Evaluation of a depression care model for the hill tribes: a family and community-based participatory research

Multimorbidity and depression have been highlighted as one of significant challenges to healthcare systems, especially in low-and middle-income countries. A meta-analysis across 43 low-and-middle-income countries estimated that the pooled odd ratio (OR) for multimorbidity and depression was 3.3 (95% CI 2.98–3.57) [1]. Depression is a risk factor for mild cognitive impairment (MCI), which affected competency and decreased quality of life, especially in the subdomains of happiness, life freedom, decision-making, interpersonal relationship, and life satisfaction [2]. Thailand ranks fourth in Southeast Asia in terms of the number of recorded incidents of depression. Even though more than 14 million persons at risk in Thailand have been assessed for depression and have received mental health education, about half of individuals with depressive disorders had access to standard care and approximately 1.7 million patients had received psychosocial interventions [3]. Despite the fact that the rates of emotional illness in Thailand continue to climb, a recent study has reported that there are 882 psychiatrists and psychiatric residents in the country [4]. It is insufficient to help the entire population, especially in rural areas.

According to the 2019 report from the WHO, there were approximately three million hill tribe members in Thailand [5]. Around one-third of these populations live in the rural border areas of Thailand, including Chiangrai, Chiangmai, Mae Hong Son, Lamphun, Nan, and Tag, as well as Myanmar and Laos [6]. The prevalence of depression varies among different ethnicities and countries [7, 8]. Rates range from around 10% in the Black Irish population to as high as 50% among Iranians [7, 8]. In our earlier research, we found a significantly high prevalence of depression among hill tribe individuals in Chiang Rai province. Among the hill tribe adults, the prevalence of depression is approximately 39% [9], whereas among other populations in Thailand, it ranged from 6 to 20% [10, 11]. Additionally, several factors have hindered the hill tribes from accessing appropriate psychosocial health services. These factors include cultural practices and beliefs, inadequate income, low education, language barriers, lack of access to roads [9], absence of Thai identification documents [12], social inferiority, and stigma associated with illegal methamphetamine and opium use, among others [13]. Following the studies of other populations, where the family unit plays a crucial role in supporting patients with mental illness [14‐16], we found that family-related factors, such as being female, 50 years or older, married, Christian, and living with a relative, were associated with depression in hill tribe individuals [17]. However, prior research has not established a unique method focusing on family and community involvement to support people with mental illnesses in Thailand, particularly those from ethnic backgrounds, including hill tribes. To address this healthcare issue, there is an urgent need for effective, low-cost community-based psychosocial prevention and interventions tailored to the specific needs of the hill tribe communities.

To strengthen a community's ability to address major health challenges, particularly depression, the community-based participatory research (CBPR), an academic-community partnership study [18], was employed to develop a depression care model called ‘the SMILE model’ for hill tribe members with depression. The SMILE is an acronym that represents the following key components: (S)stakeholders' readiness to care for people from hill tribes with depression, (M)motivation of people from hill tribes with depression to change their behaviours, and that of their family and community in depression care, (I)interpersonal relationships within the hill tribes, (L) life and community assets of the hill tribes, and (E)empowerment of the community members. This model has been developed based on WHO's Innovative Care for Chronic Condition (ICCC) framework [19]. Collaboration between mental healthcare practitioners, public health providers, academic institutions, local administration organizations, families, and the community is required to create an effective collaborative care model for depression and offer support for those who are depressed. Previous studies [20‐22] have demonstrated that community-based preventive programs effectively reduced certain mental health symptoms, including depression, while also increasing self-esteem and social support. Therefore, in this current research, our aim is to further examine the efficacy of our collaborative depression care intervention, named the 'SMILE model,' which was specifically developed for hill tribe members with depression [23]. This unique model was applied to volunteers with mild to moderate depression from Akha, Mien, and Lahu communities, and its effectiveness was assessed by analysing the changes in their PHQ-9 scores.

In the present study, the self-help group program, which is one component of the SMILE model, effectively improved the depression scores of hill tribe patients. However, no significant improvement was detected for participants in the family camp program.

