Understanding the current patient care for people from hill tribes with depression
(1) Micro-level. Most people did not understand depression, especially its definition, causes, and symptoms. They did not define depression as an emotional disorder that needed to be cured. Instead, they defined it as overthinking, suffering, isolation, laziness, headache, insomnia, and parasomnia. For them, it meant a 'Phi-Ba' or 'mad ghost', which was an evil spirit that resided in a person with depression or mental health problems. Therefore, it was associated with stigma for individuals and families to have mental health problems. Hence, it was difficult for them to understand and accept. Furthermore, they also had limitations in accessing the healthcare centre due to no Thai identification documents, communication barriers, travel obstacles, and economic issues.
(2) Meso-level.
2.1 Current depression care at the healthcare centre. We identified depressed cases when they came to the primary healthcare centre for care and treatment of their physical illness. The healthcare centre did not have an explicit system for direct depression screening. Additionally, there was no mental health clinic or specific psychosocial treatment for patients with mild and moderate depression. However, in severely depressed cases, the primary healthcare providers referred them to a specific healthcare centre/tertiary hospital. Primary healthcare providers were only responsible for home visits and cooperation with the relevant health resources.
2.2 Strengths of the current depression care in the Ban Lao-Fu community. The stakeholders were willing to solve the communities’ depression problems and help with universal health insurance and other issues. Notably, most community members loved their families and community, and supported each other. They always gathered on Sunday at the church for choir singing and to worship God. Participating in these services and cultural-related ceremonies provided the community with a sense of unity and mental support for each other. Moreover, the community members believed in and followed the heads of their communities. Through village loudspeaker broadcasting, they received information, news, and announcements from their community leaders (village heads).
2.3 Barriers to current depression care in the Ban Lao-Fu community. We found that VHVs and community members had low self-awareness and knowledge regarding mental health issues. They defined depression as an ordinary situation that could occur in everyone. Interestingly, they did not think that this problem required help from healthcare services. Since they were poor and had a low education level, they, similar to other community members, mostly paid more attention to their basic needs compared to health issues. In addition, the VHVs’ competency in caring for people from hill tribes with depression was low, especially regarding screening and basic counselling skills. Moreover, some could not speak the Thai language. Although the primary healthcare service had translators, some patients with depression did not trust and talk with the translators and health providers since depression was considered a sensitive and confidential issue. Besides these barriers, personal obstacles (for example, personality and perception) and their culture contributed to inaccessibility to depression care and treatment. Concerning the culture of self-care practice, when they were sick, most prayed to their ancestor ghosts ('Phi Banpaburut') to get better or obtain protection. Therefore, almost every household had an ancestor worship altar (‘Hing Banpaburut’). They also believed that one had a physical or mental health problem due to 'Phi-Ba' or a mad ghost that replaced one's good spirit ('Kwan'). This Phi-Ba resided in an ill person who had a weak Kwan. To chase away this evil spirit and bring back a good spirit, they had to do a ritual ceremony of 'Reak Kwan', which was to call a good spirit back to that person. This practice and belief had both positive and negative impacts on an individual’s health. Negatively, they did not seek help and care from professional healthcare providers and services. Positively, the practice and ceremony provided them with mental support from the ceremony leaders and people who participated. It also brought hope and a positive mind of getting better to the patients and their families.
2.4 Depression management. Most people from hill tribes with depression used emotion-focused coping skills to deal with their problems. They did not have enough coping skills to deal with them directly (appraisal-focused coping skills). There was no surveillance program to regularly screen and monitor patients with depression in the community.
(3) Macro-level. Although the Thai government supported the healthcare teams in screening individuals’ mental health and referring cases by following the public health guideline, it was not suitable for the hill tribes' context (communication problems and culture/beliefs). The mental health policy was appropriately established for the general population but was not suitable for the hill tribes due to communication problems, travel obstacles, and economic issues.
Developing a caring model for the hill tribes with depression.
After we reviewed and synthesized the data, we established the goals of each level regarding the ICCC framework and developed the depression care model.
(1) Micro-level. Building blocks at the patient and family interaction level
According to the ICCC framework [11], patients and their families, community partners, and healthcare teams achieved positive outcomes for chronic conditions only when they worked together, and patients and families were informed regarding their health conditions, motivated to change and maintain them, and prepared to learn behavioural skills. Therefore, our goal was to encourage patients with depression and their families to participate in activities with the community and VHVs. Families, VHVs, and community members could support patients with depression to increase their self-esteem and manage their problems themselves.
(2) Meso-level. Building blocks for the healthcare organization and community
Concerning the ICCC framework, healthcare organizations and leaders in the community could raise awareness and reduce stigma. In addition, the community could achieve better outcomes through community leadership, support, resource mobilization, coordination, and complimentary services. Hence, our goal was to raise awareness and increase the competency of VHVs as community members and healthcare leaders in the community for dealing with patients with depression. The competency preparation consisted of providing health information on how to care for patients with depression and preparing effective health strategies to increase self-awareness and reduce stigma. We also aimed to support and cooperate with healthcare organizations and other community resources for depression screening, prevention, and treatment.
