Background
Methods
Key objectives | Development of a multifaceted programme that includes an anti-stigma campaign and the systematic medical appraisal, referral and treatment (SMART) mental health intervention Evaluation of the intervention to provide evidence of feasibility, acceptability and effectiveness of the programme | |
Strategies | Training/Educating health professionals (primary healthcare physicians, healthcare professionals (ASHAs) and project staff) with updates in screening, diagnosis and treatment of population for depression, suicidal risk and emotional problems using EDSS tool Educating the community members about mental health and adherence to treatment Offering free screening /counselling services to the community in interventional areas | |
Interventional activities based on target groups | General population | Educating about mental health, non-pharmacological treatments of mental illness and the benefits of treatment Sharing brochures and posters on mental health using door-to-door campaign Video shows of a person talking about his own mental illness and a film actor talking about CMD; staging live performances of a drama on mental disorders |
Primary health care Physicians and health care professionals (ASHAs) | Organizing training workshops on the updates in screening, diagnosis and treatment of population for depression. suicidal risk and emotional problems using EDSS tool Training/educational manuals for physicians, and healthcare professionals Knowledge on key symptoms, such as psychotic features, and comorbid conditions, such as drug and alcohol use | |
Screen positives and family members | Educating about mental health, non-pharmacological treatments of mental illness and the benefits of treatment Educating patients relatives’ for screening mental illness and raising their sensitization in favor of the patients’ treatment using door to door campaign Organizing health camps for providing free counselling services Referral to the next level of care to access the trained mental health professionals |
Setting and participants
Data collection and analysis procedure
S. no. | IDI (In depth interviews) | Number of participants (N = 25) | Gender | Age (in years) |
---|---|---|---|---|
1 | PHC doctors | n = 5 | 3 males 2 females | 25–64 yrs |
2 | Community members (Screen positive visited the doctor and were given medical and/or psychological treatment | n = 3 | 0 male 3 females | 24–50 yrs |
3 | Community members (Screen positive who visited the doctor and were referred to a specialist) | n = 3 | 1 male 2 females | 41–70 yrs |
4 | Community leaders | n = 13 | 7 male 6 females | 23–74 yrs |
5 | Key Government official | n = 1 | 1 female | 55 yrs |
S. no. | FGDs (Focus group discussions) | Number of FGDs (N = 16) | Gender | Age (in years) |
---|---|---|---|---|
1 | ASHAs | n = 2 | 19 females | 25–65 yrs |
2 | Field Staff | n = 2 | 9 males 7 females | 22–42 yrs |
3 | Community members(Screen positive by ASHA who visited the doctor) | n = 6 | 25 males 36 females | 25–90 yrs |
4 | Community members(Screen Positive by ASHA who did not visit the doctor) | n = 3 | 6 males 13 females | 25–80 yrs |
5 | Community
members(Screen Negatives at all phases) | n = 3 | 11
males 15 females | 28–61 yrs |
Results
Key components from Andersen’s model | Prior SMART Mental Health Intervention Scenario | Intervention and processes implemented | Participants’ perception about the intervention (barriers, facilitators and recommendations from participants to improve the programme) |
---|---|---|---|
Environmental | |||
Healthcare system | Mental health care was not available at PHC ASHAs lacked knowledge on CMD and skills for interview people on mental health issues Primary care doctors did not have proper knowledge and skills to identify and manage CMD Patients required to travel to distantly located PHCs, leading to financial loss | 41 ASHAs and 6 doctors were trained on using the mobile technology-based application 12 Field staff were trained to communicate with ASHAs and doctors and implement the programme and supervise the process ASHAs screened 22,046 community members for CMDs using algorithm based EDSS. Among these, 900 community members were screened positive and referred to PHC for treatment Doctors used this training to manage CMD using mhGAP-IG based EDSS About 104 Health camps organized in villages to facilitate the easier access to doctors and treatment IVRS calls were sent for a period of 1 year to 41 ASHAs, 6 PHC doctors and the screen positives in the community at different intervals and different frequency on a case-to-case basis, to remind screen positive individuals about treatment and to ASHAs about their pending screenings and follow ups In all, 14,849 calls were placed during intervention period; 13,400 call placed to community members;1449 calls placed to ASHAs and doctors;8046 calls to patients | Community members, ASHAs, primary care doctors appreciated the programme and perceived it as valuable in enhancing the knowledge of community members on mental health ASHAs reported that training enhanced their confidence level and interview skills Doctors appreciated the usage of EDSS, as it provided some prior information of the patient and consume less time Almost all ASHAs, and doctors mentioned that poor signal and network connectivity was a barrier on using the applications Training sessions helped ASHAs, doctors and field staff to operate the tablets Distance, lack of public transport facility and financial burden were demotivating factors to access the care Health camps within the locality were appreciated as they reduced time and money spent in visiting the PHC ASHAs paid repeated visits to enquire about health and to motivate them to visit the doctor for treatment Few participants were aware of the IVRS sent to them on their mobile phones Family members owned only one phone set, kept at home Phone sets were owned by their family members, husbands or their children’s; and most of them were illiterate Some people simply assumed that the messages were from service provider and did not even show interest to check these messages at all |
