The interviews demonstrated the important role of social collaborators in delivering the intervention. Our analysis identified a number of benefits and challenges in working with social collaborators identified by each participant group (patients [P], social collaborators [SC], expert stakeholders [ES]), which are described below. To ensure confidentiality, we have omitted the participant code.
The role of social collaborators in the community
Social collaborators spoke of the importance of their existing relationships with patients in their home communities, as described by a social collaborator from Quang Nam:
That’s why around my neighborhood if anyone had any problems or got sick they would find me for consultation. So many people feel excited when they see me. I do everything with my heart and kindness. [SC, Quang Nam]
Another social collaborator from Khanh Hoa reported:
The advantage is that I am living in the area and loved by people so when I come, people welcome me very warmly…. I also tell people that this is a national project that wants to bring health and wellness to the people in both spirit and body, so please allow me to ask some questions for this project. Please tell me so that I can evaluate and send to the senior level, if there is any problem for you in terms of mental health issues, there will be support. People are very honest and happy. [SC, Khanh Hoa]
This social collaborator spoke of their unique position in the community and how their existing relationships resulted in people being more responsive, encouraging patients to seek help from their local social collaborators when they were ill, and also suggested that the existing relationships facilitated their ongoing work. This contributed to “the community have[ing] more confidence in social collaborators, strengthening their position in the community”.
The scope of work that social collaborators were responsible for is best described by a social collaborator from Ben Tre:
My job is to go to meetings, mobilize self-management. […] I said if she [patient] could not go, I was willing to try to relax with her, leading her to walk with a walking stick. Many times, when she lies down at home, she felt depressed, not wanting to contact anyone. […] So I often came to advocate for and motivate her. […] I calm them down, invite them to be happy, suggest we need to still live, then I ask them some questions. I approach the community and ask for support for the people to overcome their mental illness. I support them with everything, from a piece of cake, or rice. […] I approach and confide with such patients. Seeing me, they are very happy because there is no one to talk to. [SC, Ben Tre]
Participating in the study also led to the development of incentives and team building for the social collaborators. For example, an expert stakeholder from Thanh Hoa province provided an example of a program innovation where a friendly contest was organized for the social collaborators within and across different communities to help them be acquainted with each other and compete to improve the number of people screened:
Organizing competitions is a custom of the Vietnamese. In these contests, they can directly share their experiences and can talk with each other. These contests are also chances to connect between different residential communities. […] I think that the contest is the effective way of communication and help people know about the project. [ES, Thanh Hoa]
The contests helped to increase communication and collaboration between social collaborators and helped to increase awareness about the project and mental health and understanding of depression, enhancing trust and improved community connections, supporting their work.
The impact of social collaborators on community mental health
Social collaborators functioned at several levels to deliver SSM. They provided ongoing supportive coaching, including guidance and encouragement on the various tasks described in the ASW through regular visits to the patients’ homes. This engaged process, possible because of the established community involvement of the social collaborators, was considered by participants to have contributed to the effectiveness of the intervention. Social collaborators being located at the community level was seen as being conducive to frequent patient visits, which ranged from several times each week, especially in the beginning, to once a month, and helped to build “good relationship[s]”. One social collaborator from Quang Nam indicated that “sometimes she [her patient] calls me and wants to hang out, sing karaoke with me.” Social collaborators were unanimous in indicating that they dedicated a lot of their time, especially at the beginning of the intervention, to visiting patients. During their visits, they discussed the ASW, “encourage[ing] [patients] to finish the book and learn positive principles,” providing suggestions for hobbies to keep patients engaged, such as karaoke or swimming, or simply “talk[ed] to them”.
Social collaborators were described as having a particularly important impact on: 1) increased awareness of mental health in the family and community, 2) reduced stigma, and 3) a better understanding that depression is treatable.
As an expert stakeholder in Hanoi explained:
After knowing their problems, they received materials from social collaborators and they know how to take care [of their] depression…. This project helps to raise the awareness of people about depression. […] After being counselled by social collaborators, their patients’ families don’t have any stigma with depressed people. Before that, they don’t know and often have superstition, [believing] that the reason of the problem is ghosts and they look for sorcerers. And now they know what depression is and coordinate with social collaborators. [ES, Hanoi]
While some patients reported that they and their families had previously attributed mental illness to cultural beliefs about sorcery, the social collaborators helped them to increase their awareness of mental health, supporting “patients’ family members to understand and know how to better care for the patients,” and that treatment was possible. This awareness and understanding helped to reduce stigma about mental illness amongst patients themselves, their families who serve a variety of important roles in the patients’ lives, and in the wider community.
