Background
Methods
Project plan
Total project duration and eligibility criteria
Process evaluation
Ethics approval and consent to participate
Data analysis
Results
Facilitators
Knowledge of the project and CMD
“We have got a lot of awareness about this project. We did not know what a mental illness is until they [project staff] came and told [us]. When they [project staff] came we explained to them about our physical pains, etc. and during a medical camp [a] doctor saw me and informed me about the treatment. (Community member, FGD5)
“This project was excellent. We learnt all about the causes of mental illnesses and what kind of treatments should be taken for such [mental disorder] problems”. (Community member, FGD-4) “If we discuss our problems with someone, it make us happy and we feel good”. (Community Member-FGD7)
“We have learnt many things from this project. Initially we did not know the importance of mental disorders [CMD] and we had been treating people for other disease conditions, and through this study we got an idea about dealing and treating people with common mental disorders” (Doctor, IDI 4).
Benefits of involving ASHA’s
“ASHAs know everything well. ASHAs are the right people as they keep moving around the village and are familiar with the village problems” (Community member, FGD2)
“ASHAs are not new to us and our relationship with them [ASHAs] have been good. So they [ASHAs] used to give a lot of information about the patient, [at times] more than the patients. Patients [at times] did not discuss properly. As ASHAs are locals, they know what is happening in the families of the patients [and so could provide a context]”. (Doctor, IDI2)“Yes … ASHAs did a good job, they worked hard in motivating the patients. They used to accompany patients to the PHC and they used to help me understand the person’s condition. So that was very helpful”. (Doctor, IDI5)
Impact of training
Doctors indicated that the training facilitated easy use of the mhGAP-IG tool.“We have never done any interviews before so we got to know how to do it and how to approach someone and explain about the study…about mental disorders” (ASHAs, FGD1)
“This training programme was very detailed and we learnt about the treatment pattern and new tool which was easy to use” … “Because of this training programme, now I know what kind of treatment is to be given to what cases and which cases have to be sent to the specialist which are beyond my ability”. (Doctor, IDI5)
“Most of them did not even know how to operate a mobile phone, and because of this training it helped them to operate the tablets and click on the various options” (Field staff, FGD4)
Organizing medical camps in community
“Because of these medical camps we [community members] get treatment here, rather than going somewhere. So it is easier for us”. (Community member, FGD5)
“If such medical camps are conducted, people will get to know about their health condition, and will know at what stage they are, and where to seek information for getting treatment for their condition”. (Village leaders, IDI3)
Use of technology - EDSS /IVRS
“The overall use of the app was very comfortable and now I cannot see any problems from the app perspective, overall it was a good experience”. (ASHAs-FGD4)“Yes, definitely it was a great learning experience for me. I have used this tool for patients who came to me to get treated for some mental disorders”. (Doctor, IDI 5)
“Using IVR to send the messages to patients is good as it will be useful to remind people to visit the PHC or to follow instructions”. (Community members, FGD4)
Barriers
Stigma & discrimination to receive treatment
“Many people did not ‘open up’ completely. Even though we assured them [community people] about keeping all the information confidential, so I felt we should create more awareness so that they understand the problem better and come out with their problems in a better way”. (Field staff, FGD 4)
Financial livelihood and social constraints
Some members mentioned that people go to PHC for physical illnesses but ignore mental illnesses. Other community members mentioned that patients did not visit the PHC as they did not trust the doctors’ abilities to treat them.“We would need facilities near our places [to avoid] bearing the costs of the travel expenses, and medicines.”(Community members, FGD3).
