Transcript Situational analysis health care services for….: a case study

Preliminary study of the situation of health care
services for persons with depressive symptoms:
the case study from Yasothorn province
Acharaporn Seeherunwong* DNS, RN, Assist. Prof.
Prapa Yuttatri* DNS, RN, Assist. Prof.
Atittaya Pornchaikate* PhD (Nursing), RN
Walailak Pumpuang* MA (Ed. Psy. and guidance)
Kedsaraporn Kenbubha** MSc (Epidemiology)
Chintana Polmesak*** BSc (Public Health)
Therapa Thanee** MEd (Guidance and Counseling)
* Faculty of Nursing, Mahidol University
** Prasrimahabhodi Psychiatric Hospital
*** Provincial Public Health Office
Acknowledgements
• Department of Mental Health, Ministry of
Public Health
• Staff from Provincial Public Health Offices
• Director and Staff from Prasrimahabhodi
Psychiatric Hospital
• Consultants: Thoranin Kongsuk, Director of
Prasrimahabodhi Psychiatric Hospital
: Siriorn Sindu, Assoc. Prof.,
Faculty of Nursing , Mahidol University
Background
• Depressive symptoms are a common
health problem founded in all level of
health services.
• Depressive disorders are the disorders that
have the highest DALYs score among all
psychiatric disorders (cause persons lose
their years of healthy living)
(Bureau of Policy and strategy, MOPH, 1999)
• Northeastern part of Thailand has the highest
prevalence of MDD (6.33%) and Dysthymia
(2.48%)
(The 2003 National Epidemiology Survey on Mental Health in Thailand, Department of Mental Health, MOPH)
Purposes of the study
• To explore health care services for
persons with depressive symptoms in
three parts: access to care, resources,
and competency of health care
providers.
Health resources
-Material
-persons
-Technology
-budget
Health care provider
competency
-village volunters
-nurses
-Physicians
Methods
• Design:
Qualitative research design
• Data collection:
- In depth interview
- Focus group
• Data analysis
- Content analysis
Key informants
- From in depth interview
- Total 45 persons
• 5 hospital directors & 1 physician
• 2 staff from Provincial Public Heath Office
• 20 nurses
• 4 staff from District Health Office
• 14 patients
Key informants (cont.)
- From focus groups
- Total 98 persons
• 2 times of focus groups with general health
care providers (12 persons)
• 1 time of focus group with nurses (4 persons)
• 11 times of focus groups with villages
volunteers (82 persons)
Settings
•
•
•
•
•
1 general hospital
2 community hospitals (60 beds)
5 community hospitals (30 beds)
9 large primary care units (PCU)
5 small primary care units
From 8/9 districts in Yasothorn province
Map of Thailand
Map of Yasothorn province
The province is subdivided
into 9 districts (Amphoe).
The districts are further
subdivided into 78
communes (tambon)
and 835 villages.
1.Mueang
Yasothon
2.Sai Mun
3.Kut Chum
4.Kham
Khuean Kaeo
5.Pa Tio
6.Maha
Chana Chai
7.Kho Wang
8.Loeng Nok
Tha
9.Thai
Charoen
Pathway of receiving mental health services
Prasrimahabhodi Psychiatric Hospital
(PPH)
Formal service
pathway to be
covered by the
universal health
care coverage
(30 Baht policy)
General hospital
Community hospital
Primary care unit
(PCU)
- Patients receive
services at own
convenience
(pay for services
by themselves)
- 2 emergency
visits covered by
the 30 Baht
policy)
Pathway for continuing care in community
Phrasrimahabodi (PPH)
General hospital
Community hospital
Primary care unit
(PCU)
PPH refers patients to hospitals or PCU nearby their home
PPH informs PCU to provide home visit to patients
Results
• 3 major aspects
- Health Resources
Policy
Budget
Materials
Personnel
- Competency of Providers
Physicians
Nurses
Public health officers
Village volunteers
- Access to Health Care
Promotion
Prevention
Care and Cure
Rehabilitation
Health resources
4 aspects were considered
Policy
Budget
Materials
Personnel
Health resources: Policy
• There were top-down policies regarding
mental health issues from MOPH to all local
service centers.
• No specific policy about promotion and
prevention of depression, though policy to
decrease the rate of suicide was apparent.
• In addition to projects that served the central
policy, many hospitals/PCU developed their
own projects to serve the need of people in
the community
Health resources: Budgets
• Budgets were received from MOPH and MOI:
local administrative organization)
• No specific budgets for mental heath services
(Budgets were shared among all other
services within the hospitals/PCU).
• Allocation of budgets to mental health
projects depended on abilities and interests
of hospital directors and mental health teams.
Health resources: Materials
• Instruments for screening and case findings
of depression were available at all service
levels. Yet, no practice guideline as to when
such instruments would be used.
• No standardized criteria for screening risk
groups and also for treatment of depressive
symptoms.
• Most of the treatment provided at
hospitals/PCU follow guidelines from
Prasrimahabhodi Psychiatric Hospital
Health resources: Materials
• There was only TCA group (e.g.
amitriptyline) available for the treatment of
depression
• No document about depressive symptoms/
disorders provided to lay persons
Health resources: Personnel
•
•
•
•
Physicians
No psychiatrist, 1 psychologist
Normally one community hospital had 2-3
physicians
Each day one physician had to take care of
more than 100 patients; they thus did not
have much time to assess patients with
mental health problems.
