Integrating depression care within NCD provision in Bangladesh and Pakistan : a qualitative study

Background Co-morbidity of depression with other non-communicable diseases (NCDs) worsens clinical outcomes for both conditions. Low- and middle-income countries need to strengthen mechanisms for detection and management of co-morbid depression within NCDs. The Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON) study explored the acceptability and feasibility of integrating a brief depression intervention (behavioural activation, BA) into NCD services in healthcare facilities in Bangladesh and Pakistan. Methods Face-to-face qualitative interviews were conducted with 43 patients and 18 health workers attending or working in NCD centres in four healthcare facilities in Bangladesh and Pakistan, and with three policy makers in each country. The interviews addressed four research questions (1) how NCD care is delivered, (2) how NCD patients experience distress, (3) how depression care is integrated within NCD provision, and (4) the challenges and opportunities for integrating a brief depression intervention into usual NCD care. The data were analysed using framework analysis, organised by capability, opportunity and motivation factors, cross-synthesised across countries and participant groups. Results Patients and health workers described NCD centres as crowded and time pressured, with waiting times as long as five hours, and consultation times as short as five minutes; resulting in some patient frustration. They did not perceive direct links between their distress and their NCD conditions, instead describing worries about family and finance including affordability of NCD services. Health worker and policy maker accounts suggested these NCD centres lacked preparedness for treating depression in the absence of specific guidelines, standard screening tools, recording systems or training. Barriers and drivers to integrating a brief depression intervention reflected capability, opportunity and motivation factors for all participant groups. While generally valuing the purpose, significant challenges included the busy hospital environment, skill deficits and different conceptions of depression. Conclusions Given current resource constraints and priorities, integrating a brief psychological intervention at these NCD centres appears premature. An opportune first step calls for responding to patients’ expressed concerns on service gaps in provisioning steady and affordable NCD care. Acknowledging differences of conceptions of depression and strengthening psychologically informed NCD care will in turn be required before the introduction of a specific psychological intervention such as BA

Factors Responsible for Delay in Initiation of Insulin Treatment in Type-2 Diabetes Mellitus Patients with Secondary Failure of Oral Hypoglycemic Agents

Background: To assess patients’ and physicians’ perceptions regarding factors responsible for delay of Insulin initiation and compared.Methods: In this cross sectional study using mixed quantitative and qualitative approach, quantitative component included structured interviews of 400 Type 2 Diabetic patients with failure to oral hypoglycemic agents (equally stratified based on gender and public or private health care settings) who had not initiated Insulin despite physicians advice. For qualitative aspect, 4 Focus group discussions with 29 consultant physicians of diabetic patients and four including 31 diabetic patients with delay were conducted. The factors responsible for delay and mean duration of delays were assessed and also compared based on gender and health care type.Results: The mean duration of diabetes in 400 patients was 12.91±3.78 years while the duration of delay in months was 23.08±14.62 months with highly statistically significant increase in female patients. Patients identified fear of injection or needle phobia as the commonest factor (24.62%), followed by fear of side effects of Insulin (18.87%). Consultant physicians in addition to same above factors also mentioned the role of quacks and fear of loss of patients by doctors as important factors.Conclusion: Factors identified by patients and physicians responsible for delay of initiation of insulin included perceptions of fears, difficult and lifelong application, cost, storage issues, last resort of treatment, misdirection from quacks and patients reluctance tempting doctors to hold up insulin till inevitable