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Transforming the understanding
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PRISM Hub Project Summary


DR. CHUENGSATHIENSAP: Hi, this is Komatra from Thailand. I'll be presenting experience on caring for dementia on the project, Partnership in Implementation Science, from Thailand.

Thailand is a small country in southeast Asia. Here is the background information about Thailand. We are a country in southeast Asia with a gross national income around $6,000 U.S., with population about 70 million and life expectancy at birth at about 74. Our population increasingly aging and people are experiencing dementia.

So our project focused on caring of dementia.

We situated our project within the healthcare system in Thailand, which is divided into several levels. You can see in the picture that we have the primary medical care, secondary and tertiary medical care, on top of that we also have excellent centers. But these are outside of the community.

Within the community, we have the primary healthcare center which provides long-term care for the elder. It's operated by having village volunteers which we have about a million of them in Thailand. Below that, we have the family caregivers providing self-care within the family context.

And here is the situation regarding dementia in Thailand. You can see that the situation is comparative in many, many countries in this recent time. We have the problem of dementia compared to the depression and disability. You can see, in the number that male suffer a little bit less than female, and the age 60 up have increased incidence of these.

The problem of dementia, we all know that there are memory impairment, which really difficult to minimize. We don't have currently medical solution for that. So basically the problem we identify as the thing that we want to solve is the behavioral and psychological symptoms of dementia or the BPSD, which in Thailand you can see that among Thai adults, there are some mood symptoms and psychotic symptoms as well, especially delusion and hallucination, and there are also some behavioral problems and a lot of aggression, both verbal and physical aggression.

So the challenge in dementia and psychiatric care in Thailand for the demented patients is that this problem has been underrecognized as a mental health problem in Thailand. The reason is that we also lack of culturally adapted, effective evidence-based intervention. We don't have tools to work with this. So people who provide care with the elder with dementia really have nothing to do other than psychological support.

The second problem is we do have examples of other pilot project, and we can see that although the pilot project seems successful, but it's hardly can scale up to a successful national implementation. So we combine these two problems and address it through our project.

The project has the aim of developing culturally adapted implementation support model so that we can take care of elders with BPSDs in Thailand. The second aim is to build individual and institutional capacity for the implementation of this intervention, and the third is to involve and improve policymakers' capacity to use research for evidence-informed decision-making. So we will provide them with all the tools necessary to achieve these three goals.

In terms of the intervention, we have picked one of the most recognized interventions, which is RDAD. It was originally developed from the Seattle protocol, which has several interesting components, like the partnership between person with dementia, caregivers, and healthcare professionals, because we have to provide care in their home and we have -- it also includes training and support and improve communications, and this is especially important is the identifying and increasing of pleasant events in the patient's life, learning and effectively implementing ABC, which is an acronym for antecedent behavior and consequences. So we can analyze it and later on introduce way to reduce these behavioral problems.

So for the RDAD protocol, there are several things that need to be implemented, like training for caregivers, including training for knowledge, communication skills, identifying pleasant events, and behavioral management, and also there are physical activities for the patients to improve the overall performance, physical performance. So patients can have a better quality of life.

This is all developed from Professor Linda Teri's work that developed all this protocol, and it was used in helping a lot of patients with chronic illness. In terms of trying to make it more adapted to local context, we follow these ten steps suggested by Escoffery et al. They are steps taken to adapt the original protocol to better fit the cultural settings or context in Thailand.

So we start with consult with experts to really understand the implementations and aspects of things that need to be carried out. So Professor Linda Teri did visit us in the field and provide a lot of supervisions and suggestion for adaptation.

We also consult with local stakeholders like clinical practitioners to see if the clinical workflow is okay for such project, and it not interfere with any other workflow that currently within the long-term care system. We also identify some of the barriers to learning and implementing through the experience of stakeholders in various levels of implementation.

As for the pleasant events, this is really important, because the thing that people enjoy to do depends a lot on local context. So we did identify a number of things that are enjoyable, fun, or just people have skill to do it, and when they perform that kind of task, they feel more contribute to their family and they feel good about it. So we adapt that as well.

And most important thing is the physical activity, because there are a lot of assumptions about elders in society, like in Thailand you cannot ask elder to do a crazy thing like dancing or something like that. So we need to adapt so that people feel not too offended when asked to perform these physical activities. So we choose some of the activity that fit to local understanding and locally accepted ways of exercise.