The other problem that the ASHA faced was related to faulty social perceptions because of the caste system. According to them, higher caste community members believed that mental illness occurred among ‘laborers’ who were generally from low caste communities, and was not an issue in their ‘high caste communities’, hence they were reluctant to answer the questions. Some ASHAs also shared that they faced difficulty in posing the question on suicide as most community members responded poorly to being asked such questions. ASHAs further added that problems exist but people did not express them freely as they were apprehensive about where to seek treatment and what whether they would have to leave their work to get treated.“Yes, [madam] most of us had faced the issue…where we were not able to find people for the doing the interviews. We used to start doing the interviews at 5 [o’clock] in the evening…as nobody was available during the day time…..most of them used to go for agricultural work” (ASHA’s, FGD2)
Gaps in using technology–based applications/IVR messages
Doctors shared that sometimes they found mhGAP-IG tool difficult as they were unclear how to complete options based on the patient’s response. They also added that there were some difficulties in understanding certain terminology using the app.“Usually there are some calls from the mobile companies; if we receive the calls then we were asked to click on some option; because of which some service get activated and our balance (money) get deducted for activation of those services”. (Community members, FGD 5)
“We are unable to use mobile phones because of network and signal [connectivity] problem. Another issue is even if we get such calls we do not pay so much of attention as we are not aware of such things”. (Community members, FGD6)
Suggestions to improve the project
Some community members also recommended that the intervention should be continued for a longer period of time with support from government. Some community members said that they should be informed about the IVRS call number in advance prior to its implementation. Prior intimation of camps through IVR messages was also recommended. A few community members felt that there should be more involvement of village leaders so that they can motivate people to participate in such projects.“If it [camps] is organized in each panchayat [local administrative body] it will be good. If there is a need to go to the PHC they will not go as it is very far, so if there is a camp in [a] village nearby, definitely people will come for treatment”. (Village leader, IDI1)
Another suggestion was that when the patients visit the PHC, appropriate treatment should be provided. This would help in building the trust of the community in the health system.The project should be done by taking support from other organizations and the village leaders [and] administration, which will help in the success of the project. (Village leaders, IDI3)
Discussion
Key component from Andersen’s model | Scenario prior to the project | Intervention and processes implemented | Respondents perception about the intervention as mentioned in the process evaluation – positive (+)/ negative (−) |
---|---|---|---|
Environmental
| |||
Healthcare system | • PHCs were not providing any mental health care • ASHAs did not have any knowledge about CMDs • Primary care doctors lacked adequate knowledge and skills to identify and manage CMDs • Patients needed to travel to PHCs to get treated, leading to increased expenses and loss due to time spent in travel and waiting | • 21 ASHAs and 2 doctors were trained on using the mobile technology based applications • Training and supervision provided to both ASHAs and doctors to use the applications • An algorithm based EDSS implemented to facilitate screening by ASHAs • The mhGAP-IG based EDSS facilitated the doctors ability to manage CMDs • Health camps organized in villages to facilitate easier access to doctors • An algorithm based followup system developed for ASHAs to ensure treatment adherence | • Community members and village leaders felt that project was helpful (+) • Community members were able to share their mental health symptoms with ASHAs (+) • The ASHAs felt empowered by their enhanced skills acquired through training (+) • The doctors increased their knowledge and expertise to manage CMDs (+) • Additional booster training was suggested by ASHAs and doctors to supplement the current training and help them identify issues for improvement; current one time training was suggested as being g less than optimal (−) • Majority of participants appreciated the role of ASHAs and doctors (+) • The ASHAs repeatedly followed up with patients and enquired about their health which was appreciated by the community (+) • Health camps were appreciated as they reduced time and money spent in going to the PHCs (+) |
Population characteristics
| |||
Predisposing characteristics | • Poor knowledge about CMD in the community • Most community members worked in the fields during the day which prevented data collection by field staff or screening by ASHAs or help seeking if needed | • A mental health awareness campaign organized using multimedia processes • Personalized and dramatized narratives of mental illness used along with traditional posters and brochures and video of a local film actor talk about the project • Both field staff and ASHAs often interviewed community members late in the evening after they returned from work • Community members had to migrate in search of jobs | • The community members mentioned that prior to the campaign they were neither aware of CMDs nor knew where to seek treatment (+) • Community members, community leaders, ASHAs, doctors and field staff confirmed that the mental health awareness program was useful (+) • However, some community people were not interested in revealing their health problems completely due to stigma (−) • Inspite of using evenings to contact community members who were in the field due to their work, at times others could not be contacted even after repeated attempts as they had migrated out of the villages (−) • A belief persisted amongst some community members that CMDs were a problem amongst lower socio-economic status (−) • Some community members had reservations about the doctors ability to provide adequate treatment (−) |