An expert stakeholder in Thanh Hoa province commented on reduced stigma in the community:
The patients who were exposed to the program and received support from our staff, they have changed significantly and the stigma in the community is also reduced markedly. Previously, some patients were shunned because of several reasons. Firstly, some people think that they might be infected. Secondly, some patients cannot control their behaviors and sometimes can have quarrels. After our project, people have more sharings [shared understanding of mental health]. [ES, Thanh Hoa]
A patient from Da Nang emphasized they “want the program to be expanded” as they “think it’s useful for many people” by highlighting the beneficial impact that increased awareness about mental health and the options to treat and manage depression can have for an individual:
When someone has conditions that they will be depressed, if they are given this information they will understand, depression is milder. In the past, I used to sit in the corner, there was no contact with anyone, I thought I had cancer and was going to die. [P, Da Nang]
Social collaborators were recognized for contributing to: 4) increased help-seeking and 5) improved access to care.
There was increased help-seeking amongst the patients arising from the increased mental health awareness in the communities. An expert stakeholder in Khanh Hoa province stated “this year, there are many cases of depression in the area. Last year we also went but we could not find any cases, did not cover all the communes, but this year they discovered a lot of people participating in the program.” An expert stakeholder from Hanoi provided a reason for the increased number of patients with depression seen in the program:
Depression patients are instructed by our social collaborators on how to overcome their situation. They now know the symptoms of depression in the early stages, and then they will go to commune health centers to seek advice, while before this model [SSM], they don’t know what depression is. Depress[ed] people feel more confident and they know their problems. [ES, Hanoi]
SSM delivered by social collaborators was described as improving access to care, particularly for individuals in rural communities. An expert stakeholder from Thanh Hoa stated that “I just think that this model targets those who are in the early stage of depression and if we can’t control depression in the early stage, patients can be much more severe in the level of depression.” Social collaborators helped to target depression in the early stages by working closely with community members who they knew to be experiencing social and emotional difficulties, and they were able to devote a large amount of time to visiting their patients in their homes. As a patient from Thanh Hoa reported, “In general, since this program began, there are some collaborators who help me every week. I felt better.”
Challenges for program scalability with social collaborators
Although the MAC-FI trial (5) demonstrated that a community-based mental health intervention supported by social collaborators results in improved mental health, and this study has identified which aspects of the social collaborators’ role are regarded as having contributed to that outcome, we also identified factors at the system level that inhibit the full implementation of this intervention.
Age
Age was a complicating factor for social collaborator effectiveness. The age of social collaborators ranged from 37-70, with 46.6% over the age of 55.
While older retirees were well known and respected in communities, which facilitated their ability to gain patients’ trust, older age was also associated with difficulties in acquiring the new knowledge required for the intervention. As an expert stakeholder from Quang Ninh indicated, the “collaborators are mainly retirees” who are able to “take advantage of the part-time job”, with payment in the form of task-specific stipends.
Some social collaborators and expert stakeholders acknowledged that older collaborators’ “acquisition [of new skills] is limited because of their age”. For example, an expert stakeholder from Thanh Hoa commented that, while they recognize qualified social collaborators without special health training are able to provide effective service, they purposely tried to recruit younger social collaborators to facilitate faster learning and comprehension. This person suggested it was more difficult for social collaborators of an advanced age to learn new information:
Secondly, as for the selection of social collaborators and communes, we should choose the collaborators who are in the ages that are easy to learn something new. […] If they are capable and are qualified, they can participate really well. […] In our project, there are medical personnel called village health workers, despite advanced ages, they are still involved but their performances were not good enough. Therefore, when our project continues, the recruitment of collaborators should select those who are qualified and in a young age to meet the requirements of the program. [ES, Thanh Hoa]
The challenges were also reported by social collaborators themselves. For example, a social collaborator from Long An stated:
I think young people like you [referring to the interviewer] are very talented. Old person like me cannot be talented like you. In fact, people said that they would like to see the old doctor, because they are full of experience, but I think there is no experience because the things they have learnt in the past is different from now. Now when I went to big hospital like Thong Nhat Hospital, it is full of talented young doctors, I found that the youth is talented. [SC, Long An]
Thus, while age and the related experience was definitely an advantage in encouraging trust with communities, our study also suggests that scaling up the intervention might require the development of training programs that are adapted for older learners. Conversely, while young people might learn more quickly, they might not connect as well with patients and may need more training and support to establish trusting relationships with people suffering from depression in the community
Education and Training
The formal education that social collaborators had previously received was varied. One social collaborator from Quang Nam expressed concern regarding their level of education, “my education level is not high. I talk not well which can make many patients misunderstand.” Some social collaborators reported that they had difficulty communicating with patients and perceived this to be due to their limited education level. An expert stakeholder from Quang Ninh reported that education in “the remote areas sometimes ends only in the ninth grade.” Another expert stakeholder from Thanh Hoa indicated:
As for the difficulties, staff working in the villages have different levels of education and different age. For example, the number of village health workers finishing college is quite low. […] Because of the different levels of education, the screening of patients is different among different staff. [ES, Thanh Hoa]
The absence of formal education among the social collaborators was seen by some as contributing to differences in patient trust. One expert stakeholder from Quang Nam said, “there are a lot [of] collaborators [with] whom patients didn’t want to cooperate. Quang Nam still lacks a professional collaborators system in the community. There are a lot of issues in this project because we just could mobilize village staff.”
