Fuzzy-set qualitative comparative analysis of implementation outcomes in an integrated mental healthcare trial in South Africa

Figures & data

Table 1. Description of variables

Variable	Description	Measurement tool
Quality of clinic management	Composite Ideal Clinic score per clinic for the year 2017–2018	DoH Ideal Clinic measures
Availability of counsellors	Availability of counsellors per facility	Manual assessment
Other kinds of counselling received	Percentage of trial patients who received counselling from a source other than PRIME	Manual assessment
Adult Primary Care (APC) mental health training coverage	Percentage of nurses exposed to any (one or more) APC mental health sessions. Lower score means a lower proportion of nurses exposed to at least one APC mental health session	Project registers
Clinical Communication Skills (CCS) training coverage	Percentage of nurses exposed to any (one or more) CCS mental health sessions. Lower score means a lower proportion of nurses exposed to at least one CCS mental health session	Project registers
Counselling fidelity	An average score of counsellors’ scores per facility	Project registers
Counselling uptake	Number of sessions attended by patients out of a possible eight sessions per facility	Process notes
Group supervision coverage	Average number of group supervision sessions attended by counsellors per facility	Project registers
Stigma	Higher scores mean a higher level of stigma within the clinic	Mental Illness Clinicians’ Attitudes scale
Referrals	Proportion of referrals as a percentage of the total patient headcount, per facility	Referral forms
Reduction in depression scores	The proportion of patients per facility with a 50% and more reduction in PHQ9 scores	PHQ9

Table 2. Data calibration

Variables	Type	Anchor points
Quality of clinic management	Crisp	1 = Ideal Clinic status of Gold or Platinum 0 = Ideal Clinic status less than Gold or Platinum
Additional counselling received	Fuzzy	<25% = Low >75% = High 50% = Cross-over range
APC mental health training coverage	Fuzzy	100 = All nurses exposed 49 = Low exposure 75 = Cross-over
CCS training coverage	Fuzzy	80 = All nurses exposed 30 = Low exposure 55 = Cross-over
Counselling fidelity	Fuzzy	>70% = Good 60% = Cross-over <50% = Low
Counselling uptake	Fuzzy	0 = Low sessions 0.25 = Medium sessions 0.5 = High sessions
Group supervision coverage	Crisp	0 = Low number (<70) 1 = High number (>70)
Stigma	Fuzzy	None
Referrals	Fuzzy	None
50%<PHQ9	Fuzzy	>75% = Good 62% = Medium <50% = Low

Figure 1. Hypothetical causal model

Table 3. Analysis of necessary conditions

Presence of outcome (Reduction in PHQ9 scores)
Condition	Consistency	Coverage
Counselling uptake	0.585821	0.255700
~Counselling uptake	0.574627	0.538462
Group supervision	0.518657	0.278000
~Group supervision	0.481343	0.322500
Stigma	0.940298	0.363112
~Stigma	0.358209	0.466019
Quality of clinic management	0.376866	0.168333
~Quality of clinic management	0.623134	0.556667
Additional counselling	0.641791	0.442159
~ Additional counselling	0.470149	0.246575
trainingAPC training	0.835821	0.395062
~trainingAPC training	0.470149	0.378378
CCS training	0.078358	0.176471
~CCS training	0.981343	0.336748
Counsellor fidelity	0.865672	0.346786
~Counsellor fidelity	0.354478	0.411255
Referrals	0.518657	0.325527
~Referrals	0.537505	0.715956
Absence of outcome (Reduction in PHQ9 scores)
Condition	Consistency	Coverage
Counselling uptake	0.791139	0.814332
~Counselling uptake	0.276899	0.611888
Group supervision	0.571203	0.722000
~Group supervision	0.428797	0.677500
Stigma	0.825949	0.752161
~Stigma	0.300633	0.922330
Quality of clinic management	0.789557	0.831667
~Quality of clinic management	0.210443	0.443333
Additional counselling	0.390823	0.634961
~ Additional counselling	0.656646	0.812133
trainingAPC training	0.672468	0.749559
~trainingAPC training	0.457279	0.867868
CCS training	0.180380	0.957983
~CCS training	0.844937	0.683739
Counsellor fidelity	0.784810	0.741405
~Counsellor fidelity	0.308544	0.844156
Referrals	0.517405	0.765808
~Referrals	0.544304	0.727273

