Table 3.

Comparison of training provided to control and intervention clinics

Provider	Role	Training	Content of training	Method and timeframe
Control and intervention facilities
PHC nurses	Identifies, provides brief interventions and refers	Basic onsite PC101 training	Case scenarios used for training in the identification and management of common chronic diseases, including communicable diseases, NCDs (including hypertension), women’s health and mental health. Mental health components draw on the WHO’s mhGAP guidelines [91] and adopt a syndromic approach to mental health symptoms (such as stress, insomnia, suicidal thinking) with diagnostic algorithms and treatment checklists for depression	(1) PC101 Master Trainers train Facility Trainers who train PHC nurses at the facilities(2) Twelve weekly sessions over 12 weeks at facilities (two of which are on mental disorders)(3) Training uses case scenario material of patients with chronic conditions, including comorbid conditions
Intervention facilities
PHC nurses	Identifies, provides brief interventions and refers	Orientation and clinical communication skills training	(1) Overview of the system changes being made by the DoH in South Africa to accommodate the demands of integrated chronic care; their role as case managers within the collaborative care model for depression(2) Orientation to patient-centred care and clinical communication skills necessary to implement patient-centred care(3) Skills to manage patient emotions within the consultation; self-care including how to cope with their own emotions and burn-out(4) Motivational interviewing skills to promote patient self-management	Four 2-h interactive workshops at PHC facilities/regional training centre
		PC101 supplementary training in mental health	(1) Detection of depression and anxiety, psychoeducation and referral to counsellors and/or doctor for consideration of psychotropic medication in the case of moderate severe depression(2) Detection of risky alcohol use and brief intervention for harmful/hazardous drinking and for detoxification and referral to specialists rehabilitation programmes for dependency as per the mhGAP guidelines [91] (3) Assessment of suicide intent (4) Patient review after 8 weeks to assess response to treatment and onward referral for specialist care as indicated by the mhGAP evidence-based guidelines for LMICs [91], if necessary following a treatment-to-target approach as contained in the collaborative care model (Fig. 4); treatment to target involves tracking a patient’s symptom severity and adjusting or intensifying treatment should patients not show an improvement in symptoms following initial treatment.	(1) PC101 Master Trainers train Facility Trainers (2 day workshop) who train PHC nurses at the facilities(2) Three weekly sessions over 3 weeks at facilities, with an additional follow-up session 1 month later(3) Training uses case scenario material of chronic patients with comorbid mental disorders
PHC doctors	Diagnoses, initiates and monitors response to psychotropic medication	Orientation and training in mhGAP/PC101	(1) Orientation to the importance of treating comorbid depression (2) Training in mhGAP guidelines(3) Follow-up using case studies of patients	Three 1-day workshops spread over 6 months
Behavioural health counsellors	Provides evidence-based counselling	Counselling training	(1) Manualised counselling package comprising 8 sessions (delivered individually or in groups) (2) Session 1: Psycho-education session on depression; the last session is a closure session; Sessions 2–7 draw on problem solving and cognitive behavioural techniques, including behavioural activation to address the common triggers of depression and anxiety which, in this population, include poverty, interpersonal conflict, social isolation and avoidance, grief and loss, and stigma that emerged from qualitative interviews held with service users with during the formative phase of the PRIME project in South Africa in two provinces [92]; a prototype had been field tested in KwaZulu-Natal and positive results demonstrated in an individually randomised pilot trial [43]; adherence session provides information on the chronic condition(s) and chronic medication(s) the patients may have as well as helping patients with adherence difficulties (3) While developed to treat depression, the intervention has been found to promote improvements in global psychological functioning as well [43], thus having the potential for trans-diagnostic effects, in line with evidence that diagnosis-specific cognitive behavioural therapy has beneficial effects on untargeted comorbid emotional disorders [43]	One week of off-site training; one week of peer-to-peer mentoring; in vivo supervision by a psychologist of each session; weekly follow-up group supervisory sessions, augmented where possible by weekly individual supervision sessions
Specialists(Psychologist/psychiatrist)	Training, supervision of counsellors	Orientation to task sharing	Psychologists (including interns and community service psychologists) orientated to their roles	Once-off workshops

DoH Department of Health, LMICs low- and middle-income countries, mhGAP WHO Mental Health Gap Action Programme, NCDs non-communicable diseases, PC101 Primary Care 101, PHC primary healthcare