Most physicians who took care of
psychiatric patients only went through short
course training in mental health.
Health resources: Personnel
Nurses
• In PCU: one professional nurse and one
public health officer
• In community hospitals: 2-3 professional
nurses and 2-3 technical nurses working in
the psychiatric sector (some hospitals had 1-2
advance practice nurses)
• In general hospital, 5 nurses working in
psychiatric unit
Health resources: Personnel
Village volunteer
• Village volunteers received training and
worked together with health care
providers at the PCU in health promotion
and prevention in their community.
• 1 village volunteer took care of 10
households.
Health care provider competency
•
•
•
•
Physicians
Professional nurses
Public health officers
Village volunteers
Competency: Physicians
• Physicians’ skills in detecting and giving
treatment of depressive symptoms depended
on their experience.
• Physicians working more than 10 years had
more skills in detecting depressive disorders
than the novice.
• Physicians normally referred patients with
depressive symptoms to psychiatric hospital
for diagnosis and treatment.
Competency: Registered nurses
• Had skills in mental health promotion and
prevention and establish good relationship
with people in the community.
• Had skills in providing psycho-education
and counseling for persons with stress and
anxiety.
• Limited skills in detecting depressive
symptoms and provide psychosocial
treatment for psychiatric patients.
Competency: Public health officers
• Worked together with the health care team
in promoting mental health for people in the
community, but no specific roles in
assessing and providing care for people
with mental health problems
Competency: Village volunteers
• Some Village volunteers had knowledge in
taking care of persons with depressive
symptoms but no skills in detecting such
symptoms
• They visited and provided support for
people at-risk for depressive disorders and
persons after attempted suicide.
• They participated in health promotion
projects.
Access to care
•
•
•
•
Promotion
Prevention
Care & Cure
Rehabilitation
Access to care: Promotion & Prevention
• Promotion & Prevention
- Had policies about mental health
promotion and also projects to promote mental
health developed by health care providers
together with people in the community
(increase community participation)
- Had elderly club
- Had health promotion project at school
Access to care: Promotion & Prevention
- Had friend-corner at school (student
leaders helped screen friends who had
problems and refer for help)
- Covered in certain areas and age
groups depending on priority setting at the
hospitals/health services centers and
budgets allocated
Access to care: Care & Cure
• Had responsible personnel worked directly
in mental health sector in community and
general hospitals.
• Screened mental health problems in
chronic illness patients
• Developed psychosocial interventions for
chronic illness patients
• Followed up treatment among psychiatric
patients
Access to care: Care & Cure
• Lack of awareness: village volunteers, patients,
and their relatives did not aware of depressive
symptoms (thought that such symptoms were
normal) so they did not come for treatment.
• Under detection and misdiagnosis: some
patients came to the health care center, but did
not get detected (due to limitation of providers’
skills)
• Low priority setting: less severity than physical
problems and took time to assess and detect
Access to care: Care & Cure
• In order for the treatment to be covered by
the 30-bath policy, patients had to follow the
formal pathway of treatment
• Limited choices of treatment
• only had Amitriptyline
• focus only on treating with medicines, no
other psychosocial treatment.
• Limited choices of care
• no psychosocial intervention
Access to care: Care & Cure
• Financial difficulty
• Many patients had little to no money for
drugs & transportation
• Transportation difficulty
• not enough public transportation.
Access to care: Rehabilitation
• Had good referral and follow-up systems
• For known cases, had good referral systems
by attempting to refer patients to receive
treatment at nearby hospitals
• Some patients were afraid of stigma and
willing to go to receive treatment at further
psychiatric hospital (not in the community)
• Support systems were mainly from family
Access to care: Rehabilitation
• No formal community services such as
self-help group, government and NGO for
helping psychiatric patients.
• Having continuing care on drug
adherence, but no resources for helping
patients regarding social and occupational
functioning
Discussion
• Mental health problems were set in low
priority by many health care providers when
compared to physical illness:
• Less severity
• Take time to assess and detect mental
illness
• Less confidence to provide diagnosis and
treatment
Discussion
• Since Thai culture is a collective society
which normally peoples take care of each
other like their relatives, having village
volunteers to take care of peoples in the
community fit well with the life-style.
• Some other health promotion projects also
helped promote mental health.
Suggestion
• Health care providers need more training
to enhance their knowledge and skills in
detecting and taking care of persons with
depression.
• Mental health services should be
available at the community level nearby
patients' home.
Suggestion
• Raise awareness of people in the
community about depressive symptoms
and that depressive symptoms are
treatable and manageable
• Promote mental health through out the life
span (e.g. stress management skills).
• Promote community participation and
provision of support to patients
Suggestion
• Improve providers’ skills in detecting
depressive symptom, especially, at the
screening section of the OPD
• Broaden antidepressant drug frame for the
community hospitals to cover wider ranges of
antidepressant drugs for patients
• Should have guideline for screening
depression in high risk groups
• Should have occupational and social
rehabilitation projects for patients with
depressive disorders.
Conclusion
• Mental health care services at Yasothorn
province are growing.
• Many health care providers put their efforts
in improving and providing mental health
services for people in their community.
• However, patients with depressive disorders
remain under detected. Raising awareness
and enhancing knowledge and skills of
providers and people in the community
about depressive symptoms and that
depressive symptoms are treatable and
manageable are important