Participants’ accounts are organised by the research questions. Some were more relevant to particular participant groups, evident from the data presented. Where there are differences by country, healthcare facility, participant group, NCD or gender these are highlighted.
Q1. How is NCD care delivered?
All four NCD centres provided the same services: screening and monitoring (e.g. blood pressure, blood glucose, height/weight), referral for diagnostic tests (e.g. ophthalmic tests for diabetes patients), advising on self-management (e.g. lifestyle, taking medication, attending follow-up appointments) and issuing prescriptions for medications.
“New” and existing NCD patients attended the services, some who had received treatment for many years, 14 years for one diabetes patient. Patients self-referred and could access this care, free of charge. Health workers described patients presenting with physical symptoms related to their NCD, for example breathlessness (respiratory and cardiovascular disease), chest pain and headaches (cardiovascular disease), high blood sugar, foot pain and fatigue (diabetes). They also mentioned that patients come with psychological and social issues related to their NCD (see below, Q2).
Despite Bangladesh and Pakistan both having relatively well-structured health systems, policy makers observed that they struggle to provide efficient NCD services. On the frontline, it was clear from patients and health workers that these NCD centres were incredibly busy, crowded environments. Health workers in Bangladesh reported treating 100 to 150 patients a day in the primary healthcare facility, of which 10 to 15 had an NCD, and 50 to 60 patients a day in the secondary healthcare facility, 10 with an NCD. In Pakistan, the numbers were typically 50–60 NCD patients a day in the tertiary facility and 100–200 in the secondary facility. This high volume meant there could be long waiting times (reported by patients as up to 3 hours in Bangladesh and 5 hours in Pakistan) in crowded rooms often with insufficient seating.
"When a person comes, he has to wait in line at four places and his whole day gets wasted. First, we make a chit [appointment slip], then we get our blood pressure checked, then blood sugar level, and then they give us prescription chit. Then they prescribe medicine and then we get in line at the medical store."
(P_A_PM08: male patient with diabetes, tertiary care facility, Pakistan)
The busy clinics also meant that appointments could be as short as five minutes with the doctor. Health workers and patients both recognised this was insufficient. Some patients considered that their health concerns were explored in detail, having received advice on related lifestyle issues e.g. nutrition, physical activity. Others were less satisfied, complaining that health workers did not listen, focused only on physical assessment, prescribing medication and asserting the importance of concordance.
Due to time constraints it is tough to counsel patients like about the consequences of not taking medicine regularly, and the side-effects of the medicines.
(B_S_HW45: consultant doctor, primary care facility, Bangladesh)
"Doctors just said that you have to take your medicines with caution, do not miss any dose, need to take all diabetes medicines and take care of yourself."
(P_A_PF24: female patient with cardiovascular disease, tertiary care facility, Pakistan)
A further implication of the busy clinics was a strain on medication supply. In Bangladesh, whilst most patients had received free medication for cheaper medicines e.g. antihypertensives, nebulisers; a few had been asked to pay for more expensive medicines like insulin. A lack of availability of medicines in Pakistan meant some patients had to collect and pay for them at a private pharmacy. These medication costs were recognised by health workers and patients as prohibitive for some, potentially leading to poor adherence to medicine regimes.
If medicines are prescribed from here, I collect them from the pharmacies outside. Here, the cheap medicines are available only – paracetamol, anti-ulcerants, anti-hypertensive drugs, drugs for fever. They do not provide medicines for diabetes, so I buy it.
(B_S_PF29: female patient with diabetes, primary care facility, Bangladesh)
"Whenever we come to get insulin, they tell us there is no insulin, insulin is provided on a separate day and sometimes when we come on that day, they say that insulin is finished. Then we don’t take it because I am a poor man and I cannot afford it."
(P_A_PM08: male patient with diabetes, tertiary care facility, Pakistan)
Despite these frustrations, patients continued to attend the NCD centres because they were accessible (free of charge), and the majority view was that doctors were competent and delivered good care. Indeed, patients’ overall assessment of their care appeared to be based on its effectiveness. In other words, it was viewed as “good” when NCD symptoms were reduced and poor when health did not improve.
I’m fine with the treatment that I am getting because when I came here, my condition was worse and now I’m able to talk and can walk to the washroom by myself. I follow all the advice.
