Global Mental Health Seed GrantProj

Global Mental Health Seed Grant

Project title: Feasibility study in preparation for Randomized Trial of Enhanced Primary Mental Health Care Implementation

A. Project Description
I) Project Impact and Background
Depression has been found to be a prevalent condition in Viet Nam with characteristics that are similar to those found in the rest of the world (Vuong et al. 2011). Although primary healthcare services are accessible in Viet Nam to the general population, there is very limited access to specialist services for common mental disorders such as depression. This proposal is for a feasibility study, to be undertaken in preparation for a subsequent project that would undertake a cluster randomized controlled trial of enhanced primary healthcare services for depression in Viet Nam. This program of research has the potential to have a transformative effect on the quality of mental health services provided to a large proportion of the population in Viet Nam that experiences disability and distress as a result of common mental disorders. Moreover, it holds potential to demonstrate proof-of-concept for such primary healthcare enhancements for common mental health problems in low- and middle-income countries, thus addressing a large burden of disease through a low-cost intervention that could be easily integrated into existing services.
The specific challenges that are addressed in this proposal are:
• Integration of screening and core packages of services into routine primary health care
• Provision of effective and affordable community-based care and rehabilitation
• Development of effective treatments for use by non-specialists
• Incorporation of functional impairment and disability into assessment
It has been well established that an effective means of implementing improvements to the quality of mental health services for common mental health problems (e.g, depression) is through interventions aimed at changes in primary healthcare practice (e.g., Gilbody et al., 2003; Griffiths & Christensen 2008; Genischen et al. 2009; Patel et al. 2010). Our research group intends to test the feasibility of implementing an enhanced approach to addressing depression by primary healthcare providers in Viet Nam. We intend to examine the feasibility of an approach that aims to effect changes to primary healthcare practice through a carefully coordinated and supported detection and intervention program designed specifically to enhance the quality of mental health services amongst primary healthcare practitioners. Such an approach has proven to be effective in Chile (Araya et al. 2003) and there exists a strong rationale for this approach to have transformative potential in Viet Nam and other low- and middle-income countries (Patel et al. 2009).
The rationale for and success of such primary mental healthcare enhancements include: the extensive contact and ‘reach’ that primary healthcare providers (including general practice physicians and other front-line health workers) have with large numbers of people with common mental disorders (Dietrich et al. 2004); the clinical effectiveness of relatively small behavioural changes by primary healthcare providers in addressing mental health issues and the relatively low cost and high return on investment of such improvements to primary healthcare practice (Patel et al. 2009), and; the well-developed evidence base to guide successful knowledge translation and implementation of educational interventions in primary healthcare (Goldner in press).
A number of countries and regions have implemented specific initiatives focused on primary mental healthcare enhancement. These have been undertaken primarily within high-income countries, however policy-makers, clinicians and scientists now see excellent potential for similar approaches in low and middle-income regions (Patel et al. 2009) and preliminary evidence has been demonstrated in trials in Chile (Araya et al. 2003) and India (Patel et al. 2010). Previously, Vietnam had focused heavily on institution-based mental healthcare but there has been a substantive movement in the past few decades to replace institutional care with community-based mental health services and this has been established as a policy goal since 1999. Consequently, this program of research would greatly assist this important transformation of mental health service delivery. We wish to study the