Population characteristics | |||
Predisposing characteristics | Limited awareness about mental health among community members Social issues like poverty, unemployment, and caste system exist in villages | Organized awareness campaign on mental health using several strategies Brochures and pamphlets were used in the door-to-door campaign and community meetings to raise mental health awareness and discuss issues related to stigma; this was repeated 3–4 times in each village A promotional video where a local film actor speaks about mental health and stigma was screened A video of a person with mental disorder to talk about his/her experience was screened and discussed during the campaign Staging a drama by a local theatre group on domestic violence, mental disorder and the need for getting treated | Door-to-door campaign was a key strategy to approach people for face- to face interaction and motivate them for treatment, if required The drama was received very well and there was good participation at all the villages Domestic violence, family restrictions, preoccupation with work were the other reasons which prevented people from visiting the doctors ASHAs were scared to enter in some houses belonged to economically well-off people or to the higher caste Community leaders shared that in some families, the elders did not allow daughters/daughters-in-law to go out for seeking treatment, specifically for mental illness Alcohol addiction and loneliness were perceived as reasons for mental illness Stigma is associated with mental illness, and were highly prevalent |
Enabling resources | No pre-existing mental health services in villages Community members were not oriented towards identifying CMD | Local administration and village leaders were informed about the project at each phase ASHAs and doctors used to provide care and treatment Field staff were trained using standard operational procedures and their activities monitored regularly Field staff monitored ASHAs regularly and ensured the quality of data collected by them; supervisors followed up with doctors regularly to check for any problems that they might be facing with the application Health camps in villages enabled patients with CMD to seek care from doctors closer to home | Village leaders reported that people suffering from mental illness needed some support, which they received through this programme Peer learning and sharing of experiences encouraged people to seek health care |
Need | Perceived need to seek care for CMDs was negligible as there was no awareness about CMDs ASHAs and doctors were not trained to identify or manage the CMD | Screening of the whole population by ASHAs led to increase in help seeking | Participants suggested more training programs for
doctors and ASHAs Most participants recommended that communities need to be more educated about the facts pertaining to mental illness |
Personal health practices | Stigma related to mental health was highly prevalent Poor knowledge about CMDs amongst community members and health workers | A campaign was organized to increase mental health awareness and reduce stigma | All participants reported the campaign was beneficial Project increased the awareness about CMDs and the need to seek care |
Outcomes | |||
Use of health services | There was no treatment for CMDs in PHCs | The intervention had a focus on increasing mental health services use for CMDs Task shifting was used to enable mental health care for the rural population Technology driven platforms were used to facilitate provision of mental health services A system developed to ensure follow up by ASHAs and doctors Out of 900 patients, 731 visited the doctor at least once. The doctors were able to deliver the healthcare effectively 104 Health camps organized in villages to facilitate the easier access to doctors and treatment | Programme should be implemented through PHCs, and in collaboration with 104s (ambulance services in the rural areas), assisting them to have access to the nearest treatment facilities |
Perceived health status | A comprehensive mental health intervention implemented | The intervention was well received and appreciated in the community | |
Consumer satisfaction | A pre-post evaluation of the project provided objective assessment of the outcomes | Community members were satisfied with SMART mental health intervention as it led to increase in the knowledge of CMDs in the community |
Environment: healthcare system, external system
Training of primary health workers
“It was easy for us to deal with patients as everything was put on the tab, time was saved and work was fast.....otherwise have to write everything on the paper.” (Doctor, IDI-3).
