Task sharing in mental health service provision : developing a model for clinical associates in South Africa

Abstract

Background There is a shortage of the human resources needed to deliver mental health services in South Africa. Clinical associates are possibly an under-utilised resource in mental health task sharing approaches in South Africa. The study aimed to develop a model of task sharing in mental health in South Africa focussed on clinical associates.

Methods and results by objective Objective 1: To describe the mental health content of the three clinical associate training programmes in South Africa A collective case study approach was utilised involving the three universities offering undergraduate clinical associate degrees. In-depth interviews using videoconferencing were conducted with individuals involved in each programme and documents such as study guides and timetables were reviewed. We found that mental health was included in the curricula and assessments of all three programmes. The approach to facility-based training was different at the three universities with one adopting a practical approach at a hospital with a mental health unit, the second a more theoretical approach with limited practical exposure, and third not have a universal approach as there was considerable variation between facilities.

Objective 2: To determine knowledge, attitudes and practices of clinical associates with respect to management of mental illness A cross-sectional study of clinical associates based in South Africa was conducted. The questionnaire incorporated the 16-item Mental Illness Clinicians’ Attitudes scale version 4 (MICA-4) as well as questions related to knowledge, confidence, practices, and interest in mental health service provision and further training. Only 50.3% of participants felt ‘quite confident’ or ‘very confident’ taking a mental health history and even fewer (43.2%) in carrying out a mental health examination. The mean MICA-4 score recorded was 37.55 (SD 7.33) which is at the lower end of the scale indicating less stigmatising attitudes. There was considerable interest in mental health work (83.8%) and in a specialisation in mental health (66.5%).

Objective 3. To describe the attitudes of health managers, medical doctors and nurses towards mental health task sharing involving clinical associates Focus group interviews of medical doctors and nurses involved in mental health service provision, and health managers were conducted in four districts of South Africa.The participants felt that the performance of clinical associates in other disciplines suggests their potential usefulness in mental health but there are barriers and constraints that needed to be addressed.

Objective 4: To identify the key elements of a mental health task sharing model for clinical associates The Delphi method was utilised to reach consensus on the key elements of a model for mental health training and service provision. The Delphi panel consisted of family physicians and psychiatrists from the public and private sectors in South Africa. The panel reached consensus on 10 of the 21 tasks provided that could be performed based on undergraduate training and 20 of the same 21 provided tasks for those with a postgraduate qualification in mental health.

Conclusion Based on our findings, clinical associates have a potentially important role to play in addressing the mental health crisis in South Africa. They could help improve access to mental health services in the public sector particularly in rural areas. The proposed model comprises training and service provision components and highlights the policy and regulatory changes that are needed to enable mental health task sharing and optimise the contribution of clinical associates to the mental health system.