(P_A_PM09: male patient with cardiovascular disease, tertiary care facility, Pakistan)
Q2. Do NCD patients experience distress - how?
Patients frequently described cognitive (negative thoughts, pessimism), affective (low mood, anger, worry, irritation, feeling stressed) and somatic (tiredness, headache, insomnia) symptoms commonly accepted as depression. Health workers also mentioned patients presenting with these symptoms.
Sometimes I do not feel like doing anything, not even eating a meal. Sometimes I feel like crying, from sorrow. Because I cannot take my medicines properly, cannot do anything properly.
(B_N_PF26: female patient with respiratory disease, secondary care facility, Bangladesh)
Patients have insomnia, they share their emotions, saying I sit all night and I was feeling panic and have been fighting a lot or weeping.
(P_A_HW42: house officer, secondary care facility, Pakistan)
Health workers in both Pakistan facilities estimated that 50% of NCD patients presented with mental health issues including depression, with one health worker in the secondary care facility suggesting it was as high as 90%. In Bangladesh, these estimates were 50% (primary care) and 20–60% (secondary care). In both countries, their perception was that the typical profile of these patients were women. A few health workers in Bangladesh believed that people with no/low education suffered more from depression as they were less likely to be able to accept their NCD diagnosis. Three health workers in Pakistan mentioned education, oscillating between either being highly educated or not educated as associated with depression.
Health workers’ interpretation and patients’ accounts suggested that patients did not typically view symptoms as a “separate illness” to their NCD or use the term “depression”.
Our patients are not oriented to it [mental health]. They are in depression, but they do not understand it. They are saying that they are suffering from diabetes or hypertension but the depression is a burden for the patient. It is a greater mental trauma than their diabetes, but patients do not have that understanding. They think that every disease is about physical illness.
(B_N_HW44: Medical officer, secondary care facility, Bangladesh)
Instead, distress was largely associated with their NCD and patients’ links to physical symptoms and disability as well as anxiety about the disease itself and the prognosis. Some patients referred back to when they were diagnosed, recalling their worry at that time.
“Most of the patients are suffering from depression because they think that these disorders are chronic illnesses and are only controllable but not curable and somatization of their symptoms.” (P_B_HW43: medical officer, tertiary care facility, Pakistan)
I had a lot of adjustments during first three months of being detected with high pressure. I was quite devastated mentally. I was scared because, if I die with stroke, what will happen to my family?
(B_N_PM01: male patient with cardiovascular disease, secondary care facility, Bangladesh)
Interconnected to patients’ worry about their NCD and the reported causes of distress were concerns about the costs of treatment, implications of their illness for work, strain on family life and what should happen if they die. Women commonly related these worries and distress to family, whilst men spoke more about money concerns, including providing for their family.
I keep on thinking that even whilst I can earn today, I am unable to pay for 2000 BDT to purchase medicines. There will be a time when I will not have any means. I won’t be able to earn my living?
(B_N_PM03: male patient with diabetes, secondary care facility, Bangladesh)
It was unclear from the interview data whether this distress was ascribed as an actual symptom of their NCD. Patients with diabetes tended to directly link their tiredness and headaches to their physical health. Irrespective of these attributions, it was clear that for patients only a reduction in NCD symptoms or complications would reduce their distress.
Non-NCD related causes of symptoms of depression were also identified by patients and health workers. These typically focussed on (un)employment, financial and family stresses (e.g. divorce, poor relations with in-laws, difficulties with children). A small minority were adamant that their psychological health was completely unrelated to their NCD.
Poverty is one cause of depression in Pakistan.
(P_A_HW42: house officer, secondary care facility, Pakistan)
I feel stress because of my children, I am tired and worried. This is not related to the disease.
(P_B_PF21: female patient with diabetes, tertiary care facility, Pakistan)
Finally, a few health workers in both countries spoke of the negative impact of depression on patients’ self-management of their NCD, seen to threaten good medication compliance and general self-care.
They do not come for follow-up. That means they become tired and think not to take medicine anymore. They may come again to the facility after two or three years; meanwhile their health has deteriorated.
(B_N_HW44: Medical officer, secondary care facility, Bangladesh)
Q3. How is depression care integrated within NCD provision?
A strong message from health workers and policy makers was that there are currently no specific guidelines or training for treating depression, and no standard screening tools or system for recording patients’ depression diagnosis or care at the NCD centres.