Enabling resources | • No pre-existing mental health services in the village • Community were not oriented towards identifying CMDs • No treatment was sought from PHC for any psychological problems • Getting treated at PHCs was both time consuming and involved travel expenses | • Village leaders and local administration were kept informed about the project at each step • Local health staff – ASHAs and doctors used to provide care, and no additional resources were recruited for treatment purpose • Field staff 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 • Supervisor coordinated with the doctor and ASHA about the health camps | • Village leaders appreciated the project (+) • Using ASHAs and doctors in primary care for providing the intervention were seen as a positive move by most community members including ASHAs and doctors (+) • ASHAs were found to be particularly useful because – they made repeated visits; used their knowledge about the community while explaining the case to the doctor; accompanied the patient to the doctor (+) • All respondents supported health camps (+) • Health camps were also seen as a place where patients discussed problems amongst themselves and sought peer-led advice on an informal basis (+) • The quality of training and its value for field staff, ASHAs and doctors were underlined by them (+) • Quantitative data showed that a large number of population were screened (>5000), there was significant increase in the proportion of screen positive individuals seeking treatment from doctors (+) |
Need | • Perceived need to seek care for CMD was negligible as awareness about CMD was absent • Health workers including PHC doctors were not trained to identify or manage CMDs • No mechanism to increase the perceived need of those with CMD | • Mental health awareness activities and screening of the whole population by ASHAs led to increase in help seeking • The ability of primary health workers including doctors to identify and manage CMD was enhanced by using evidence-based algorithm driven EDSS • 1243 IVRS calls were attempted to remind screen positive individuals about treatment adherence and ASHAS and doctors about regular followups | • With increased perceived and evaluative need, identification of CMD and uptake of services was increased (+) • The treatment provided by doctors and provision of such through health camps also helped to increase ability of the community to seek care (+) • ASHAs provided brief suggestions to cope with stressful situations (+) • The EDSS was found to be acceptable and easy to use by ASHAs and doctors (+) • The mhGAP-IG based doctors app was found a bit time consuming by doctors at least initially (−) • IVRS was opined as a positive move to enhance care (+) • Only 65% of attempted IVRS calls were successful due to various reasons: i. Some community members failed to receive calls as they were either apprehensive about the source of the call or assumed that it will cost them in form of loss of talk time (−) ii. Mobile phones were at times not with the screen positive person as someone else had them, as only one phone was shared in the household (−) iii. Network connectivity was patchy across the villages leading to call drop (−) |
Health Behaviour
| |||
Personal health practises | • Stigma related to mental health and help seeking • Poor knowledge about CMDs amongst community members and health workers | • A campaign to increase mental health awareness and reduce stigma organized • Enquiring about suicide was a sensitive issue during the intervention | • Overall the campaign was beneficial (+) • Everyone opined that the project led to increased awareness about CMDs and the need to seek care, and led to more people visiting doctors (+) • Some community members did not seek treatment because they continued to be apprehensive about the kind of treatment they would receive (−), or stigma associated with help-seeking (−) • Many community members found the suicide question to be negative and did not like to respond (−) |
Use of health services | • 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 followup by ASHAs and doctors • Only 3 camps could be organized in the short time period | • Overall the interventions were thought to be useful by all (+) • Reluctance to seek care to avoid being marked as a family with mental disorders thus jeopardizing the ability to get their children married off (−) • ASHAs and doctors worked collaboratively to provide care (+) • ASHAs were deemed as instrumental to the intervention by everyone (+) • The EDSS and IVRS were seen as facilitating the intervention (+) • Medical camps facilitated increased service use (+) |
Outcomes
| |||
Perceived health status | • Community members were unaware about CMDs | • A comprehensive mental health intervention implemented | • Most respondent felt that the intervention led to greater perception about CMDs in the community (+) • Some community members were not convinced about seeking care or being screened even after the mental health awareness campaign (−) |
Evaluated health status | • No screening or treatment provided at primary care level for CMDs | • All components of the intervention had a primary care level focus | • Mental health services use was increased significantly; depression and anxiety scores reduced significantly (+) |
Consumer satisfaction | • No measure of consumer satisfaction in the community | • A pre-post evaluation of the project provided objective assessment of the outcomes | • Most respondents felt that the intervention was beneficial in not only providing increased awareness about CMDs but also the need for seeking care (+) • Some community members highlighted that the project helped then to discuss and share their problems with others which in turn helped those individuals (+) • The role played by ASHAs and doctors were seen positively (+) • Repeated followup by ASHAs was appreciated by the community as a process that motivated the community to access care (+) • Organizing medical camps in villages was appreciated (+) |