Evaluating the Implementation and Impacts of Integrated Depression and Diabetes Treatment in India: A Process Evaluation of the INDEPENDENT Study 公开
Johnson, Leslie Carol Munoz (Fall 2018)
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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