Without exception, health workers across all four NCD centres used intuition to identify depression in patients; from their behaviour, for example crying, subdued, not following self-management advice; their untidy appearance and negative body language; and the cognitive, affective and somatic symptoms that patients describe (outlined above, see Q2). In Pakistan they spoke of using a “deductive method” during assessment concluding that a patient may be depressed if the symptoms they describe were not associated with their NCD. They also relied on family members’ feedback to assess depression.
”The depressed patient’s face tells that they are actually suffering from depression. They smile less, and seeing their face it can be understood that they have lots of sorrow in their mind. These patients do not always express their mental pain.”
(B_S_HW45: consultant doctor, primary care facility, Bangladesh)
The absence of guidelines was seen to run the risk of health workers not asking the right questions and a patient’s depression being missed.
There is no proper checklist for diagnosis and treatment system of depression, so there are chances that patients might get missed.
(P_B_HM61: consultant doctor, tertiary care facility, Pakistan)
Another perceived challenge was that patients may choose to not share with health workers how they are feeling in terms of their mental health. Indeed, a stigma associated with having depression was mentioned by health workers and policy makers. In Pakistan, they also wondered if patients would see discussing mental health as a legitimate remit of the NCD doctor.
”They think ‘If I express such things then the society will be little me and will address me as a lunatic’. Though this [depression] is a very normal thing and has treatment, but they do not want to disclose it.”
(B_N_HW44: Medical officer, secondary care facility, Bangladesh)
Health workers spoke of delivering two different treatments for depression - anti-depressant medication and ‘counselling’; severe cases were referred to psychiatry. The pressure of time meant that while prescription of medication was straightforward, there was insufficient time for counselling. Value was placed on interacting with patients in a way that ‘consoled’ and ‘motivated’. It was clear that these conversations focused on NCD management not mental health, because this was the health workers’ area of expertise.
“If we think they have depression then we start them on antidepressants. We treat them pharmacologically. Usually these kinds of patients are referred to me for treatment by the NCD doctor.“
(P_B_HM61: HM61: consultant doctor, tertiary care facility, Pakistan)
In addition to having no formal guidelines for assessment or treatment, there were also no formal recording mechanisms for patients’ depression diagnosis or treatment. Only NCD details of patients were recorded.
”We do not have a register for mental health patients. There are two register books, one is for general patients and another one is for NCD patients.”
(B_N_HW43: senior staff nurse, secondary care facility, Bangladesh)
Health workers were clear they had not been formally trained in mental health, except doctors who had done a rotation in psychiatry during their medical training. In Bangladesh doctors with this background were perceived to be better at recognising patients’ distress as depression, and they appeared in their interviews to be more familiar with mental health protocols used elsewhere. Whilst experienced NCD doctors in Pakistan were considered as able draw on their general medical experience, junior doctors clearly could not. Overall, NCD doctors lacked confidence in this field and formal training was seen as required.
A doctor sitting in the NCD corner does not have enough knowledge and skills relating to psychiatry and mental health.
(P_B_HM61: consultant doctor, tertiary care facility, Pakistan)
Q4. What are the challenges and opportunities for integrating a brief depression intervention into NCD provision?
All three participant groups were presented with a description of a brief depression intervention (BA) in their interview and asked their thoughts on its potential integration into NCD care. The opportunities and challenges they identified are presented here, organised by the COM factors [22].
Capability
Capability presented as a challenge related to the lack of relevant knowledge and skills of health workers and low levels of understanding about mental health amongst patients.
As described above (see Q3), health workers in both countries acknowledged their lack of training, confidence and expertise in depression care. Indeed, there was some misunderstanding that BA requires mental health specialists to deliver it. They were clear that to deliver this brief intervention they would need training on the rationale, content and delivery mechanism of this “talking therapy”. They were motivated to receive this training (see Motivation) and once trained thought they would be competent to deliver BA.
Policy makers also recognised the lack of health workers trained in mental health, a particular challenge for Pakistan. In Bangladesh, they reported national commitment to train all health workers in mental health and NCDs. However, the scale and pace of training were lagging far behind the targeted levels and there was perceived to still be a “mental health gap” in service provision.
For non-communicable diseases and mental health they [health workers] don’t have the skilled people, this requires training and capacity building.