The results of the adaptations, you can see from this slide that we have changed a few things to make it fit in our healthcare system, like provider of care, rather than in the original protocol, they have healthcare professionals; we changed it to care manager and community caregivers, which is already there in our long-term care system. We also provide the way to deliver care rather than with direct provision. We integrated it into the care system that caregiver in the long-term care scheme already provided.
Follow-up, we don't have phone calls, but we do have regular home visits. So we incorporate that into the system of home visits.

Other than that, we also provide training manuals and posters, especially the large printout and stick it to the wall as reminders. This is what the local health professionals suggest us to do. It can remind me to exercise, for instance, or not to forget to do some kind of thing that we plan to do. And of course, the pleasant events at the end is all context-based. So we have to adapt it into our own context.

On top of the RDAD protocol, we also have this implementation science which helps us to implement our intervention and can expect better outcomes at the end. So with the implementation science, Getting to Outcomes, as the framework, we introduce this process into our implementation process.

The pilot study introduced these concepts and practices. We do have focus group with people, pilot tests, and also then develop an integrated approach of GTO and RDAD to make it a coherent system of intervention.

So the focus group, for instance, we discuss with local people to see what is the experience and how is the readiness for implementing new ideas? What do we need to do to make sure that this new idea is well implemented? The pilot training and delivery also we take time to build capacity among technical assistant providers, which is part of the GTO system. We need to have technical assistance so that people want to have some advice or were not quite sure about ways of doing things, can talk to technical assistance and make sure to implement it accordingly.

We do also create some additional capacity for clinical staff that need to do case identifications or case confirmation as well. These are all tested in our pilot training before implementation in the larger scale.

The larger scale implementation of RCT study is the process of doing this, all the clinical screening and also implementing our intervention, which will be presented by Professor Hongtu and I'm ending my presentation here.
Thank you.

DR. CHEN: I'm Hongtu Chen. I will summarize our study from this point on. We conducted the randomized control trial in one province of Thailand. The central purpose is to test whether the implementation support strategy will lead to better implementation and outcome, clinical outcomes, compared with the group that delivered the treatment intervention without the implementation support.

One challenge is to identify the right case for participating in the study. Because the primary care doctors do not do that normally, they don't know how to do it, and psychiatrists who know how to do it, identify cases, there are very few in the country. So we have to rely on so-called community health professionals, which traditionally we call them village volunteers.

The first step was to train them. As you can see on the left side, the front line are the junior faculties that were professors from a local nursing college. We teach them first, and then they will teach the care managers in the village who identify cases for us.

The second step is we find a pool for them who are in the long-term care system. They show some signs of cognitive impairment or the family reported them so, and we identify about 1,000 of them as prescreened results, and then we screened them with the instruments we developed, which means we go to the home and really go through those questionnaires and interviews with them.

And then we have a special step here, because we need to exclude those who have severe mental health problems, such as schizophrenia or severe medical conditions who can not participate in some of our elements of intervention, such as prescribed exercise. So we ask the local physicians, most of them are psychiatrists, those rare psychiatrists, to come to help us.

The way they do it is that the nurse will present the case, the information, the medical records, and then a physician will make the judgment to see whether the patient should be excluded or not, and that was during the coronavirus, and the whole thing stopped. Then after several months, I think our group realized that we could continue to do the work virtually. I think we reached that realization a little bit earlier than the whole society. So we continued to conduct the case confirmation process online.
In the end -- by the way, cluster means, each cluster means a district. So we started with 26 districts, and after excluding some districts, we finally get to 16 districts. In the 16 districts, we screened near 1,000 people, and then end with 353 people enrolled in the study.

The study, here is the process of study, all you need to know is that they divide into two groups. One is the so-called implementation support group; the word GTO means implementation support. And then the control group is the one without implementation support. Want to see the effect of the implementation support.

The teaching part lasts for three months, but then they continue to do as they're instructed for another three months. So we have three months follow-up assessment and six months follow-up assessment.

Right now, we have finished the whole study and all the data has been collected, and we also through the process we have developed quite a lot of training materials which is I think is very valuable for the Thai society.

Next steps, we'll continue to analyze the data and to later point report the final outcome and also we will figure out how to use the materials we have developed to scale up or to disseminate mostly within the country first, and we also are thinking how to put things together to develop a policy recommendation package for the society for the system to consider.

Thank you.