Browsing by Author "Folb, Naomi"

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    Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial
    (BioMed Central, 2018-03-22) Fairall, Lara; Petersen, Inge; Zani, Babalwa; Folb, Naomi; Georgeu-Pepper, Daniella; Selohilwe, One; Petrus, Ruwayda; Mntambo, Ntokozo; Bhana, Arvin; Lombard, Carl; Bachmann, Max; Lund, Crick; Hanass-Hancock, Jill; Chisholm, Daniel; McCrone, Paul; Carmona, Sergio; Gaziano, Thomas; Levitt, Naomi; Kathree, Tasneem; Thornicroft, Graham
    Background The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART. Methods The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively. Discussion The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings. Trial registration ClinicalTrials.gov ( NCT02407691 ) registered on 19 March 2015; Pan African Clinical Trials Registry ( 201504001078347 ) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) ( DOH-27-0515-5048 ) NHREC number 4048 issued on 21/04/2015.
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    Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial
    (BioMed Central, 2018-03-22) Petersen, Inge; Bhana, Arvin; Folb, Naomi; Thornicroft, Graham; Zani, Babalwa; Selohilwe, One; Petrus, Ruwayda; Mntambo, Ntokozo; Georgeu-Pepper, Daniella; Kathree, Tasneem; Lund, Crick; Lombard, Carl; Bachmann, Max; Gaziano, Thomas; Levitt, Naomi; Fairall, Lara
    Background The high co-morbidity of mental disorders, particularly depression, with non-communicable diseases (NCDs) such as cardiovascular disease (CVD), is concerning given the rising burden of NCDs globally, and the role depression plays in confounding prevention and treatment of NCDs. The objective of this randomised control trial (RCT) is to determine the real-world effectiveness of strengthened depression identification and management on depression outcomes in hypertensive patients attending primary health care (PHC) facilities in South Africa (SA). Methods/design The study design is a pragmatic, two-arm, parallel-cluster RCT, the unit of randomisation being the clinics, with outcomes being measured for individual participants. The 20 largest eligible clinics from one district in the North West Province are enrolled in the trial. Equal numbers of hypertensive patients (n = 50) identified as having depression using the Patient Health Questionnaire (PHQ-9) are enrolled from each clinic, making up a total of 1000 participants with 500 in each arm. The nurse clinicians in the control facilities receive the standard training in Primary Care 101 (PC101), a clinical decision support tool for integrated chronic care that includes guidelines for hypertension and depression care. Referral pathways available include referrals to PHC physicians, clinical or counselling psychologists and outpatient psychiatric and psychological services. In the intervention clinics, this training is supplemented with strengthened training in the depression components of PC101 as well as training in clinical communication skills for nurse-led chronic care. Referral pathways are strengthened through the introduction of a facility-based behavioural health counsellor, trained to provide structured manualised counselling for depression and adherence counselling for all chronic conditions. The primary outcome is defined as at least 50% reduction in PHQ-9 score measured at 6 months. Discussion This trial should provide evidence of the real world effectiveness of strengtheneddepression identification and collaborative management on health outcomes of hypertensive patients withcomorbid depression attending PHC facilities in South Africa. Trial registration South African National Clinical Trial Register: SANCTR ( http://www.sanctr.gov.za/SAClinicalTrials ) (DOH-27-0916-5051). Registered on 9 April 2015. ClinicalTrials.gov : ID: NCT02425124 . Registered on 22 April 2015.
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    Non-communicable diseases in public sector primary care clinics in South Africa: multimorbidity, control, treatment, socioeconomic associations, and evaluation of educational outreach with a clinical management tool
    (2017) Folb, Naomi; Fairall, Lara; Bachmann, Max O
    This thesis uses experience gained from a large implementation trial in two rural districts of the Western Cape, South Africa, to address the needs of patients with non-communicable diseases (NCDs) and depression, and to identify solutions to those needs. The Primary Care 101 intervention supports and expands nurses' role in integrated care, in particular for NCDs. It comprises a comprehensive clinical management tool implemented in primary care services using educational outreach training. It was evaluated using a pragmatic cluster randomised controlled trial: 38 clinics in the Eden and Overberg districts of the Western Cape were randomised to receive the intervention or to continue with usual care. 4393 Patients were enrolled and four cohorts identified: hypertension, diabetes, chronic respiratory disease and depression. Patients were re-interviewed once, 14 months later. Primary outcomes for the trial were treatment intensification for the hypertension, diabetes and chronic respiratory disease cohorts, and case detection for the depression cohort. Multimorbidity, NCD care and their socioeconomic associations were assessed on the whole trial cohort (combining intervention and control arms) at baseline and follow-up. The results are presented in published papers. Baseline data revealed considerable multimorbidity and unmet treatment needs (Paper 1). Socioeconomic indicators such as education, and modifiable clinic-level factors such as adequate staffing and communitybased chronic medication collection services were associated with blood pressure control (Paper 2) and depression management (Paper 3). The intervention was shown to be feasible and safe but none of the four primary outcomes showed significant improvement (Paper 4). The thesis addresses the public health challenge of providing integrated chronic disease primary care in South Africa by: • Providing original evidence for high levels of NCD multimorbidity and unmet treatment needs. • Identifying modifiable factors that could improve care for these diseases. • Providing new evidence from South Africa to support the bidirectional relationship between poverty and depression. • Reporting evidence of the effectiveness of a novel intervention aimed at improving NCD care. The findings point to the need for improved strategies for NCD care, including equipping primary health care providers to manage the complexities of multimorbidity.