(Participant B).
The general feeling from the participants and the research team was that the model was urgently needed.
We need an intervention model that will guide and help to ensure the effective implementation of this national mental health policy framework, but… mmhh… [mumbling], that model must address exactly what need to be done and how (Participant X).
Participants felt that the model should involve all levels of health care provision and there needs to be a provision of workshops and in-service training for the effective implementation of the policy.
The model must address these policy developers from national down to districts level and communities (Participant C).
Another participant said:
What we are saying is yes, we need a model but people from national [National Department of Health] must communicate about the existence of model developed so that it can be implemented well, and we need to be workshopped [trained] on policy developed (Participant G).
Health care practitioners showed great interest in seeing the National Mental Health Policy Framework being successfully implemented and mental health care being integrated into HIV services at primary health care settings
We are saying, let us develop this model then now and see if it does address what we want to happen and see (Participant A).
Process for generating the model
In the process of generating the model, the research team started by describing what the model was trying to represent and to identify, as well as describing the gaps that made the National Mental Health Policy Framework experience a failed implementation, and then analysed them in relation to the phenomenon of interest. The research team, together with the researcher, deliberated on what could then generate a positive result of integrating mental health into HIV services by implementing the National Mental Health Policy Framework accordingly for the benefit of the clients. The process followed was suggested by several authors, such as (Netemeyer, Bearden, & Sharma, 2003), as they also deliberated on the visual representation of a model which was also attempted by the research team and the researcher.
The model was amended several times until the research team and the researcher were all satisfied that it had produced a good model that could be followed for the effective and active implementation of an existing National Mental Health Policy Framework on the integration of mental health into HIV services. The research team and the researcher searched and read some literature as a guide. The research team members reflected on the proposed components of the various adapted models and discussed how to best capture the components they had identified as most significant to the idea of developing a model that was going to be realistic and practical, as well-being understood in simple language by everyone.
The research team then provided verbal and written constructive criticism related to the overall applicability of the model. The constructive criticism was then integrated into later versions of the model as it was being developed, which were subsequently presented to the research supervisor. The research team thought of the best ways to capture the important concepts from the literature and the findings from cycles one, and three. The researcher’s responsibility during model development and in the research team was to frequently draw the research team back to cycles one, two, and three of the study findings, making sure that findings were being merged so that they did not just base everything on the reviewed literature (Hatch, 2002).
This continuous process of refining and working with findings gave birth to a draft model that had the items that assisted in creating the foundation for developing the concepts to be included in the developed model to implement the existing National Mental Health Policy Framework on the integration of mental health into HIV services at selected primary health care settings. The researcher then engaged the research team in the vital process of deliberating and arguing on a newly developed model in order to clarify the specific concepts of the model, to ensure that the concepts were theoretically equally exclusive, in a manner, to have clinical effectiveness.