Table 1
Description of community psychiatry services.
| CO-LOCATED CLINIC (CLINIC-1) | PHYSICALLY INTEGRATED CLINIC (CLINIC-2) | |
|---|---|---|
| Catchment population | The clinic is located in a suburban area accessed by a racially mixed population of mixed socio-economic status. | The clinic is located in a township accessed by Black South Africans of poor socio-economic status. |
| Physical space | Separate outbuilding behind the PHC. | Back of the PHC clinic with limited space. |
| Service load | Approximately 580 HCUs. | Approximately 910 HCUs. |
| Filing systems (paper-based) | Separate clinical records and filing systems. | Shared clinical records and filing system. |
| Community psychiatry Staff | Community psychiatry services in both clinics have the same amount of allocated human resources who provide care to only mental HCUs: • Approximately five nurses are available daily on weekdays in each clinic. • One psychiatrist supervises both clinics for all age groups. • Each clinic has two to four doctors who provide psychiatric care once a week for adults, and once a week for children and adolescents. • Psychologists, social workers and occupational therapists provide individual therapeutic care bi-weekly. | |
| Physician roles | Psychiatric doctors provide outpatient psychiatric and general health care for uncomplicated medical comorbidities for HCUs with mental health conditions, whereas PHC doctors provide more complex physical health care for HCUs with mental health conditions and after-hours mental health care. | |
| Nurse roles | • Conduct mental health screening of new HCUs when they first access community psychiatry services. • Issue psychotropic medication and provide clinical follow-up for HCUs every month. | |
| Focuses primarily on mental health. | Provides PHC nursing and mental health duties. | |
| Down-referrals to PHC | Stable HCUs with SMD are down-referred to the mental health champion in the PHC clinic who issues repeat medication (that are prescribed by psychiatric doctors every six months). | |
| Follow-up | There is no formal system to follow-up with HCUs who do not attend their appointments. | |
[i] Notes: (1) Township refers to an area located on the outskirts of a city that was historically reserved for Black South Africans during the Apartheid era. (2) The racial categories used in this study are based on the South Africa government’s classification system used in official statistical reports [28].
Table 2
Data collection methods.
| METHOD | SAMPLING | INCLUSION CRITERIA | DATA COLLECTED |
|---|---|---|---|
| Retrospective Record Review | Systematic sampling method selecting every 3rd clinical record. A total of 384 clinical records were selected (193 records from clinic-1, and 191 from clinic-2). | 1)Age 18+ 2)Attended community psychiatry service at least once since their first admission to the clinic. | Demographics, mental and behavioural disorders, medical comorbidities, referrals, appointment and treatment adherence, and hospital admissions. |
| Semi-structured Interviews | Purposive sampling was used to select HCUs from the waiting room if they met the inclusion criteria. A total of 23 participants were interviewed (13 interviews clinic-1, and 10 interviews in clinic-2). | 1)Age 18+ *2)Retained in care for a minimum of 24 months 3)Active clinic attendees (defined as having attended the psychiatric service at least once in the last 6 months), *4)Seen by PHC and/or allied health care providers, 5)Stable with no severe cognitive impairment, 6)Capacity to provide informed consent | Interview guide contained questions regarding the HCUs’ 1)Illness narratives, 2)Experiences of integrated care 3)Referral pathways, and 4)Treatment adherence. |
| Field notes | Using a pen-and-paper method, detailed field notes were taken each field day, including: • Clinic observations (physical layout, the flow of HCUs and staff, and interactions observed in waiting areas). • Observations of participants during interviews: mood, tone, non-verbal cues, and perceptions of the interviewee’s comfort level, hesitance, enthusiasm, etc. • Challenges and personal reflections on daily events to identify biases. | ||
[i] *These criteria were included to gain rich insights into HCUs’ experiences of care.
