1. Assoc. Professor and Vice Rector, Hanoi University of Public Health
For the GACD Annual Scientific Meeting, Sao Paulo, November 2018
AMED (Japan Agency for Medical Research and Development)/Global Alliance for Chronic Diseases (GACD) Project (GACD-182): Mental health promotion at workplace in low- and middle-income countries in Asia
Norito Kawakami, MD, PhD
Professor of Mental Health, School of Public Health/Graduate School of Medicine, The University of Tokyo
Nguyen Thanh Huong, PhD
Assoc. Professor and Vice Rector, Hanoi University of Public Health

2. … The project focuses on a smartphone-based mental health promotion of hospital nurses in Vietnam

3. Background 1: Stress among nurses
Nurses can suffer from work stress as a result of lack of stress management skills and/or organizational factors at work (Martín-Del-Río et al., 2018). This often leads to depression/anxiety, burnout and other health problems, and deterioration in quality of life and service provision.
Work stress increases among nurses in Vietnam (Thu Nguyen et al., 2018) and other South East Asian countries, because of rapidly increasing demands to medical care in the aging society. Work stress also affects the quality of health care service in these countries (e.g., Saimasi et al., 2015)

4. Background 2: Prevention of work stress among nurses
There is evidence that cognitive-behavioral therapy (CBT) and relaxation reduce stress compared to no intervention among nurses (Ruotsalainen et al., 2015).
Individual-oriented interventions (such as CBT stress management) showed a better effect size (-0.34) than organizational interventions (working conditions, job rotations, etc., to 0.07 )(Ruotsalainen et al., 2015).

5. Background 3: Impacts and challenges of Internet CBT programs
It is well known that iCBT programs successfully reduced depression in general populations (Carolan et al., 2017; Joyce et al., 2016; Stratton et al., 2017).
A challenge exists in the completion rate: low (49-99%) (Christensen et al., 2009) in the experimental settings; even lower (7-42%) in the real world (Fleming et al.,2018).

6. Aims of the project A randomized controlled “hybrid type 2” trial
To investigate effects of e-stress management programs among nurses (effectiveness study).
To investigate comparative implementation between two types of e-stress management programs (implementation study).
To know the implementation of the interventions in hospital nurses in a naturalistic setting after the trial (an observational implementation study).
To know the process to disseminate the interventions to hospital nurses in Vietnam (a qualitative implementation study for scaling up).

7. Mental health promotion at workplace in low- and middle-income countries in Asia: A project overview
Project team
Project outputs
Impact
Future extension
E-stress management for nurses
Capacity building
Scales and tools
Improving quality of life of nurses (workers)
Hospital nurses in Vietnam
Developing occupational mental health system for nurses (workers)
Other sector workers
Other countries in South East Asia
Promoting research & practice in occupational mental health

8. iCBT stress management programs
Six-week programs
Contain six modules
Based on cognitive behavioral theory (CBT)
Accessible from smartphones (android or i-phone)
Include a dialogue between a counselor and a nurse guiding the learning

9. Two types of e-stress management programs
PROGRAM A：Free-choice
May choose only one module per week
LOGIN
Sakuraya et al (2017 & 2018)
A module (for 15 min)
May choose any of six modules every week
PROGRAM B: Fixed-order
May choose only one module per week
LOG IN
Imamura et al (2014, 2015, 2016, & 2018)
A module (for 15 min)
Required to study one module per week in a fixed order

10. Adaptation of the programs to the target population
Translated to the local language
Hearing from 20 chief nurses of the target hospital to adjust the content of the programs
Review by collaborators at the Hanoi University of Public Health (HUPH)
Collecting opinions from 50 senior nurses of the target hospital on the programs and Apps

11. RCT design: participant flow
Open for free use (3 months)
7-month follow-up
3-mont follow-up
Random assignment
Inclusion/
exclusion criteria
Call for participation
Nurses of Bach Mai Hospital (N=2,000)
Inclusion: 1. Nurses; 2. full-time; 3. Using smartphones
Exclusion: 1. Those who plan to move out in the next 7 months; 2. nurse assistants & helpers; 3. part time; or more days of sick leave in the past 3 months; 5. under treatment for mental illness
Group A n=317
n (%)
Group B n=317
Control n=317
対象者のフローチャートです。
２回のフォローアップ調査とも、対照群の回答率が10%以上高い結果となりました。
All nurses of Bach Mai Hospital (N=2,000)
Trial registration: UMIN

12. Outcome indicators of the RCT
1. Primary outcomes
Depression & anxiety: Depression Anxiety Stress Scales (DASS) 21-item version (Lovibond & Lovibond, 1995; Le et al., 2017)
Work engagement: Utrecht Work Engagement Scale (UWES): 9 items (Schaufeli et al., 2006)
Sick leave days and on-the-job performance: The WHO Health and Performance Questionnaire short form (Kessler et al., 2003)
2. Secondary outcomes
Job stressors : Job Content Questionnaire (JCQ) (Karasek, 1985)
Health-related QOL: EQ-5D-5L (Herdman et al., 2011)
3. Process indicators
Program satisfaction
Progress of learning (e.g., number of modules completed)
Trial registration: UMIN

13. Implementation of the interventions in hospital nurses in the naturalistic setting (post-RCT observation)
To observe the usage of and satisfaction to the interventions by nurses of the target hospital during the 3 months (May- July 2019).
To know the association of basic characteristics (sex, age, division/ward, etc.) and other factors on the usage
To understand a contextual effect of messages from a hospital representative and ward supervisors on the usage (qualitatively)

14. Dissemination of the project outputs to hospital nurses in Vietnam
Government involvement: Ministry of Health & Health and Environment Management Agency, Ministry of Labor, Invalids and Social Affairs, etc.
Involvement of professional associations: hospital associations, nurse associations, occupational health associations, etc.
Translation to legislations/guidelines/ recommendations
Service providers in occupational mental health
Academics

15. A review of the project from the implementation research view
Implementation outcome
The RCT part
Open use part
Dissemination part
Acceptability X
Adoption NR
Appropriateness
Feasibility
Fidelity
Implementation cost
(X)
Coverage
Sustainability
X: To be checked. (X): partly assessed. NR: not relevant.
Source: Peters et al., BMJ 2013;347:f6753

16. The project is based on the partnership between the HUPH and UTokyo