Understanding the barriers to integrating maternal and mental health at primary health care in Vietnam.

The prevalence of common perinatal mental disorders in Vietnam ranges from 16.9% to 39.9%, and substantial treatment gaps have been identified at all levels. This paper explores constraints to the integration of maternal and mental health services at the primary healthcare level and the implications for the health system's responsiveness to the needs and expectations of pregnant women with mental health conditions in Vietnam. As part of the RESPONSE project, a three-phase realist evaluation study, we present Phase 1 findings, which employed systematic and scoping literature reviews and qualitative data collection (focus groups and interviews) with key health system actors in Bac Giang province, Vietnam, to understand the barriers to maternal mental healthcare provision, utilization and integration strategies. A four-level framing of the barriers to integrating perinatal mental health services in Vietnam was used in reporting findings, which comprised individual, sociocultural, organizational and structural levels. At the sociocultural and structural levels, these barriers included cultural beliefs about the holistic notion of physical and mental health, stigma towards mental health, biomedical approach to healthcare services, absence of comprehensive mental health policy and a lack of mental health workforce. At the organizational level, there was an absence of clinical guidelines on the integration of mental health in routine antenatal visits, a shortage of staff and poor health facilities. Finally, at the provider level, a lack of knowledge and training on mental health was identified. The integration of mental health into routine antenatal visits at the primary care level has the potential help to reduce stigma towards mental health and improve health system responsiveness by providing services closer to the local level, offering prompt attention, better choice of services and better communication while ensuring privacy and confidentiality of services. This can improve the demand for mental health services and help reduce the delay of care-seeking.

Implementation of medicines pricing policies in sub-Saharan Africa: protocol for a systematic review.

INTRODUCTION: Ensuring universal availability and accessibility of medicines and supplies is critical for national health systems to equitably address population health needs. In sub-Saharan Africa (SSA), this is a recognised priority with multiple medicines pricing policies enacted. However, medicine prices have remained high, continue to rise and constrain their accessibility. In this systematic review, we aim to identify and analyse experiences of implementation of medicines pricing policies in SSA. Our ambition is for this evidence to contribute to improved implementation of medicines pricing policies in SSA. METHODS AND ANALYSIS: We will search: Medline, Web of Science, Scopus, Global Health, Embase, Cairn.Info International Edition, Erudit and African Index Medicus, the grey literature and reference from related publications. The searches will be limited to literature published from the year 2000 onwards that is, since the start of the Millennium Development Goals.Published peer-reviewed studies of implementation of medicines pricing policies in SSA will be eligible for inclusion. Broader policy analyses and documented experiences of implementation of other health policies will be excluded. The team will collaboratively screen titles and abstracts, then two reviewers will independently screen full texts, extract data and assess quality of the included studies. Disagreements will be resolved by discussion or a third reviewer. Data will be extracted on approaches used for policy implementation, actors involved, evidence used in decision making and key contextual influences on policy implementation. A narrative approach will be used to synthesise the data. Reporting will be informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guideline. ETHICS AND DISSEMINATION: No ethics approvals are required for systematic reviews.Results will be disseminated through academic publications, policy briefs and presentations to national policymakers in Ghana and mode widely across countries in SSA. PROSPERO REGISTRATION NUMBER: CRD42020178166.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol.

BACKGROUND: Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam. METHODS: We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance. DISCUSSION: The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

Not a level playing field: A qualitative study exploring structural, community and individual determinants of greenspace use amongst low-income multi-ethnic families.

Greenspace is important for physical and mental health. Low-income, multi-ethnic populations in deprived urban areas experience several barriers to using greenspace. This may exacerbate health inequalities. The current study explored structural and individual determinants of greenspace use amongst parents of young children in an urban, deprived, multi-cultural area situated in the North of England, UK. Semi-structured in-depth interviews and focus group discussions were conducted with 30 parents of children aged 0-3 between December 2016 and May 2017 from a range of ethnic groups. Thematic analyses were informed by the Human Health Habitat Map and the Theoretical Domains Framework. The results show that whilst all families recognised the benefits of greenspaces, use was bounded by a variety of structural, community, and individual determinants. Individual determinants preventing use included lack of knowledge about where to go, or how to get there and confidence in managing young children whilst outdoors. Fear of crime, antisocial behaviour and accidents were the overriding barriers to use, even in high quality spaces. Social and community influences both positively encouraged use (for example, positive social interactions, and practical support by others) and prevented use (antisocial or inappropriate behaviours experienced in greenspace). The built environment was a key barrier to use. Problems related to unsuitable or unsafe playgrounds, no gardens or safe areas for children's play, poor accessibility, and lack of toilets were identified. However, the value that parents and children placed on natural blue and green features was an enabler to use. Contextual influences included external time pressures, difficulties of transporting and caring for young children and poor weather. Multi-sectoral efforts are needed to tackle the uneven playing field experienced by multi-ethnic, urban, deprived communities. Initiatives to increase use should tackle structural quality issues, addressing fears about safety, whilst simultaneously encouraging communities to reclaim their local greenspaces.