Introducing supported self-management for depression to primary care in Vietnam: A feasibility study in preparation for a randomized controlled trial

An integrated knowledge translation (iKT) approach to advancing community-based depression care in Vietnam: lessons from an ongoing research-policy collaboration

BACKGROUND

Evidence-based mental health policies are key to supporting the expansion of community-based mental health care and are increasingly being developed in low and middle-income countries (LMICs). Despite this, research on the process of mental health policy development in LMICs is limited. Engagement between researchers and policy makers via an integrated Knowledge Translation (iKT) approach can help to facilitate the process of evidence-based policy making. This paper provides a descriptive case study of a decade-long policy and research collaboration between partners in Vietnam, Canada and Australia to advance mental health policy for community-based depression care in Vietnam.

METHODS

This descriptive case study draws on qualitative data including team meeting minutes, a focus group discussion with research team leaders, and key informant interviews with two Vietnamese policy makers. Our analysis draws on Murphy et al.'s (2021) findings and recommendations related to stakeholder engagement in global mental health research.

RESULTS

Consistent with Murphy et al.'s findings, facilitating factors across three thematic categories were identified. Related to 'the importance of understanding context', engagement between researchers and policy partners from the formative research stage provided a foundation for engagement that aligned with local priorities. The COVID-19 pandemic acted as a catalyst to further advance the prioritization of mental heath by the Government of Vietnam. 'The nature of engagement' is also important, with findings demonstrating that long-term policy engagement was facilitated by continuous funding mechanisms that have enabled trust-building and allowed the research team to respond to local priorities over time. 'Communication and dissemination' are also crucial, with the research team supporting mental health awareness-raising among policy makers and the community, including via capacity building initiatives.

CONCLUSIONS

This case study identifies factors influencing policy engagement for mental health system strengthening in an LMIC setting. Sustained engagement with policy leaders helps to ensure alignment with local priorities, thus facilitating uptake and scale-up. Funding agencies can play a crucial role in supporting mental health system development through longer term funding mechanisms. Increased research related to the policy engagement process in global mental health will further support policy development and improvement in mental health care in LMICs.

Considerations for supporting meaningful stakeholder engagement in global mental health research

The need to ensure that research evidence is adopted by health systems and is informed by lived experience expertise has been increasingly recognised in mental health research. In the field of global mental health (GMH), though some progress has been made, the meaningful engagement of key stakeholders in research remains low. This editorial outlines recommendations to support the meaningful engagement of policy makers and people with lived or living experience of mental illness in GMH research. Recommendations include: increasing funding structures that are designed to support meaningful engagement; urging institutions to consider administrative structures that support engagement with lower resourced partners; promoting capacity development opportunities and resources to support researchers to promote meaningful engagement; developing research governance structures that include key stakeholders; and, taking steps to ensure the needs of diverse stakeholders are met through their engagement in research. Examples of good practice from these areas are provided. Though not an exhaustive list of recommendations, this editorial represents a call to the GMH research community to take a deliberate and proactive approach to prioritising meaningful stakeholder engagement in GMH research with the ultimate goal of improving accessible and appropriate mental health care.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Is supported self-management for depression effective for adults in community-based settings in Vietnam?: a modified stepped-wedge cluster randomized controlled trial

Background

This study tested the effectiveness of a supported self-management (SSM) intervention to reduce symptoms of depression among adults compared with enhanced treatment as usual in community-based and primary care settings in Vietnam.

Methods

The cluster randomized trial included 376 adults in 32 communes in eight provinces. Eligible participants scored > 7 on the SRQ-20 depression scale. Patients with severe symptoms were excluded and referred to tertiary care. Randomization took place at the commune level. The immediate intervention group included 16 communes with 190 participants and the delayed group included 16 communes with 186 participants. Participants in communes randomized to the immediate intervention group received a two-month course of SSM, consisting of a workbook and supportive coaching. Those in communes randomized to the delayed group received enhanced treatment as usual and, for ethical purposes, received the SSM intervention after 4 months. The primary outcome is the effect of SSM on reduction in depression scores as indicated by a reduced proportion of participants with SRQ-20 scores > 7 at 2 months after commencement of SSM intervention. Blinding was not possible during intervention delivery but outcome assessors were blinded. Analysis was intention-to-treat.

Results

At 2 months, 26.4% of the intervention group and 42.3% of the delayed group had SRQ-20 scores > 7. The adjusted odds ratio of having depression between the intervention and control was 0.42 (p < 0.0001), 95% CI (0.28, 0.63). Receiving the intervention thus reduces the odds of having depression by 58%, compared with receiving the control after 2 months of treatment. No adverse events were reported.

Conclusions

Results suggest that SSM is effective for decreasing depression symptoms among adults in community-based settings in Vietnam.

Trial Registration This trial is registered at ClinicalTrials.gov, number NCT03001063.

Barriers and facilitators to the integration of depression services in primary care in Vietnam: a mixed methods study

BACKGROUND

Although the prevalence of depression in Vietnam is on par with global rates, services for depression are limited. The government of Vietnam has prioritized enhancing depression care through primary healthcare (PHC) and efforts are currently underway to test and scale-up psychosocial interventions throughout the country. With these initiatives in progress, it is important to understand implementation factors that might influence the successful integration of depression services into PHC. As the implementers of these new interventions, primary care providers (PHPs) are well placed to provide important insight into implementation factors affecting the integration of depression services into PHC. This mixed-methods study examines factors at the individual, organizational and structural levels that may act as barriers and facilitators to the integration of depression services into PHC in Vietnam from the perspective of PHPs.

METHODS

Data collection took place in Hanoi, Vietnam in 2014. We conducted semi-structured interviews with PHPs (n = 30) at commune health centres and outpatient clinics in one rural and one urban district of Hanoi. Theoretical thematic analysis was used to analyse interview data. We administered an online survey to PHPs at n = 150 randomly selected communes across Hanoi. N = 226 PHPs responded to the survey. We used descriptive statistics to describe the study variables acting as barriers and facilitators and used a chi-square test of independence to indicate statistically significant (p < .05) associations between study variables and the profession, location and gender of PHPs.

RESULTS

Individual-level barriers include low level of knowledge and familiarity with depression among PHPs. Organizational barriers include low resource availability in PHC and low managerial discretion. Barriers at the structural level include limited mental health training among all PHPs and the existing programmatic structure of PHC in Vietnam, which sets mental health apart from general services. Facilitators at the individual level include positive attitudes among PHPs towards people with depression and interest in undergoing enhanced training in depression service delivery.

CONCLUSIONS

While facilitating factors at the individual level are encouraging, considerable barriers at the structural level must be addressed to ensure the successful integration of depression services into PHC in Vietnam.