Nguyen Thi Ngoc Lan, MD,MPH Program Coordinator, MCNV Vietnam VU University in Amsterdam WEAVING INTO THE SOCIAL FABRIC OF COMMUNITIES IN VIETNAM FOR MENTAL HEALTH CARE A qualitative study Nguyen Thi Ngoc Lan, MD,MPH Program Coordinator, MCNV Vietnam www.mcnv.org

OUTLINE Introduction Research question Methodology Results Conclusions Mental health (MH) in Vietnam MCNV pilot project, community MH Research question Methodology Results Conclusions Recommendations fg

I. Introduction: I. Mental health (MH) situation In the world: Mental health (MH) problems affect 450 million people, ranking as a high priority public health issue In Vietnam MH care receives too little attention Health care focuses on selected MH problems MH therapy is not comprehensive, medical focus. Lack of MH professionals especially psychologists. General health care staff and community lack knowledge about MH.

MCNV pilot project

Pyramid WHO, 2009

Objective of pilot project: Improve quality of life of MH patients and their families Interventions: individual (patient) level, family level and community level to improve MH care at institutional level. Capacity development for health staff, village health workers through connecting them with provincial MH specialists Set up self-help groups for families of MH patients, with at least 8 meetings to learn and share about care of MH patients Raise community awareness using innovative behavior change communication by village health workers Deliver services based on personal development plans of MH patients: medication, social and economic participation

II. Research question What are the effects of the MH pilot project on different stakeholders at different levels? Sub-questions: What has changed for MH patients, family members, at institutional and community level? What factors contributed to these changes?

III. Methodology Methods: in-depth interviews (IDI), focus group discussion (FGD), participatory workshop with stakeholders Study areas: Quang Tri province, Vietnam one lowland rural commune, 100% Kinh ethnicity one mountainous commune, 99% Van Kieu ethnic minority Study population: IDI: Total 52: 4 MH patients, 15 family members, 15 VHWs, 6 health staff in commune health center/district health center/provincial hospital, 2 representatives of DPO. FGD: 2 FGD with family members and 2 FGD with VHWs.

IV. 1. Results at different levels Individual level (MH patients): Patients now understand to take medication more regularly. MH patients’ health improved and more stable, both MH status and psychology. Patients became able to participate in household work and life, which makes them happier. “My son now has less attacks, headache, is much calmer and able to sleep better.” (Mother of epilepsy patient)

“I attended the meetings and understood about the disease and the side effects of the medication. I encouraged him to take regular medication. So he can assist me with the work and whenever he is feeling tired he lays down a bit and stops working.” (Wife of a schizophrenic patient)

V.1.2. At family level: reduced burden of care “I am satisfied and my life is more comfortable since the medication is effective. We don’t have to keep her in the separate room anymore. She can have dinner with us together and help with daily activities like washing, gardening or caring for the pigs.” (Father of schizophrenic daughter) Objective burden Reduced time for daily tasks like giving medication, caring for the patient, and less financial expenditure. Have more time to focus on their work. Happier because MH patients are more confident and can share in family life and work.

Stigma surrounding these families is reduced. Subjective burden Families felt better when the psychological burden was reduced: They worry less, need less attention to patients as they improved. They feel less ashamed, and are confident to name the MH problem. Stigma surrounding these families is reduced. “The meeting showed me that I am not the only family who have to take care of a mentally ill patient. I saw cases which were even worse than ours, this gave me hope” (Mother of schizophrenia patient)

IV.1.3. At community level: knowledge and attitude of neighbours, family group and DPOs improved significantly The community understood that MH can happen to anybody and is not about ‘being crazy or mad’. Villagers in commune are more open, changed their attitude towards MH. The family group help each other, and together try to give better care to the MH patients. “Before the community perceived people with a MH problem as manic and the families and patients felt ashamed. Now it changed to a more positive attitude towards people with MH problems, they are more open” (FGD with VHWs )

V.1.4. At institutional level Improved health literacy among primary level health staff “We gained more knowledge about schizophrenia, depression and epilepsy. This helped us to detect patients early and refer them to the commune health centre where a diagnosis can be made”(FGD of VHWs ) Village health workers gained more knowledge on MH, can detect MH problems earlier and refer MH patients to the commune health centre. Health staff at commune know how to refer patients better and staff at district level are more confident to change/adapt medication when needed.

(Village health worker) Village health workers and doctors at commune health centre make regular visits to the patients’ homes for monitoring and counselling on care and medication Families and patients gained more trust in health staff and village health workers. “The villagers have more trust in me because I have more knowledge. So I can convince people.” (Village health worker)

IV.2. Factors contributing to change Training/workshops, coaching by national/ provincial level psychiatrists Collaboration between psychiatrist from provincial and grass-root level to visit the communities to support and advise health staffs Regular meetings of family groups under facilitation of specialist in psychiatry. “The training in Danang improved my knowledge on MH. Before, my knowledge was vague. I got a training before about depression, but still it remained unclear what the symptoms are.” (Doctor at commune health center).

IV.2. Factors contributing to change Families are encouraged by village health workers, doctors and family groups. Close communication among village health workers, DPO, villagers, and commune health staff DPO leaders shared their knowledge and experience with their members and community. “The VHW encouraged me to take medication. This is very helpful. She also provided information for me and my family.” (Schizophrenia patient)

IV.2. Factors contributing to change Learning from meetings of family group improved care and medication. Patients take medication more regularly, making it more effective. Innovative methods of behaviour change communication by village health workers increased community understanding of MH. “The puppet theatre for health education is more interesting for people than just information, because it is interative and entertaining” (Provincial psychiatrist)

V. Conclusions The pilot project contributed to improved quality of life of MH patients and reduced the burden of care for family members. Literacy on MH increased in communities, especially families of MH patients thanks to community interventions including family group meetings. Community gained a more positive attitude towards MH. Local health care providers gained better knowledge, attitude and skills on MH care.

VI. Recommendations MH care based on families and self-help groups should be promoted within the existing health system. Role of self-help groups in MH care should be recognized and integrated in current MH system. Community and family involvement should be part of training for health care providers in psychiatric care. This approach should be promoted during learning exchange and stakeholder workshops among NGOs and other institutions/agencies.

Acknowledgements Thanks for people who involved in research: Students from VU of Amsterdam: Josine Siedenburg and Agnes Walk My dear colleagues: Dr Pamela Wright, Akke Schuurmans, Dr Pham Dung Local key health workers in Quang Tri province Thanks MCNV for funding

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