Randomized Control Trial On Implementation Strategies for Task-Shifting Depression Care in Vietnam

研究摘要 抑郁症是世界上最大的医疗负担；没有其他疾病占其一半 负担。最近，世界银行、世卫组织和NIMH强调了不解决问题的严重经济代价 抑郁症以及在全球范围内扩大抑郁症护理的必要性。在越南，我们发现了合作护理 是有效的，并进行了分组随机对照试验，显示出对 抑郁症多成分协作护理模式(MCCD)，其中抑郁症护理是任务转移的 提供给当地社区卫生诊所的初级保健提供者，并得到流动精神病医生的支持。而当 协作治疗抑郁症的好处是公认的、最合适和最有效的 尚未确定扩大这一模式的实施战略。为了解决这一知识鸿沟， 我们的R01提案将建立在我们团队之前关于MCCD的工作的基础上，并利用当前的政策倡议 与越南的抑郁症护理相关，以确定最有可能导致成功的实施模式 在资源不足的情况下实施和维持有效的服务。我们将与当地和 国家社区和政府组织进行随机对照试验(RCT)比较 三种执行模式的有效性：(A)通常包括一种执行模式 讲习班和工具包；(B)加强监督(ES；包括模拟用户界面)；和(C)社区参与学习 协作性(CELC；包括专家系统)。根据RE-AIM实施评估框架， 人口层面的影响，提供者必须采用EBI，覆盖目标患者的很大比例 人口，忠实地实施，有效地改善结果，并在研究后保持 资金被撤回，因此我们将评估组织、提供商和患者的实施结果 基于此框架的级别。此外，我们还将评估与以下方面相关的组织和提供商因素 成功实施，并衡量每项实施战略的增量成本效益。 对RE-AIM实施结果和成本效益的实施模式进行比较可以指导 关于最佳战略的政策决定，以支持扩大抑郁症和其他疾病的协作护理模式 EBIS。这项全面而严谨的执行成效研究将有助于我们 了解在培训最佳实践之外使用CELC战略的附加值， 即使在高收入国家也没有做到这一点。对抑郁症护理任务的及时评估- 转变将提供关于实施战略和因素促进什么的急需的知识 在资源有限的低资源环境中采用、提供和维持高质量的抑郁症护理 提供精神卫生人力资源，填补全球优先执行知识差距 科学和心理健康研究。

Research Abstract Depression is the single largest health care burden in the world; no other illness accounts for even half its burden. Recently, the World Bank, WHO, and NIMH highlighted the crippling economic costs of unaddressed depression and the need to scale up depression care globally. In Vietnam, we have found collaborative care to be effective and have conducted clustered randomized control trial that has shown large effect sizes for a Multicomponent Collaborative Care Model for Depression (MCCD), in which depression care was task-shifted to primary care providers in local community health clinics and supported by mobile psychiatrists. While the benefits of collaborative care for depression are well-established, the most appropriate and effective implementation strategies for scaling up this model have not been identified. To address this knowledge gap, our R01 proposal will build on our team's previous work on the MCCD and leverage current policy initiatives related to depression care in Vietnam to identify implementation models most likely to lead to successful implementation and sustainment of effective services in low resource settings. We will partner with local and national community and government organizations to conduct a randomized controlled trial (RCT) comparing effectiveness of three implementation models: (a) usual implementation (UI), which typically includes one workshop and toolkit; (b) enhanced supervision (ES; includes model UI); and (c) community-engaged learning collaborative (CELC; includes ES). According to the RE-AIM Implementation Evaluation framework, to have a population-level impact, an EBI must be adopted by providers, reach a large proportion of the targeted patient population, be implemented with fidelity, effectively improve outcomes, and be maintained after research funds are withdrawn, thus we will assess implementation outcomes at the organizational, provider, and patient levels based on this framework. Additionally, we will assess organizational and provider factors associated with successful implementation and measure incremental cost-effectiveness of each implementation strategy. Comparing implementation models on RE-AIM implementation outcomes and cost-effectiveness can guide policy decisions on best strategies to support scale-up of collaborative care models for depression and other EBIs. This comprehensive and rigorous implementation effectiveness study will contribute to our understanding of the added value of using a CELC strategy over and above the best practice in training (ES), which has not been done even in high-income countries. This timely evaluation of an depression care task- shifting will provide much needed knowledge about what implementation strategies and factors promote adoption, delivery, and sustainment of high-quality depression care in low-resource settings where limited mental health human resources are available, addressing global priority knowledge gaps in implementation science and mental health research.