BackgroundWhile decentralized and integrated primary mental healthcare forms the core of mental health policies in many low- and middle-income countries (LMICs), implementation remains a challenge. The aim of this study was to understand how the use of a common implementation framework could assist in the integration of mental health into primary healthcare in Ugandan and South African district demonstration sites. The foci and form of the services developed differed across the country sites depending on the service gaps and resources available. South Africa focused on reducing the service gap for common mental disorders and Uganda, for severe mental disorders.MethodA qualitative post-intervention process evaluation using focus group and individual interviews with key stakeholders was undertaken in both sites. The emergent data was analyzed using framework analysis.ResultsSensitization of district management authorities and the establishment of community collaborative multi-sectoral forums assisted in improving political will to strengthen mental health services in both countries. Task shifting using community health workers emerged as a promising strategy for improving access to services and help seeking behaviour in both countries. However, in Uganda, limited application of task shifting to identification and referral, as well as limited availability of psychotropic medication and specialist mental health personnel, resulted in a referral bottleneck. To varying degrees, community-based self-help groups showed potential for empowering service users and carers to become more self sufficient and less dependent on overstretched healthcare systems. They also showed potential for promoting social inclusion and addressing stigma, discrimination and human rights abuses of people with mental disorders in both country sites.ConclusionsA common implementation framework incorporating a community collaborative multi-sectoral, task shifting and self-help approach to integrating mental health into primary healthcare holds promise for closing the treatment gap for mental disorders in LMICs at district level. However, a minimum number of mental health specialists are still required to provide supervision of non-specialists as well as specialized referral treatment services.

Within the context of a large treatment gap for depression and a scarcity of specialist resources, there is a need for task shifting to scale up mental health services to address this gap in South Africa. This study assessed the feasibility of an adapted manualized version of grouped based Interpersonal Therapy (IPT) for use by supervised community health workers through a pilot study on 60 primary health care clinic users screened as having moderate to severe depression. Retention was good and participants in the group-based IPT intervention showed significant reduction in depressive symptoms on completion of the 12-week intervention as well as 24 weeks post baseline compared to the control group. Qualitative process evaluation suggests that improved social support, individual coping skills and improved personal agency assisted in the reduction of depressive symptoms.

Integrating mental health into primary health care is widely promoted for a host of reasons, chief among which is providing a more comprehensive health care service. However, only a few countries have adequate mental health resources to undertake the integration of mental health into primary health care in a uniform manner, with wide variations among countries. This paper examines the extent to which two low-income countries (Ghana and Uganda) and one middle-income country (South Africa) are managing the integration of mental health into primary health care using the recommendations of the WHO World Health Report, 2001. Primary and secondary data sources from a situational analysis of mental health services in the three countries were analysed. The findings indicate that significant challenges remain in integrating mental health care into primary health care. Poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons advanced. Aside from better human resource planning for mental health, integration may be advanced by the development of packages of care which adopt a task-shifting approach suited to a country's needs.

Against the backdrop of a large treatment gap for mental disorders in low- to middle-income countries (LMICs), the 2007 Lancet series on global mental health calls for a scaling up of mental health services. Community participation is largely harnessed as one strategy to facilitate this call. Using a participatory implementation framework for the development of mental health services for common mental disorders (CMDs) in a rural subdistrict in South Africa as a case study, this study sought to understand the benefits and challenges of community participation beyond that of scaling up. Qualitative process evaluation involving interviews with service providers and users was employed. The results suggest that in addition to promoting mobilization of resources and actions for scaling up mental health services, community participation can potentially contribute to more culturally competent services and personal empowerment of recipients of care. In addition, community participation holds promise for engendering community-led public health actions to ameliorate some of the social determinants of mental ill health. Challenges include that community members involved in these activities are mainly marginalized women, who have limited power to achieve structural change, including cultural practices that may be harmful to the mental health of women and children. We conclude that in addition to contributing to scaling up mental health services, community participation can potentially promote the development of culturally competent mental health services and greater community control of mental health.

We report three studies that develop and test a new measure of racial attitudes, the Racial Justice Scale (RJS). The concept of racial justice was developed inductively in Study 1 by means of a thematic analysis of existing measures of racial attitudes as well as a database of over 7 000 comments about racism and discrimination, taken from South African newspapers. Studies 2 and 3 investigate the reliability and validity of the RJS, and compare it with Duckitt's measure of subtle racism. The data suggest that the preliminary RJS, reported in Appendix 2, is a unidimensional and reliable measure. Although the two studies provide a mixed picture of its correlates, it does measure a different construct of racial attitudes to Duckitt's scale, which is strongly correlated with oldfashioned racism. Participation in all the studies was done on a voluntary basis, with full informed consent of the participants.