effectiveness of this strategy in Viet Nam using a randomized controlled design, and provide high quality evidence that will be valuable in efforts to enhance both the reach and quality of mental health services in low-resource settings. Further, we intend to build upon the research that has already been undertaken in this area to examine optimal implementation and knowledge translation strategies. However, it is essential to address the feasibility issues that exist in implementing such an intervention in a country such as Viet Nam. In order to lay the foundation for a full randomized controlled trial, we are proposing a feasibility study that will obtain pilot data and will promote a well-designed study and improve the likelihood of a successful scale-up and implementation of primary healthcare enhancements.
The target population for our intervention will be primary healthcare providers such as general practitioners and other healthcare providers (e.g., ‘commune health workers’) who work at the level of primary healthcare. We will aim to achieve specific changes in their practice, including: the incorporation of enhanced, yet very brief standardized assessment of common mental health conditions; adherence to brief effective interventions when indicated, and; implementation of a ‘supported self-management’ strategy that has been shown to be effective and also has the benefit of engaging patients, families and communities in health promotion and illness prevention strategies (Bilsker & Goldner 2011). This ‘package’ of enhancements has been successfully implemented previously in various settings, achieving proof-of-concept and some of the current investigators have been involved in successful implementation and research studies in Canada. Subsequently, our team wishes to prepare a proposal for a full cluster randomized controlled trial of enhanced primary healthcare services for depression, following the methodological approaches applied in other studies (Araya et al. 2003; Dietrich et al. 2004; Genschen 2009; Patel et al. 2010) while adding unique research components to further extend the knowledge base in this area. Working as an integrated team, the Viet Nam and Canadian investigators intend to undertake the important pilot and feasibility activities that will be important to this program of research. The Viet Nam investigators will ensure that the study is designed optimally to fit the cultural context and the Canadian investigators will contribute research experience and familiarity with implementation of the interventions, providing a foundation for refinement, testing and implementation of an approach that is well suited to the environment. Moreover, one of the collaborators (Lee) will bring particular expertise related to the effects of globalization on health care services in Asia and will help to ensure that the refinements that are incorporated fit well with anticipated trends and developments.
Amongst the target population for the interventions we will implement, an important subgroup will be the group of healthcare workers known in Viet Nam as ‘commune health workers’. They provide a range of primary healthcare services and could greatly assist with the provision of first contact mental health services. One of the aims of the project will be to develop refinements that will be successful in enhancing the role of this group of health workers in relation to mental healthcare. This group will play an important role in enhancing community-based care and rehabilitation through ‘supported self-management’ strategies (Bilsker & Goldner 2011).
Although the key target population for our intervention will be primary healthcare service providers, the outcomes that will be measured will examine both outcomes in relation to the service providers and individuals receiving services. By the end of this project, our proof of concept will establish whether or not a full study of primary mental health care enhancement can be successfully undertaken and implemented in Viet Nam. We will have materials and measures that have been tested for acceptability and validity. Careful field testing will have helped us to refine our procedures and approaches to optimize success and we will establish realistic recruitment numbers. Our goal will be to have all conditions, materials, relationships and structures well in place to undertake a successful randomized trial and implementation study.