The SMILE model has been successfully developed by incorporating the CBPR approach with the ICCC framework specifically for the hill tribe population [23]. Based on intensive review articles [31, 32], CBPR studies offer new perspectives and are inclined to approach mental health promotion differently than traditional methods that focus on illness. Furthermore, there is a growing demand for more culturally relevant and comprehensive research approaches and methods from community leaders, nurses, public health technical officers, health volunteers, and potential research participants, especially when working with minorities and underserved populations [31, 32]. Previous articles indicate that collaborative care interventions for psychiatric disorders have consistently shown success in improving key outcomes in both research and clinical intervention studies, enhancing the quality of patient care, and improving population health [33‐36]. Furthermore, cost analyses also suggest that this model is cost-effective [37]. For the first time in this study, the effectiveness of implementation processes and adaptation of this collaborative care model to align with the clinical realities of general practice for individuals from the hill tribe with depression has been proven. Therefore, it is important to note the SMILE model, precisely the self-help group program developed by our team [20], as a unique, cost-saving, and effective program for hill tribe individuals with depression.

The depressive symptoms of people from hill tribes participating in the self-help group were improved. This improvement is likely due to the fact that the main activity of the self-help group program was counselling. Counselling involves helping those with depression change their way of thinking, feeling, and behaving. Furthermore, counselling was a goal-based collaboration process between interventionists and those with depression to set goals, develop strategies, and plan to achieve the goals. At the start of the program, the interventionist built a good relationship between the group leader and members, and within group members to create a culture of trust. All group members created their rules to participate in counselling with acceptance and empathy. During counselling, the group leader used active listening, silence, open-ended questions, and exploration to facilitate [38]. All these techniques helped those with depression to trust, share their feelings, thoughts, and behaviours, and deal with their problems [39]. Furthermore, praise when members offer their thoughts in the group. These compliments made members feel pleased and like they were a part of the group [40], and they were the cause of less depression [41].

Most people from hill tribes with depression were uncomfortable sharing their thoughts and feelings with family members due to cultural beliefs. Thus, the development of a family relationship based on the Satir model, a main component of the family camp program, might be unsuitable for them. A possible reason might be related to the program concept, which focused on expressing feelings for each other and encouraged family members to share their thoughts and feelings, especially on the topic of family relationships, which was too sensitive [42]. In addition, the Satir Model was limited in dealing with family issues, particularly sexual abuse and family violence. Within the hill tribes, the head of the family-controlled family members. This hierarchy is common in Southeast and South Asia, which are characterized by a high level of gender inequality. A preference for sons and an aversion to daughters are common in many countries. The man is the heir of the family, but the woman, once married, is the property of her husband [43]. Families in the hill tribe communities had hierarchical and collectivist values. Therefore, a discussion of the family roles and expectations was unsuitable. Moreover, most activities during the family camp program were specific in teaching communication skills (for example, wording, posture, and body movement). Unfortunately, these activities might not be suitable for traditional hill tribe families, who strongly believe in their culture of keeping secrets (not sharing anything with others). It will be a challenge for health providers and researchers to create a new communicative strategy for hill tribe family members. Further culturally sensitive and focused research is required.

The SMILE model can be effectively applied to address depression in the hill tribe communities. However, model users need to consider cultural sensitivity and language barriers and adjust the model to the hill tribes' contexts. Motivation to learn the language and to have hope for the future is also the key to success in depression care at the patient-family micro level. It is also critical to strengthen the community's roles in providing care for patients with depression through VHVs. Aside from adhering to the Ministry of Public Health's policies and guidelines, stakeholders, particularly health care providers, and authorities, should provide mental health care to hill tribes suffering from depression in accordance with policies and guidelines established explicitly by the community and implemented in the community. Further research should explore cultural beliefs and practices of self-care of patients, families, and communities as it relates to caring for depression among other hill tribes. In addition, future studies should examine the effectiveness of the "SMILE model" in other hill tribe groups with depressions.

One of the main limitations of this study is the small sample size. Only twelve participants completed the intervention. For the family camp, only five families participated in the camp due to their economic backgrounds and work. They did not think the camp was important because they needed to work for their family's living. Therefore, to gain better family and community participation in a project or activity, it should be conducted on Sunday afternoons, when most are free, and the church services finish. In addition, individual family therapy instead of group therapy, should be provided to the patients and families due to depression and family issues being very culturally and familial sensitive.

The ‘SMILE model’ is a depression care model based on family and community participation and designed for people from hill tribes with depression. It is a well-formulated, framework-based, and effective model for addressing depression in hill tribe communities. The model implementation led to positive outcomes for people from hill tribes with depression, their families, and the community.