(3) Macro level. Building blocks for a favourable policy environment
At this level, the policy environment to support chronic healthcare in the community included leadership and advocacy, policy integration, consistent financial support, human resource development and allocation, legislative framework, and partnership strengthening. Consequently, our goal was to provide and create a healthcare policy that supported healthcare, related organizations, and the community in caring for patients with depression. These organizations included sub-district administrative organizations, administrative staff, heads of the hill tribes, and community leaders. The policy changes included strategies to increase access to healthcare centres for patients with depression even without the Thai identification documents required to receive universal healthcare. These patients have access to social welfare benefits and services such as routine transportation from the villages to the hospitals, the home-visit program conducted by well-trained healthcare staff, and funding offered by the local government to support the patients during their treatment process. They helped and coordinated with patients, their families, the community, and other related organizations to facilitate the hill tribes’ access to mental health services, even without Thai identification documents.
To reach all the goals, we created a new care model for people from hill tribes with depression. We named it ‘SMILE’ and implemented it through activities that aimed to inform, motivate, and prepare patients, families, and the community for depression care. The model aimed to increase patients’ self-awareness and self-esteem and involve the community and stakeholders in the depression care model. Each letter of the ‘SMILE’ model was defined as:
S: stakeholders' readiness to care for people from hill tribes with depression.
M: motivation of people from hill tribes with depression to change their behaviours and of their family and community in depression care. The motivation was divided into two parts: external and internal motivation. The external motivation was the power of stakeholders that supported the patients with depression to receive treatment. The internal motivation was the power of mind among the stakeholders and people from hill tribes with depression for enhancing the willingness to engage in care. Internal and external motivations were developed through the motivation strategies of "we think, we can do" to improve self-esteem among the patients and the self-confidence of the families and community members, particularly VHVs in depression care [22].
I: interpersonal relationships, such as the relationship between patients, their family members or relatives, VHVs, and community leaders, or the relationship between patients and their families and healthcare providers. Interpersonal relationships were built and promoted through all activities and programs in the model’s development and implementation.
L: 'life and community asset' of the hill tribes. People from the hill tribes loved their families and community. They viewed their lives in positive ways, and always had hope for the future. They believed in and followed their tribe’s heads. The community had four churches that provided them with positive mental and spiritual support.
E: 'empowerment'. To achieve the goals of model implementation, the stakeholders, such as healthcare providers, needed to empower the patients, their families, VHVs, and community members to take care of the patients with depression, based on their culture and contexts (Fig. 2).
Concept of the "SMILE" model
We developed this model based on humanistic theory, which emphasizes that people have motives and rational beliefs, and that they can be socialized. Everyone could choose their way to improve competency and achieve their goal if they had enough freedom to decide and environmental support. All these led them to be a full potential person with self-actualization. Roger classified the human-self into three characteristics [23]; 1) perceived self, which was defined as how a person saw the self and others saw them; 2) real self or authentic self, which was how a person truly was; and 3) ideal self, which was how a person would like to be. To decrease depression, patients, their families, the community, healthcare providers, and other stakeholders should work together to help the patients recognize their perceived, real, and ideal selves and be aware of their problems. For a flow diagram of the depression care model based on family and community participation, see Fig. 2.
Training VHVs in the “SMILE” Model
For VHVs, we provided 28 VHVs with a three-day health education program. We invited stakeholders, such as healthcare providers at the healthcare centre and mental health care personnel, to participate in the training. The program included depression care, basic health counselling, and VHVs' roles in mental health problems. We involved a real patient in a counselling role play performed by a VHV and led by a psychologist. This patient shared with the community to overcome the stigma.
In all the activities, 15 stakeholders, including 7 community leaders, 4 heads of the hill tribes, 2 officers from the local administration organization of Ban Lao-fu and 2 healthcare providers, supported the implementation of SMILE model and the mental health policy, guided by the Ministry of Public Health. They helped and coordinated with patients, their families, the community, and other related organizations to facilitate the hill tribes’ access to mental health services, even without Thai identification documents.
Basic screening and counselling for village health volunteers.
Of the 28 participants, 78.60% were female, see Table 1. The participants’ ages ranged from 32 to 58 years old, with a mean age of 42.32 years (SD = 6.00). The majority (92.9%) of the participants were married. Most participants had a primary school education (82.10%), and 57.14% had sufficient income.
Among the 28 VHVs who attended the workshop, we found that they had more depression screening skills compared to before and could provide basic health counselling to the patients and families. We also used the Wilcoxon signed-rank test to assess the scores of knowledge relevant to depression and the roles of VHVs before and after the training. In accordance with Table 2, both scores were significantly increased (p<0.001).