Table 4. Analysis of necessary combination conditions

Presence of outcome (reduction in PHQ9 scores)
Condition	Consistency	Coverage
Referrals+Counselling uptake	0.805970	0.287617
Counsellor fidelity+Referrals	1.000000	0.352632
APC training+CCS training	0.835821	0.366013
Absence of outcome (Reduction in PHQ9 scores)
Condition	Consistency	Coverage
~Referrals+~Counselling uptake	0.667722	0.691803
~Counsellor fidelity+~Referrals	0.631329	0.707447
~APC training+~CCS training	0.916139	0.700968

Table 5. Truth table with presence and absence of outcome (Reduction in PHQ9 scores), minimised and sorted

Counselling uptake	Group supervision	Stigma	Quality of clinic management	Additional counselling	APC training	CCS training	Counsellor fidelity	Referrals	Number	PHQ9	Raw consist.	PRI consist.	SYM consist
Presence of Reduction in PHQ09 scores
0	0	1	0	0	0	0	1	1	1	1	1.000000	1.000000	1.000000
1	1	1	0	1	1	0	1	0	1	1	0.858824	0.858824	0.858824
1	1	1	1	0	1	0	0	1	1	0	0.506494	0.000000	0.000000
1	0	1	1	1	0	1	1	0	1	0	0.061538	0.000000	0.000000
1	1	1	1	0	0	0	1	0	1	0	0.041667	0.000000	0.000000
1	1	1	1	1	1	0	1	1	1	0	0.037500	0.000000	0.000000
0	0	1	1	0	1	0	1	1	1	0	0.033898	0.000000	0.000000
1	1	1	0	0	1	0	0	0	1	0	0.000000	0.000000	0.000000
Absence of Reduction in PHQ09 scores
0	0	1	1	0	1	0	1	1	1	1	1.000000	1.000000	1.000000
1	0	1	1	1	0	1	1	0	1	1	1.000000	1.000000	1.000000
1	1	1	0	0	1	0	0	0	1	1	1.000000	1.000000	1.000000
1	1	1	1	0	0	0	1	0	1	1	1.000000	1.000000	1.000000
1	1	1	1	1	1	0	1	1	1	1	1.000000	1.000000	1.000000
1	1	1	1	0	1	0	0	1	1	1	0.857143	0.710526	1.000000
0	0	1	0	0	0	0	1	1	1	0	0.507692	0.000000	0.000000
1	1	1	0	1	1	0	1	0	1	0	0.141176	0.141176	0.141176