Table 3
Demographic profile of HCUs.
| CATEGORY | CO-LOCATED CLINIC (CLINIC-1) n = 193 | PHYSICALLY INTEGRATED CLINIC (CLINIC-2) n = 191 | OVERALL n = 384 | |||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Sex | ||||||
| Female | 112 | 58.6 | 96 | 50.3 | 208 | 54.5 |
| Male | 79 | 41.4 | 95 | 49.7 | 174 | 45.6 |
| Age (median: 45; range: 18–84 years) | ||||||
| Adolescents (18–19) | 2 | 1.0 | 2 | 1.1 | 4 | 1.1 |
| Young adults (20–39) | 54 | 28.1 | 62 | 32.9 | 116 | 30.4 |
| Adults (40–59) | 96 | 49.8 | 87 | 46 | 183 | 47.9 |
| Older adults (60+) | 41 | 21.2 | 38 | 20.2 | 79 | 20.6 |
| Highest level of education | ||||||
| None | 5 | 2.8 | 3 | 1.8 | 8 | 2.3 |
| Primary | 23 | 12.9 | 41 | 24.1 | 64 | 18.4 |
| Secondary | 85 | 47.8 | 70 | 41.2 | 155 | 44.5 |
| Matric (final school examination) | 55 | 30.9 | 49 | 28.8 | 104 | 29.9 |
| Tertiary | 10 | 5.6 | 7 | 4.1 | 17 | 4.9 |
| Employment status | ||||||
| Employed | 35 | 18.3 | 43 | 22.6 | 78 | 20.5 |
| Unemployed | 156 | 81.7 | 147 | 77.4 | 303 | 79.5 |
[i] Note: Age groups reflect the categories used by the WHO for public health and policy making.
Table 4
Clinical profile and referral pathway of HCUs.
| CATEGORY | CO-LOCATED CLINIC (CLINIC-1) n = 193 | PHYSICALLY INTEGRATED CLINIC (CLINIC-2) n = 191 | OVERALL n = 384 | |||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Mental and behavioural disorders | ||||||
| Anxiety and stress related disorders | 35 | 18.1 | 9 | 4.7 | 44 | 11.5* |
| Major depression | 83 | 43.0 | 50 | 26.2 | 133 | 34.6* |
| Bipolar and related disorders | 53 | 27.5 | 64 | 33.5 | 117 | 30.5 |
| Psychotic disorders | 84 | 43.5 | 116 | 60.7 | 200 | 52.1* |
| Medical comorbidities | 103 | 53.3 | 117 | 61.3 | 220 | 57.3 |
| Substance use | 113 | 58.5 | 109 | 57.1 | 222 | 57.8 |
| History of missing medication | 64 | 39.5 | 102 | 58.0 | 166 | 49.1* |
| Psychiatric admissions | 139 | 72.0 | 144 | 75.4 | 283 | 73.7 |
| Institution from which initial referral was made to community psychiatry* | ||||||
| Hospital | 80 | 50.3 | 116 | 63.4 | 196 | 57.3 |
| Another PHC clinic | 42 | 26.4 | 27 | 14.8 | 69 | 20.2 |
| PHC in same clinic | 25 | 15.7 | 30 | 16.4 | 55 | 16.1 |
| Other (NGOs, schools, correctional services) | 12 | 7.6 | 10 | 5.5 | 22 | 6.4 |
| Years accessing community psychiatry | ||||||
| <5 years | 67 | 34.7 | 65 | 34.0 | 132 | 34.4 |
| 5–9 years | 58 | 30.0 | 66 | 34.6 | 124 | 32.3 |
| 10+ years | 68 | 35.2 | 60 | 31.4 | 128 | 33.3 |
| Referrals to allied health | 91 | 47.2 | 95 | 49.7 | 186 | 48.4 |
[i] Note: *p < 0.05.
(1) Anxiety and stress related disorders include post-traumatic stress disorder (PTSD) and panic disorders. Psychotic disorders include schizophrenia, schizoaffective disorder, and substance-induced psychosis.
(2) History of missing medication refers to HCUs who had a history of missing their medication as noted by their providers on their clinical records.