Impact: Improved Quality of Primary Healthcare Services in Identification and Treatment of Depression in Viet Nam
Outcome(s): Determination of Feasibility of Implementing Primary Mental Healthcare Enhancement for Identification and Treatment of Depression in Viet Nam
Objectives Activities Critical milestones / Metrics of success Estimated dates Risk assumption
Objective 1: To engage and develop collaboration with key stakeholders, knowledge users and influential organizations working in mental health services in Vietnam Activity 1.1:
Consolidation of Policy-Maker Support Qualitative measures of engagement and support from key policy makers in Viet Nam government Month 1 - 24
Activity 1.2:
Engagement of General Physicians and other Healthcare Providers
Qualitative measures of engagement and support from key physician and healthcare professions leaders and organizations Month 1 - 24
Activity 1.3:
Engagement of Provincial and Local Health Administration
Qualitative measures of engagement and support from Provincial and Local Health Administration Month 1 - 24
Objective 2:
Localize the

Kết quả (Việt) 1:

Toàn cầu sức khỏe tâm thần hạt giống GrantDự án tiêu đề: nghiên cứu khả thi để chuẩn bị cho ngẫu nhiên thử nghiệm của tăng cường chính tâm thần chăm sóc sức khỏe thực hiệnMô tả dự án A.I) dự án tác động và nềnKhủng hoảng đã được tìm thấy là một tình trạng phổ biến tại Việt Nam với những đặc tính tương tự như tìm thấy trong phần còn lại của thế giới (Vương et al. năm 2011). Mặc dù dịch vụ y tế chính có thể truy cập tại Việt Nam với dân số nói chung, đó là rất hạn chế quyền truy cập vào chuyên gia dịch vụ cho phổ biến rối loạn tâm thần như trầm cảm. Đề xuất này là dành cho một nghiên cứu tính khả thi, được thực hiện để chuẩn bị cho một dự án tiếp theo sẽ thực hiện một cụm ngẫu nhiên kiểm soát xét xử của nâng cao dịch vụ chăm sóc y tế chính cho trầm cảm ở Việt Nam. Chương trình này của nghiên cứu có tiềm năng để có một tác động biến đổi về chất lượng dịch vụ sức khỏe tâm thần cung cấp cho một tỷ lệ lớn của Việt Nam có kinh nghiệm tình trạng tàn tật và đau khổ là kết quả của rối loạn tâm thần phổ biến, đô thị này có dân. Hơn nữa, nó có tiềm năng để chứng minh bằng chứng của khái niệm cho những cải tiến chính chăm sóc sức khỏe cho sức khỏe tâm thần vấn đề thường gặp ở thấp - và middle - thu nhập quốc gia, vì vậy địa chỉ một gánh nặng lớn của bệnh thông qua một sự can thiệp chi phí thấp có thể dễ dàng tích hợp vào các dịch vụ sẵn có.Những thách thức cụ thể được đề cập trong đề xuất này là:• Tích hợp chiếu và lõi gói dịch vụ vào thói quen chăm sóc sức khỏe ban đầu • Cung cấp hiệu quả và giá cả phải chăng chăm sóc dựa vào cộng đồng và phục hồi chức năng • Phát triển của phương pháp điều trị hiệu quả cho sử dụng bởi các chuyên gia phòng không • Kết hợp chức năng khiếm khuyết tật vào đánh giá Nó đã được cũng thành lập một phương tiện hiệu quả của việc thực hiện các cải tiến chất lượng của dịch vụ sức khỏe tâm thần cho phổ biến các vấn đề sức khỏe tâm thần (ví dụ như, trầm cảm) là thông qua các biện pháp can thiệp nhằm vào những thay đổi trong thực hành y tế chính (ví dụ như, Gilbody et al., 2003; Griffiths & Christensen 2008; Genischen et al. 2009; Patel et al. 2010). Nhóm nghiên cứu của chúng tôi dự định để kiểm tra tính khả thi của việc thực hiện một cách tiếp cận nâng cao đến địa chỉ khủng hoảng bởi chính các nhà cung cấp chăm sóc y tế tại Việt Nam. Chúng tôi dự định để kiểm tra tính khả thi của một cách tiếp cận đó nhằm mục đích để thay đổi có hiệu lực chính y tế thực hành thông qua một phối hợp một cách cẩn thận và được hỗ trợ phát hiện và can thiệp chương trình được thiết kế đặc biệt để nâng cao chất lượng dịch vụ sức khỏe tâm thần trong chính các học viên y tế. Một cách tiếp cận như vậy đã chứng minh là có hiệu quả tại Chi-lê (Araya et al. 2003) và có tồn tại một lý do mạnh mẽ cho cách tiếp cận này có tiềm năng biến đổi ở Việt Nam và thấp - và middle - thu nhập quốc gia khác (Patel et al. năm 2009).The rationale for and success of such primary mental healthcare enhancements include: the extensive contact and ‘reach’ that primary healthcare providers (including general practice physicians and other front-line health workers) have with large numbers of people with common mental disorders (Dietrich et al. 2004); the clinical effectiveness of relatively small behavioural changes by primary healthcare providers in addressing mental health issues and the relatively low cost and high return on investment of such improvements to primary healthcare practice (Patel et al. 2009), and; the well-developed evidence base to guide successful knowledge translation and implementation of educational interventions in primary healthcare (Goldner in press).A number of countries and regions have implemented specific initiatives focused on primary mental healthcare enhancement. These have been undertaken primarily within high-income countries, however policy-makers, clinicians and scientists now see excellent potential for similar approaches in low and middle-income regions (Patel et al. 2009) and preliminary evidence has been demonstrated in trials in Chile (Araya et al. 2003) and India (Patel et al. 2010). Previously, Vietnam had focused heavily on institution-based mental healthcare but there has been a substantive movement in the past few decades to replace institutional care with community-based mental health services and this has been established as a policy goal since 1999. Consequently, this program of research would greatly assist this important transformation of mental health service delivery. We