(P_PM72: policy maker with remit for NCDs, Pakistan)
Health workers and policy makers suggested that a potential implication of poor awareness and understanding of depression amongst patients (described above, see Q2), particularly those with low levels of education, was that they may not perceive a need to attend for mental health support or be aware it is available. In Pakistan several health workers and a policy maker believed that patients come to the NCD centres wanting medication and it will require a huge cultural shift to propagate knowledge of the use of psychological and behavioural science principles instead of pharmacological treatments in the general healthcare of NCD patients.
“Patients are okay with medication, drugs, and access to treatment issues, but to convince them of the importance and the role of non-pharmacological interventions is another policy challenge."
(P_PM73: policy maker with remit for mental health, Pakistan)
Patients’ own views were that they had never heard of this type of talking therapy and several would want more information about it before signing up to participate. Indeed, within the interviews they struggled to understand what the BA intervention was from the brief description provided. It was clearly misunderstood to be an opportunity to discuss their NCD with a health worker (described further in Motivation).
"It should focus on medicine and to ensure regular check-ups and facilitation. It should decrease our fatigue. That way we will feel less stressed and that would be great."
(P_A_PM08: male patient with diabetes, secondary care facility, Pakistan)
Social opportunity
In terms of social opportunity, stigma associated with depression was perceived by health workers as a barrier to patients attending for this type of treatment in Bangladesh (described above, see Q3). Social support for patients attending for additional appointments was another factor, particularly for women in Bangladesh. For the health workers, a significant challenge was a combination of their very busy roles in delivering NCD services (described above, see Q1, Q3).
There were mixed views amongst patients about the support they received from their family and friends to attend the NCD centre, and whether this support would be available for them to come for a psychological treatment. In Pakistan men and women usually reported that they were not accompanied to the facility by others and didn’t necessarily receive help with household/childcare responsibilities to attend. Whereas in Bangladesh, several participants reported that people would come to the NCD facility with them. Here, challenges for women were particularly evident, both in terms of needing support with household/childcare duties and requiring their husband’s permission to attend. One woman mentioned several times in her interview that she had a disabled son and no one to help look after him so her husband would not allow her to attend the facility.
He [my husband] is the primary guardian, I have to inform him that I am going to such-and-such place today, or for such-and-such purpose. If he does not permit me to come, how can I come?
(B_N_PF26: female patient with respiratory disease, secondary care facility, Bangladesh)
Physical opportunity
Several physical opportunity challenges, and some drivers, for integrating the brief depression intervention into NCD care were evident. These related to health worker and patient time, physical space in the clinic, patient travel, and the policy context.
The frenzied NCD centre environment and short consultation times (described above, see Q1) meant that health workers were unable to see how it would be possible to include a brief depression intervention within their NCD duties, unless they were scheduled to focus solely on that. Some identified a need for additional “nominated” staff and a dedicated space.
They [doctors] in a whole day 2–3 minutes are given to patients for examination. BA sessions are not possible along with line of duty in OPD [outpatient department]. If 250 patients come there and 100 of them are associated with symptoms of depression, how can they adjust 100 patients each day for 45 minutes per patients for session.
(P_A_HM62: assistant professor of medicine, secondary care facility, Pakistan)
“Yes, there is a lack of manpower. Plus, the room is small. If I talk to a patient, another is listening. I think that if there is a separate room then the doctor can check him and can understand whether the patient needs behaviour therapy [BA] or not, then s/he can send the patient in the separate room to receive it. But it is not possible to do it in the same room.
(B_N_HW43: senior staff nurse, secondary care facility, Bangladesh)
Time was also mentioned by patients; specifically, time needed to travel to the health facility (ranging from 15 minutes to 7 hours) and time spent in the waiting room (described above, see Q1). Most said they could find time to attend, although some would need to organise appointments to align with family and work commitments.
There are many garment workers. They cannot make time other than Friday. If you call her/him and say, “Today is Sunday [a working day], please come to the centre and provide us some of yours time” can s/he provide it? No, s/he cannot.
(B_N_PM03: male patient with diabetes, secondary care facility, Bangladesh)
I travel for my NCD and I face problems so I cannot come for it due to traveling issues, I travel 2 to 3 hours to reach the hospital.