Use of EDSS
“This program helped us professionally to improve our counselling skills and how to spend 180 more time with patients and how to speak with patients. In this way we are improving our skills as a doctor.” (Doctor, IDI-4).
“Signals…very poor at time. Sometimes they [the data] are not synchronizing. So many times, we faced inconvenience because of this synchronizing process. The data collected by ASHA’s did not synchronize into our tabs. It took so many days for that [to be sorted out].” (Doctor, IDI-4).
Use of IVRS
“One of the community members shared, “No, I don’t have any idea about messages. I never checked whether I got it or not. I saw few messages but do not know what messages they are… I never paid much interest.” (Community member, FGD 3).
Population characteristics-predisposing characteristics, enabling factors, needs
Mental health awareness and perceptions about stigma
“In my family also, people won’t agree to go to a hospital. Now, I never told them that I am coming here for treatment. They already shouted at me for talking with ASHA workers and for taking doctor appointment.” (Screen positive-visited the doctor, IDI15).
“They [community member] fear that other people [will] think they have mental [health] issues and they are mad. Many people have these perceptions.” (ASHAs, FGD2).
“They [community members] might be thinking that mental health problems are like a contagious disease.” (Community member, FGD-4).
“…..sometimes we tell our problems to friends and family members but normally people would not consider the problem as a serious one” (Community member, FGD-11).
“I think women have less freedom to visit doctors whereas men don’t need permission. They are free to go anywhere, anytime; whereas it is not like that they have to inform family members.” (Village leader, IDI- 6).
Delivering the mental health awareness and anti-stigma campaign
Accessing health care: distance, financial and socio-cultural constraints
“With transportation issues, some people are not going… We need to walk 3kms to come out of the village, from where they have to go to another village and walk another 1km to reach PHC, so because of these transportation issues some people are not going.” (ASHA, FGD-5).
Organizing health camps to increase access to care
“Definitely these [health] camps were useful. If doctors come voluntarily, check everyone and provide treatment for the patients…it is really good.” (Community member, FGD 10).
“When we used to hear their problems, we felt that our problems are very less and we tried to handle our problems and helped them also to come out of them.” (ASHA FGD).
Health behaviour: personal health practices, use of health services
Mental health service use
“the training should be provided for at least entire one day at regular intervals and 324 follow up classes should be conducted at least once in a month” (Doctor,IDI-1).
Preference for awareness campaign strategy
“The program was very good…90% useful. One drama was shown to us as a part of the program. It was good, and people understood how a person suffers from mental disorders. We all felt very happy and people changed a lot.” (Village leader, IDI- 8).
“Door to door campaigning is better because everyone get[s] information and knowledge about mental health.” (Community members, IDI-13).
“It is very important to conduct review meetings…every fortnight or month. So that we can get an exact idea about the status of the patients and make our services [mental health services] better.” (Doctor, IDI- 5).
IVRS use
Social support
Outcomes: perceived health status, evaluated health status, consumer satisfaction
Appraisal of the SMART Mental Health programme
“We always welcome your health programmes. These programmes should be continued forever. People shall always be in need of a psychiatrist because some (or) other shall always face some problem regularly and they need someone to lift them up.” (Community leader, IDI-9).
“The team can support in a PPP programme which is a public private partnership by explaining the SMART Health programme and its objective.” (Government Official IDI 1).
Benefits of involving ASHAs
“Yes, definitely they [community members] pay attention to ASHA. Ladies mostly approach ASHA only whatever be their problem. It is only the ASHA who takes care of ladies all through their pregnancy. Once the child is delivered, they take care of vaccines and other things.” (Community Member, FGD-1).
“ASHA workers are really good. They persuade us to go to doctor and sometimes they accompanied us also to visit the hospital.” (Community member, FGD-4).
Appraisal about the anti-stigma campaign and mental health services
“Interacting with the patient and getting information about their health is really good. Actually, these people don’t know that they have CMD they imagine it differently …as mad …as abnormal.” (Doctor, IDI 03).