Evaluating the Implementation and Impacts of Integrated Depression and Diabetes Treatment in India: A Process Evaluation of the INDEPENDENT Study Restricted; Files Only

Johnson, Leslie Carol Munoz (Fall 2018)

Permanent URL: https://etd.library.emory.edu/concern/etds/8s45q980c?locale=en
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Abstract

The mental health treatment gap in low- and middle-income countries (LMICs) is a significant public health problem. The number of people living with chronic diseases is increasing in LMICs, with depression negatively impacting people’s health and chronic disease management. Faced with a shortage of trained mental health professionals and a high burden of diabetes, India presents an ideal setting to test a non-specialist health worker-led, chronic disease-focused depression treatment model. There is growing evidence that integrated models of chronic disease care offer effective, low-resource alternatives to specialty mental health care, but currently there is a lack of evidence documenting how integrated depression treatment models are implemented and adapted for use in LMICs. The INDEPENDENT study was designed to test a collaborative, health worker-led care delivery model for depression and diabetes in ambulatory diabetes clinics in India. The aim of this mixed methods dissertation was to fill this gap in the literature and gain a comprehensive understanding of how health care providers implement an integrated depression and diabetes care model in India, and how patients respond to this model of care. Three studies were conducted as part of this dissertation. Study one identified what resources, mechanisms, and contextual factors are necessary to successfully integrate depression treatment in the diabetes care setting in India. Study two identified the factors that determine patients’ motivation to engage in an integrated depression treatment model and self-manage their diabetes and depressive symptoms. Study three identified patient practices and strategies that enabled patients receiving the INDEPENDENT care model to reduce their depressive symptoms and self-manage their chronic conditions. Results of this dissertation suggest that the successful implementation of an integrated depression and diabetes care model is feasible in a low-resource setting, but that care coordinators require additional support and training if they are to take on the burden of patient mental health care. The accumulation of health education, motivation, and engagement triggered patient activation, with positively deviant patients identifying strategies to overcome barriers to self-management. Future work should test the presented program theories in new settings to evaluate how different contexts impact implementation processes and patient experiences.  

Table of Contents

Chapter 1: Introductory Literature Review............................................................................................................1

      The INDEPENDENT Care Model.......................................................................................................................4

      Facilitating the Successful Implementation of Integrated Care Models...........................................................9

      Evaluating the Implementation Process..........................................................................................................15

      Rationale for Research.....................................................................................................................................22

      Figures and Tables

Figure 1.1 Factors that Contribute to the Bi-directional Relationship between Diabetes and Depression..25

           Figure 1.2 PARIHS Framework Constructs and Sub-elements.....................................................................26

           Figure 1.3 PARIHS Framework Matrix of Influence.....................................................................................27

           Figure 1.4 Realist Evaluation Context-Mechanism-Outcome Configuration..............................................28

      Chapter 1 References.......................................................................................................................................29

Chapter 2: A Realist Process Evaluation of a Chronic Disease-focused Depression Treatment Model in India....44

      Abstract...........................................................................................................................................................45

      Introduction....................................................................................................................................................46

      Methods..........................................................................................................................................................50

      Results............................................................................................................................................................54

      Discussion......................................................................................................................................................68

      Conclusion.....................................................................................................................................................75

      Figures and Tables

           Figure 2.1 INDEPENDENT Care Process....................................................................................................77

           Figure 2.2 Logic Model of the INDEPENDENT trial...................................................................................78

           Table 2.1 Hypothesized Context-Mechanism-Outcome Configurations (CMOCs)....................................79

           Table 2.2 Study Phases with Respective Data Collection Methods and Analytic Approach.......................80

           Table 2.3 Health Care Provider Sampling..................................................................................................81

           Table 2.4 Organization of EXCEL Analysis Spreadsheet............................................................................82

 Figure 2.3 The Ways Implementation Actors are Involved with Intervention Activities Composing the INDEPENDENT Care Model...83

 Figure 2.4 Mental Health Treatment Related Contexts, Mechanisms, and Outcomes...............................84

           Figure 2.5 Case Review and Patient Follow-up Related Contexts, Mechanisms, and Outcomes...............85

           Figure 2.6 Specialist Oversight Related Contexts, Mechanisms, and Outcomes.......................................86

           Table 2.5 Rationale for Anti-Depressant Treatment Prompt Modification...............................................87

           Figure 2.7 Revised Program Theory..........................................................................................................88

      Chapter 2 References....................................................................................................................................89

Chapter 3: Factors that Facilitate Patient Activation in the Self-management of Diabetes and Depression in India...94

      Abstract........................................................................................................................................................95

      Introduction.................................................................................................................................................96

      Methods.......................................................................................................................................................99

      Results.......................................................................................................................................................105

      Discussion.................................................................................................................................................118

      Conclusion................................................................................................................................................124

      Figures and Tables

           Table 3.1 Hypothesized Context-Mechanism-Outcome Configuration (CMOC)..................................126

           Figure 3.1 INDEPENDENT Evaluation Study Recruitment...................................................................127

           Figure 3.2 Revised Program Theory.....................................................................................................128

Figure 3.3 Patient Participation and Self-Management Related Contexts, Mechanisms, and Outcomes...129

Table 3.2 Characteristics of VIP Treatment..........................................................................................130

      Chapter 3 References...............................................................................................................................132

Chapter 4: Practices and Strategies that Differentiate Patients Who Achieved the Highest and Lowest Reduction in Depressive Symptoms through Engagement in an Integrated Depression and Diabetes Care Model...140

      Abstract...................................................................................................................................................141

      Introduction............................................................................................................................................142

      Methods..................................................................................................................................................145

      Results....................................................................................................................................................149

      Discussion..............................................................................................................................................157

      Conclusion.............................................................................................................................................162

      Figures and Tables

           Figure 4.1 Extreme Arm Patient Recruitment...................................................................................164

           Figure 4.2 Example Timelines for Extreme Arm Patients in Both Groups.........................................165

           Figure 4.3 Depressive Symptoms among Extreme Arm Patients Over Time.....................................166

           Figure 4.4 Patient Health Outcomes among Extreme Arm Patients across Both Sites at Baseline...167

           Figure 4.5 Spectrum Display of Data from Thematic Issues.............................................................168

      Chapter 4 References............................................................................................................................169

Chapter 5: Overall Summary and Conclusions...........................................................................................174

      Implementation of Mental Health Treatment......................................................................................177

      Chronic Disease Self-Management.......................................................................................................179

      Implications for Future Research.........................................................................................................185

      Conclusion...........................................................................................................................................187

Chapter 5 References................................................................................................................................189

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