Similarly, pre-existing training and skills of the social collaborators, while varied, was also limited, which contributed to challenges in delivering the intervention. This is not surprising considering that many were retirees with no specialized training prior to the study, with a number of social collaborators indicating their previous responsibilities as “just farming,” “housewife,” “work[ing] in the countryside and sell[ing] rice”, “garden[ing]”, and being “a soldier”. This is compounded with “limited” and “short-term training programs” that could result in barriers to implementation. Similar to the challenges associated with age, the introduction of a professional development program for social collaborators, geared to their level of formal education, would further support the scalability of this intervention.
Contextual factors influencing scalability of working with social collaborators
There were additional challenges highlighted by participants arising from a lack of policy and regulation for social collaborators around their roles and responsibilities, training and supervision received, and remuneration.
Roles and responsibilities
Social collaborators had to juggle numerous work and personal responsibilities, such as harvesting. An expert stakeholder from Hanoi stated that the main barrier they saw to the project’s scalability was the workload of the social collaborators: “They are working for the project but when it comes to the time for harvesting, they don’t have enough time to go to the house to ask and screen patients,” which leads to high turnover. An expert stakeholder from Quang Ninh similarly reported, “the capacity of a collaborator is limited because they have too much work”. This was emphasized by a social collaborator from Quang Nam: “I just want to talk about the collaborators, they were enthusiastic, but they did not have time.”
Training
Training available to social collaborators was variable across provinces. One expert stakeholder from Thanh Hoa indicated, “in addition to the training programs from the Institute of Population, Health and Development, we also have many other training programs related to this problem such as training programs from DOH [Department of Health]. In our center, we also have training programs for our staff.” This was not reflected consistently across the province or in other provinces. One expert stakeholder from Thanh Hoa pointed out, “there are some limits in their training programs and their implementation of the screening questionnaire” and “they just received short-term training programs”.
DOH officials were also concerned about the social collaborators’ lack of “knowledge about medicine” that “hindered their ability to deliver the intervention and their patients’ trust in them”. This resulted in patients at times “discriminat[ing] [against] the collaborators and closing their doors” as they were not receptive to their services, with a number indicating they instead preferred “treatments with medicine” or “the hospital”, highlighting the point that some patients prefer a provider they perceive as an expert, which fits with a more medical model of mental health care.
In our study, province-level social workers provided most of the supervision for the social collaborators. However, at a country level, supervision varied across provinces and communes as the capacity among the social workers also differed, emphasizing the need for enhanced training for both social collaborators and the social workers supporting them. As suggested by an expert stakeholder from Thanh Hoa:
Additionally, in order to have effectiveness for patients, it could be necessary to have training programs for provincial supervisors and collaborators, which are not one- or two-days training sessions as we did. The training programs should be long-term training because [increasing knowledge][…] cannot be [achieved] in one or two days. [ES, Thanh Hoa]
Payment
Social collaborators received a small stipend from the project of approximately 30,000 VND [equivalent to roughly CAD$1.70] per patient. Although the amount of the stipend was determined by MOLISA staff as consistent with other stipends provided to social collaborators and village health workers, respondents indicated this was “not commensurate with their effort” given their frequent patient visits. Despite the fact that social collaborators “work because of the passion”, a lack of, or insufficient, payment poses a particular problem considering that social collaborators often “have many things to do” and would need to prioritize tasks that provide a living.
An expert stakeholder from Thanh Hoa said, “Because the funding spent to support collaborators is still limited, they are not very enthusiastic about our activities.” The lack of core salary funding from government, combined with a lack of coverage by health insurance programs for mental health services, may not provide sufficient motivation for this provider group. This will be a challenge for sustainability, as a model dependent on a system of volunteers is unlikely to be sustainable (35). As an expert stakeholder from Khanh Hoa stated bluntly, “They are very enthusiastic now, but if they have money they will be more enthusiastic.”
Support from government
As noted by an expert stakeholder from Hanoi: “The second weakness of this project is the coordination between multiple sectors such as health sector, education and mass organizations because sometimes our social collaborators cannot take the responsibility to do all the things and they need to transfer their jobs to other sectors.” Improved coordination between sectors would provide clarity on their role.
The overarching challenge to working with social collaborators, not just to deliver SSM but more broadly, is the fact that “there is no policy about social work,” as reported by an expert stakeholder from Quang Nam. Without a social work policy that clearly defines their roles and responsibilities, training and supervision available, and payment, there will be challenges to their full engagement and integration into the health system. The social collaborators’ broad scope of work was undefined and unregulated, which can impact quality of care and potentially lead to disempowerment. These factors may have contributed to the high turnover rate of social collaborators that was observed.