The effectiveness of Technology-assisted Cascade Training and Supervision of community health workers in delivering the Thinking Healthy Program for perinatal depression in a post-conflict area of Pakistan – study protocol for a randomized controlled trial

The study is a non-inferiority, single-blinded randomized controlled trial with two arms, comparing the effectiveness of two training strategies for the THP. Consolidated Standards of Reporting Trials (CONSORT) guidelines [18] will be followed in the design, implementation and reporting of this randomized controlled trial.

We intend conducting the study in the Swat district in Northern Pakistan which has been affected by multiple humanitarian crises in recent years. Swat has a population of 1,257,602 persons, 86 % of whom live in rural areas with the average household size of 8.8 persons with a low female literacy. The resurgence of the Taliban movement in the Swat Valley of Pakistan since 2004, and the military operations in 2009 and the displacement of residents has created a humanitarian crisis in the area [19]. The devastating floods of 2010 led to thousands of people losing of their homes, and caused destruction to houses, roads, schools and health facilities [20, 21]. A recent community-based cross-sectional survey of 349 pregnant women in Swat showed that the prevalence of current psychological distress was 38.1 % [22]. Mental health impacts of conflict are often severe [8, 23] and may not be depicted in the national statistics. The health infrastructure of a post-conflict zone like Swat is particularly fragile with the health workers under threat of being attacked, thus compromising their training and supervision. The district has a functioning LHW program and LHWs, who have 10–14 years of education and provide preventive primary care services in the community, have the capacity to use technology. A Lady Health Supervisor (LHS) supervises 15–20 LHWs in one supervisory zone.

The LHW program will be approached in the Swat district of Pakistan to obtain a list of the LHSs and LHWs who are currently working in the six LHS supervisory zones. Since Swat has extreme winter weather making some parts inaccessible in winters, the supervisory zones will be selected on the basis of accessibility throughout the year. The LHW program will be asked to inform all the LHSs and LHWs in the zones about the study. By simple random sampling 80 LHWs will be selected for the study and written informed consent will be obtained by the research team from the LHWs.

The primary outcome of the study is the mean competence scores post training and at 3 months. We define non-inferiority as a difference of 5 points or less (corresponding to a 10 % difference on the outcome measure score) in the mean competence score between the two groups. A sample size of 80 LHWs (40 LHWs per arm) will have 99 % power to detect a 5-point margin with a 0.05 one-sided alpha level. Even after potential attrition in this area, at 3 months we will need 30 health workers in each group for a power of 80 % and a two-sided alpha error of 0.05.

The selected LHWs will be randomly allocated to the technology experimental arm or the specialist group control arm. Randomization will be conducted by an individual not involved in the study by using computer-generated random numbers (Fig. 1).

A tablet-based multimedia manual is developed for THP training and supervision purposes. The intervention material is divided into five training sessions, which are converted into narrative scripts by a panel of THP experts. The narratives have incorporated all the core techniques and principles of the intervention such as effective use of counseling skills, collaboration with the mothers’ families, guided discovery (style of questioning to probe mother’s health beliefs), and setting health-related tasks. Culturally appropriate real-life characters for the trainers and the trainees have been developed. An artist has converted the characters into “Avatars” (graphic image representing each character) (Fig. 1), which were used to voice the narrative scripts. Our group had successfully used this methodology of Technology-assisted Cascade Training (TACT) for training parents of children with developmental disorders [22]. The TACTS has also used case scenarios and role plays to reinforce key messages and training skills. For example, the role plays have demonstrated: sessions’ delivery by THP-trained LHWs to depressed mothers, dealing with challenging situations and dealing with adverse events. The training has been made interactive through suggesting activities for the actual trainees using a pause button and instructions. These activities are aimed to help them practice delivery of sessions through the role plays, peer assessment of role plays, reflecting on one’s learning, sharing relevant personal and work experiences, and practicing problem-solving strategies. A separate module on supervision has been developed for the LHSs to guide them on conducting supervisions. The software has the provision to modify and update the training scenarios. The software will be tested with LHSs and academics during and after the development process. The qualitative feedback regarding multiple aspects of the system and the user interface will be recorded.

In the intervention arm THP trainers (who have experience of delivering THP for 1 year) will give 5 days’ training to the LHS on THP-TACTS and will supervise three practice cases delivered by the LHSs. The LHSs will then cascade this training using THP-TACTS to train LHWs in 5-day training sessions (Fig 2).

The control group of LHWs will be directly trained by specialists in a 5-day training program and supervised as in the original THP. Specialists are experienced mental health academics who have a clinical background of delivering CBT and THP. The LHWs in both arms will deliver the intervention in the community to depressed women using the original THP manuals. Five LHWs will deliver the TACTS intervention using a tablet.