Study design

This Type-II Hybrid Implementation-Effectiveness study [40] will primarily test implementation strategies on provider adoption and implementation quality. We will use a cluster RCT design to test the effectiveness of the implementation models on provider- and client-level outcomes with a mixed-methods approach. Specifically, this three-arm trial compares the three multi-component strategies for implementing depression care guidelines: (1) UI arm which includes basic depression care capacity workshops, limited technical assistance, and toolkits, 2) ES arm which includes all components of UI and additional structured clinical supervision from provincial and district supervisors, and 3) CELC arm which includes all components of ES, combined with the activation of a community-wide network of providers and stakeholders who are implementing continuous QI strategies (Fig. 1). The primary outcome is to compare the fidelity of MCCD on three implementation models using the RE-AIM framework [41], which will be assessed based on implementation outcomes (Reach, Adoption, Implementation quality, and Maintenance) and provider and client-related outcomes (Effectiveness) (Table 1). The secondary outcome is to assess factors associated with barriers and facilitators of quality implementation, which may serve as mechanisms for implementing additional supports for the ES and CELC arms. The tertiary outcome is to evaluate the incremental cost-effectiveness which quantifies the cost savings to policymakers when integrating various strategies for task-shifting depression care into primary care settings.

Study design diagram

UI: Usual implementation; ES: Enhanced supervision; CELC: Community-engaged learning collaborative; CHSs: Community Health Stations

RE-AIM Indicators, Description, and Data Sources

Active Implementation Support;

Transitional Support