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Advantages and Challenges of A Village Doctor-Based Cognitive Behavioral Therapy for Late-Life Depression in Rural China: A Qualitative Study.

ABSTRACT: The delivery of mental health services in rural China has been notably limited due to lack of qualified mental health professionals among other impeding factors. A village doctor-based cognitive behavioral therapy intervention may be one way of improving accessibility. The purpose of this study was to explore the advantages and challenges of implementing this intervention, as delivered by trained village doctors, to treat late-life depression in rural China.We conducted one focus group discussion with 10 village doctors, 10 individual interviews with each of the village doctors, and individual interviews with 19 older adults. The topic guides were advantages and challenges of the intervention program from the perspective of the village doctors and older adults. Interviews were audio-recorded, transcribed, coded using NVivo 8, and analyzed using thematic analysis.The village doctors stressed the importance of role-playing and using instructive manuals in the training. Proper supervision was also a key component of the program. The benefits received from the intervention for the village doctors and the elders were positive such that both the doctors and the older adults were willing to implement/receive this intervention. Cultural and political factors (renqing and perceived policy consideration) facilitated the elders' access to mental health services. Challenges included a lack of real therapy (in contrast to role-playing) demonstrated in the training and lack of a step-by-step manual based on different types of problems encountered. Other impediments to the successful implementation of the intervention included the time constraints of village doctors and the presence of other people when conducting the intervention.The present study has demonstrated that the intervention program is likely to be an acceptable geriatric depression intervention in rural China if several challenges are appropriately addressed.

SUBMITTER: Tang X

PROVIDER: S-EPMC4570773 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Project description:BackgroundAlthough the progress in global health initiatives has improved the availability of primary health care (PHC), unqualified healthcare remains a serious challenge in low- and middle-income countries, where PHC is often underutilized. This study examines factors associated with patients' healthcare-seeking behaviors in rural Chin-seeking healthcare at village-level PHC providers, at higher-level health facilities, self-medicating, and refraining from seeking medical help. We focus on provider-side factors, including (1) the unobservable quality indicator, (2) the observable quality indicator, and (3) the observable signal indicator.MethodsWe analyzed 1578 episodes of healthcare-seeking behaviors of patients with diarrhea or cough/runny nose symptom from surveys conducted in July 2017 and January 2018 in 114 villages of the Yunnan province. We investigated the correlation between quality-related factors with patients' healthcare-seeking behaviors by multinomial logit regression.ResultsWe found that rural patients were insensitive to the unobservable quality of healthcare providers, as measured by standardized clinical vignettes, which might be attributable to the credence nature of PHC. The observable quality indicator, whether the clinician has received full-time junior college formal medical education, was associated with patients' healthcare choices. Patients, however, were more likely to select healthcare based on the observable signal indicator, which was measured by the availability of medicines. Additionally, the observable signal indicator had no significant association with two quality indicators. Notably, socioeconomically-disadvantaged patients relied more on the village-level PHC, which emphasized the role of PHC in promoting the welfare of rural populations.ConclusionsOur study found an inconsistency between objective quality of healthcare provided by providers and subjective quality perceived by patients. Patients could not identify the actual quality of PHC precisely, while they were more likely to make decisions based on the observable signal indicator. Therefore, the quality of PHC should be more observable to patients. This study not only supplements the literature on healthcare-seeking choices by examining four types of behaviors simultaneously but also clarifies rural patients' perceptions of the quality of PHC for policy decision-making on increasing the utilization of PHC and improving the medical welfare of the vulnerable.

Project description:BackgroundPreliminary evaluations have found that family doctor contract services (FDCSs) have significantly controlled medical expenses, better managed chronic diseases, and increased patient satisfaction and service compliance. In 2016, China proposed the establishment of a family doctor system to carry out contract services, but studies have found the uptake and utilization of these services to be limited. This study aimed to investigate rural residents' preferences for FDCSs from the perspective of the Chinese public.MethodsA discrete choice experiment (DCE) was performed to elicit the preferences for FDCSs among rural residents in China. Attributes and levels were established based on a literature review and qualitative methods. Five attributes, i.e., cost, medicine availability, the reimbursement rate, family doctor competence, and family doctor attitude, were evaluated using a mixed logit model.ResultsA total of 609 residents were included in the main DCE analysis. The respondents valued the high competence (coefficient 2.44, [SE 0.13]) and the good attitude (coefficient 1.42, [SE 0.09]) of family doctors the most. Cost was negatively valued (coefficient - 0.01, [SE 0.01]), as expected. Preference heterogeneity analysis was conducted after adjusting the interaction terms, and we found that rural residents with higher educational attainment prefer a good attitude more than their counterparts with lower educational attainment. The estimated willingness to pay (WTP) for "high" relative to "low" competence was 441.13 RMB/year, and the WTP for a provider with a "good" attitude relative to a "poor" attitude was 255.77 RMB/year.ConclusionThe present study suggests that strengthening and improving the quality of primary health care, including the competence and attitudes of family doctors, should be prioritized to increase the uptake of FDCSs. The contract service package, including the annual cost, the insurance reimbursement rate and individualized services, should be redesigned to be congruent with residents having different health statuses and their stated preferences.

Project description:ObjectiveTo identify the facilitators and barriers to implement family doctor contracting services in China by using Consolidated Framework for Implementation Research (CFIR) to shed new light on establishing family doctor systems in developing countries.DesignA qualitative study conducted from June to August 2017 using semistructured interview guides for focus group discussions (FGDs) and individual interviews. CFIR was used to guide data coding, data analysis and reporting of findings.Setting19 primary health institutions in nine provinces purposively selected from the eastern, middle and western areas of China.ParticipantsFrom the nine sampled provinces in China, 62 policy makers from health related departments at the province, city and county/district levels participated in 9 FGDs; 19 leaders of primary health institutions participated in individual interviews; and 48 family doctor team members participated in 15 FGDs.ResultsBased on CFIR constructs, notable facilitators included national reform involving both top-down and bottom-up policy making (Intervention); support from essential public health funds, fiscal subsidies and health insurance (Outer setting); extra performance-based payments for family doctor teams based on evaluation (Inner setting); and positive engagement of health administrators (Process). Notable barriers included a lack of essential matching mechanisms at national level (Intervention); distrust in the quality of primary care, a lack of government subsidies and health insurance reimbursement and performance ceiling policy (Outer setting); the low competency of family doctors and weak influence of evaluations on performance-based salary (Inner setting); and misunderstandings about family doctor contracting services (Process).ConclusionsThe national design with essential features including financing, incentive mechanisms and multidepartment cooperation, was vital for implementing family doctor contracting services in China. More attention should be paid to the quality of primary care and competency of family doctors. All stakeholders must be informed, be involved and participate before and during the process.

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Advantages and Challenges of A Village Doctor-Based Cognitive Behavioral Therapy for Late-Life Depression in Rural China: A Qualitative Study.

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