(P_A_PF05: female patient with diabetes, secondary care facility, Pakistan)
A further travel-related issue for patients was the cost of public transport. Whilst men in Pakistan often had their own transport, most patients travelled to the health facility by rickshaw, bus, vans or autos, often for long journeys (a 20 km journey mentioned in Bangladesh, up to 3 hours’ travel mentioned in Pakistan). Approximately one third of Bangladeshi patients and nearly half of the Pakistani patients mentioned this financial cost of coming to the NCD facility, recognising that for some, this was prohibitive.
I do not have the money to come here every week, and obviously I don’t have ability to come here daily. I cannot manage, it is very difficult for me.
(B_S_PF32: female patient with cardiovascular disease, primary care facility, Bangladesh)
In summary, an implicit message from patients was that the BA appointments need to be co-ordinated with their existing NCD visits; to reduce the impact of time and cost requirements; or otherwise additional travel expenses should be reimbursed.
The readiness of the policy context to support integration of a brief psychological intervention into NCD centres was different in each country. In Pakistan, whilst mental health was a priority, policy makers believed that government level commitment and associated funding was lacking for prioritising mental health within NCD care.
“To try and convince people who were not ready to bring mental health issues into the fold of non-communicable diseases - this was a huge challenge. The attitude of people was that mental health is not a part of the grand scheme of things.”
(P_PM73: policy maker with remit for mental health, Pakistan)
On the other hand, the commitment for integrating mental health and NCD care in Bangladesh, was evident within the Mental Health Act and associated financing. Multiple NCD initiatives were underway. Their challenges were a lack of national level data to inform initiatives and delays in decision-making due to new jurisdictions within directorates.
Motivation
Health worker and patient motivation for the integration of a brief depression intervention was generally positive (albeit based on some misunderstanding of what it entails). However, it was clear that the capability and opportunity challenges described above would be potential threats to these positive intentions becoming reality. In addition, patients' prior experience of their NCD care emerged as an important factor in their motivation.
Health workers believed in the value of a talking therapy for treating NCD patients with depression. They would be motivated to take on this work (seen as additional to their existing responsibilities) if it improves patients’ recovery, or if they personally gain new knowledge through formal training, and are rewarded by financial incentives or management appreciation.
Recovery of patients is a motivation for them. They [health workers] will feel proud of themselves and their seniors as well for recovery of patients.
(P_B_HW44: trainee of vocational training institute, tertiary care facility, Pakistan)
If there is provision of some incentives, it would be better. Willingness is the main thing. Without it, nothing can be done.
(B_N_HM61: resident medical officer, secondary care facility, Bangladesh)
Patients had clear enthusiasm for this brief depression intervention. However, this was based on a misunderstanding about what this intervention is (described above, see Capability). In reality, they were keen to have the opportunity to talk to a health worker about their NCD as there was no time for this within their consultation. Most appeared particularly motivated by the idea of improving their NCD rather than their mental health; therefore, if BA offered the potential for this, they were keen to try it.
"This programme is good. We can change our mind through it and people will automatically get better."
(P_B_PM12: male patient with respiratory disease, tertiary care facility, Pakistan)
Patients always expect to have treatment that provide cure.
(B_N_PF26: female patient with respiratory disease, secondary care facility, Bangladesh)
As a slight caveat to this enthusiasm, particularly amongst men in Pakistan, motivation appeared to be influenced by patients’ experience of NCD treatment; namely a poor experience, for example, insufficient or rude doctors, long waiting times and medication not always being available (see Q1) threatened their willingness to come back for this type of programme. Conversely a kind, helpful doctor, and a nice setting would motivate them to attend.
"Just that everything should be good, the doctors should be good, the poor people should get assistance. The person becomes happy. Once the patient doesn’t speak the disease gets worse. I believe that the doctor should speak to patients in a good manner. It’s why the patient comes to the doctor to get consultation."
(P_A_PF23: female patient with respiratory disease, secondary care facility, Pakistan)
In Bangladesh, the patients spoke less of the impact of a negative experience, focusing instead on the positive features they would like - a pleasant physical environment (e.g. nice chairs in the waiting room, a private room for consultations) and certain attributes of the person delivering the BA intervention (e.g. kind, well-educated, credible).
”A separate room should be used for conducting behavioural activation. No queue of patients should be here. Patients should not feel uneasy. There should be seating for doctors and patients, there should be fans for cooling.”
(B_S_PF27: female patient with cardiovascular disease, primary care facility, Bangladesh)