wish to study the effectiveness of this strategy in Viet Nam using a randomized controlled design, and provide high quality evidence that will be valuable in efforts to enhance both the reach and quality of mental health services in low-resource settings. Further, we intend to build upon the research that has already been undertaken in this area to examine optimal implementation and knowledge translation strategies. However, it is essential to address the feasibility issues that exist in implementing such an intervention in a country such as Viet Nam. In order to lay the foundation for a full randomized controlled trial, we are proposing a feasibility study that will obtain pilot data and will promote a well-designed study and improve the likelihood of a successful scale-up and implementation of primary healthcare enhancements. The target population for our intervention will be primary healthcare providers such as general practitioners and other healthcare providers (e.g., ‘commune health workers’) who work at the level of primary healthcare. We will aim to achieve specific changes in their practice, including: the incorporation of enhanced, yet very brief standardized assessment of common mental health conditions; adherence to brief effective interventions when indicated, and; implementation of a ‘supported self-management’ strategy that has been shown to be effective and also has the benefit of engaging patients, families and communities in health promotion and illness prevention strategies (Bilsker & Goldner 2011). This ‘package’ of enhancements has been successfully implemented previously in various settings, achieving proof-of-concept and some of the current investigators have been involved in successful implementation and research studies in Canada. Subsequently, our team wishes to prepare a proposal for a full cluster randomized controlled trial of enhanced primary healthcare services for depression, following the methodological approaches applied in other studies (Araya et al. 2003; Dietrich et al. 2004; Genschen 2009; Patel et al. 2010) while adding unique research components to further extend the knowledge base in this area. Working as an integrated team, the Viet Nam and Canadian investigators intend to undertake the important pilot and feasibility activities that will be important to this program of research. The Viet Nam investigators will ensure that the study is designed optimally to fit the cultural context and the Canadian investigators will contribute research experience and familiarity with implementation of the interventions, providing a foundation for refinement, testing and implementation of an approach that is well suited to the environment. Moreover, one of the collaborators (Lee) will bring particular expertise related to the effects of globalization on health care services in Asia and will help to ensure that the refinements that are incorporated fit well with anticipated trends and developments. Amongst the target population for the interventions we will implement, an important subgroup will be the group of healthcare workers known in Viet Nam as ‘commune health workers’. They provide a range of primary healthcare services and could greatly assist with the provision of first contact mental health services. One of the aims of the project will be to develop refinements that will be successful in enhancing the role of this group of health workers in relation to mental healthcare. This group will play an important role in enhancing community-based care and rehabilitation through ‘supported self-management’ strategies (Bilsker & Goldner 2011).
Although the key target population for our intervention will be primary healthcare service providers, the outcomes that will be measured will examine both outcomes in relation to the service providers and individuals receiving services. By the end of this project, our proof of concept will establish whether or not a full study of primary mental health care enhancement can be successfully undertaken and implemented in Viet Nam. We will have materials and measures that have been tested for acceptability and validity. Careful field testing will have helped us to refine our procedures and approaches to optimize success and we will establish realistic recruitment numbers. Our goal will be to have all conditions, materials, relationships and structures well in place to undertake a successful randomized trial and implementation study.

Impact: Improved Quality of Primary Healthcare Services in Identification and Treatment of Depression in Viet Nam
Outcome(s): Determination of Feasibility of Implementing Primary Mental Healthcare Enhancement for Identification and Treatment of Depression in Viet Nam
Objectives Activities Critical milestones / Metrics of success Estimated dates Risk assumption
Objective 1: To engage and develop collaboration with key stakeholders, knowledge users and influential organizations working in mental health services in Vietnam Activity 1.1:
Consolidation of Policy-Maker Support Qualitative measures of engagement and support from key policy makers in Viet Nam government Month 1 - 24
Activity 1.2:
Engagement of General Physicians and other Healthcare Providers
Qualitative measures of engagement and support from key physician and healthcare professions leaders and organizations Month 1 - 24
Activity 1.3:
Engagement of Provincial and Local Health Administration
Qualitative measures of engagement and support from Provincial and Local Health Administration Month 1 - 24
Objective 2:
Localize the