Table 6. Results of the standard sufficiency analysis

Solutions
Outcome: PHQ9
Complex			Raw coverage	Unique coverage	Consistency
~Counselling uptake*~Group supervision*Stigma*~Quality of clinic management*~Additional counselling*~APC training*~CCS training * Counsellor fidelity*Referrals			0.242537	0.242537	1.000000
Counselling uptake*Group supervision*Stigma*~Quality of clinic management*Additional counselling*APC training*~CCS training* Counsellor fidelity*~Referrals			0.272388	0.272388	0.858824
solution coverage: 0.514925	solution consistency: 0.920000
Intermediate			Raw coverage	Unique coverage	Consistency
Referrals*Counsellor fidelity*~Additional counselling*~Quality of clinic management*Stigma			0.317164	0.250000	0.674603
Counsellor fidelity*APC training*Additional counselling*~Quality of clinic management*Stigma*Group supervision*Counselling uptake			0.294776	0.227612	0.868132
solution coverage: 0.544776		solution consistency: 0.780749
Parsimonious			Raw coverage	Unique coverage	Consistency
~Quality of clinic management*Counsellor fidelity			0.623134	0.623134	0.755656
solution coverage: 0.623134		solution consistency: 0.755656
Outcome: ~PHQ9
Complex			Raw coverage	Unique coverage	Consistency
Counselling uptake*Group supervision*Stigma*~Quality of clinic management*~Additional counselling*APC training*~CCS training*~Counsellor fidelity*~Referrals			0.096519	0.096519	1.000000
Counselling uptake*Group supervision*Stigma*Quality of clinic management*~Additional counselling*~APC training*~CCS training*Counsellor fidelity*~Referrals			0.113924	0.099684	1.000000
~Counselling uptake*~Group supervision*Stigma*Quality of clinic management*~Additional counselling*APC training*~CCS training*Counsellor fidelity*Referrals			0.093354	0.079114	1.000000
Counselling uptake*~Group supervision*Stigma*Quality of clinic management*Additional counselling*~APC training*CCS training*Counsellor fidelity*~Referrals			0.102848	0.088608	1.000000
Counselling uptake*Group supervision*Stigma*Quality of clinic management*~Additional counselling*APC training*~CCS training*~Counsellor fidelity*Referrals			0.104430	0.094937	0.857143
Counselling uptake*Group supervision*Stigma*Quality of clinic management*Additional counselling*APC training*~CCS training*Counsellor fidelity*Referrals			0.126582	0.112342	1.000000
solution coverage: 0.599684		solution consistency: 0.971795
Intermediate			Raw coverage	Unique coverage	Consistency
~Counsellor fidelity*~CCS training*Quality of clinic management*Stigma			0.183544	0.055380	0.906250
~CCS training*Additional counselling*Quality of clinic management*Stigma			0.295886	0.112342	0.869767
~CCS training*Quality of clinic management*Stigma*~Group supervision*~Counselling uptake			0.153481	0.064873	0.776000
~Referrals*~CCS training*~APC training*Quality of clinic management*Stigma			0.257911	0.099684	0.936782
~Referrals*~Counsellor fidelity*~CCS training*APC training*~Additional counselling*Stigma			0.162975	0.000000	1.000000
~Referrals*~Counsellor fidelity*~CCS training*~Additional counselling*Stigma*Group supervision			0.145570	0.000000	1.000000
~Referrals*~Counsellor fidelity*~CCS training*~Additional counselling*Stigma*Counselling uptake			0.162975	0.000000	1.000000
~Referrals*~APC training*Additional counselling*Quality of clinic management*Stigma*~Group supervision			0.175633	0.044304	0.909836
solution coverage: 0.680380		solution consistency: 0.914894
Parsimonious			Raw coverage	Unique coverage	Consistency
Quality of clinic management			0.789557	0.375000	0.831667
Counselling uptake*~Additional counselling			0.504747	0.000000	0.914040
Group supervision*~Additional counselling			0.430380	0.000000	0.900662
~Additional counselling*APC training			0.506329	0.039557	0.909091
solution coverage: 0.981013		solution consistency: 0.836707

Table 7. Results of the specific sufficiency analysis

Least parsimonious		Raw coverage	Unique coverage	Consistency
~Counselling uptake*~Group supervision*stigma*~Quality of clinic management*~Additional counselling*~APC training*~CCS training*Counsellor fidelity*Referrals		0.242537	0.242537	1.000000
Counselling uptake*Group supervision*Stigma*~Quality of clinic management*Additional counselling*APC training*~CCS training*Counsellor fidelity*~Referrals		0.272388	0.272388	0.858824
solution coverage: 0.514925	solution consistency: 0.920000
Most parsimonious		Raw coverage	Unique coverage	Consistency
~Quality of clinic management*Counsellor fidelity		0.623134	0.623134	0.755656
solution coverage: 0.623134	solution consistency: 0.755656

Data availability statement

The raw data used during the current study are available from the corresponding author on reasonable request. Additional data from PRIME can be accessed on request from www.prime.uct.ac.za in line with PRIME’s data sharing policies.