Promoting wellbeing and improving access to mental health care through community champions in rural India: the Atmiyata intervention approach

Training community health volunteers to use mobile platform during the COVID-19 pandemic: The Kenya experience

This study describes an alternative to face-to-face training method for community health volunteers (CHVs) as used by a collaborative group from the University of Nairobi, University of Washington and the Nairobi Metropolitan Mental Health Team during the COVID-19 lockdown in Kenya. This qualitative study describes the experiences of 17 CHVs enrolled in a training study, required to utilize different digital platforms (Google Meet or Jitsi) as a training forum for the first time. Verbatim extracts of the participants' daily experiences are extracted from a series of write-ups in the group WhatsApp just before the training. Daily failures and success experiences in joining a Google meet or Jitsi are recorded. Then, 17 participants, 10 women and 7 men, aged between 21 and 51 years (mean = 33), owning a smartphone, were enrolled in the study. None had used Jitsi or Google meet before. Different challenges were reported in login to either and a final decision to use Jitsi, which became the training platform. Training CHVs to deliver a psychosocial intervention using smartphones is possible. However, the trainer must establish appropriate and affordable methods when resources are constrained.

The Trajectory of Depression through Disenfranchised Grief in Young Widows in Times of COVID-19: A Case Report from Rural India

The COVID-19 pandemic was one of this century's deadliest and most widespread viral outbreaks, with higher mortality rates in men than women. Disruptions in funeral rituals and customs, no social recognition of the losses, and limited social support have complicated the grieving process and are linked to disenfranchised (not openly acknowledged, socially recognized, or publicly mourned) grief. Depression is also highly comorbid with complicated grief. Losing a spouse can be devastating, and this is more severe for women with limited or no resources, who are vulnerable because of the patriarchal society. In the current COVID-19 era, increased uncertainty and disenfranchised grief can worsen the clinical scenario and hamper interventions, as highlighted by the present case report on disenfranchised grief with depressive symptoms in a 30-year-old woman from rural India who, after a year of marriage, lost her husband due to COVID-19. This case study emphasizes the impact of multiple types of disadvantages due to sociodemographic and cultural determinants that can complicate the grieving process in the current context. The bioecological model of grief recovery considers individual features and societal/environmental factors to postulate the appropriate intervention. Finding meaning and purpose in life and restoration-oriented coping were successful for the clinical management of the patient.

Positive mental health for all serving the under-served

Mental disorders are major contributors to global burden of disease measured in Disability Adjusted Life Years (7% of all disease burden in 2017). Large treatment gaps for these disorders exist in all parts of the world. In India, overall treatment gap for mental disorders was found to be 83%. Women, children and adolescents, ethnic minorities, LGBTQ+ community, elderly and those living in remote and inaccessible areas have disproportionately higher rates of mental illness. They face unique and characteristic barriers to access to mental healthcare which increases treatment gap. These gaps have persisted despite global efforts and interventions to mitigate these barriers. Hence, there is a need to find alternatives to reduce mental health gap in these groups. Positive Mental Health interventions focuson well-being and health promoting activities, rather than on illness. The potential role of these interventions in promoting mental health and reducing treatment gap has been explored in this article.

Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While effective lay-health worker models for mental health care have been demonstrated through efficacy trials, there is limited evidence of the effectiveness of these models implemented in rural LMIC settings.

AIM

To evaluate the impact of a volunteer community-led intervention on reduction in depression and anxiety symptoms and improvement in functioning, and social participation among people living in rural Gujarat, India.

METHODS

Stepped-wedge cluster randomized controlled trial was used to assess the effectiveness of delivery of psychosocial intervention across 645 villages in Mehsana district of Gujarat, India between April 2017 and August 2019. The primary outcome was an improvement in depression and/or anxiety symptoms assessed using GHQ-12 at 3-month follow-up. Secondary outcomes were improvement in (a) depression and anxiety (Patient Health Questionnaire, (PHQ-9), Generalized Anxiety Disorder (GAD-7) & Self-Reporting Questionnaire-20 (SRQ-20); b) quality of life (EQ- 5D); c) functioning (WHO-DAS-12), and social participation (Social Participation Scale SPS). Generalized linear mixed-effects models were used to assess the independent effect of the intervention.

RESULTS

Out of a total of 1191 trial participants (608- intervention & 583-control), 1014 (85%) completed 3-month follow-up. In an adjusted analysis, participants in the intervention condition showed significant recovery from symptoms of depression or anxiety (OR 2.2; 95% CI 1.2 to 4.6; p<0.05) at the end of 3-months, with effects sustained at 8-month follow-up (OR 3.0; 95% CI 1.6 to 5.9). Intervention participants had improved scores on the PHQ-9 (Adjusted mean difference (AMD) -1.8; 95%CI -3.0 to -0.6), and SRQ-20 (AMD -1.7; 95%CI -2.7 to -0.6), at 3-months and PHQ-9, GAD-7, SRQ-20, EQ-5D and WHO-DAS at 8 months follow-up.

CONCLUSION

Findings suggest that Atmiyata had a significant effect on recovery from symptoms of depression and anxiety with sustained effects at 8-month follow-up.

TRIAL REGISTRATION

Trial registration details. The trial was registered prospectively with the "Clinical Trial Registry in India" (registry number: CTRI/2017/03/008139).

Understanding Lay Counselor Perspectives on Mobile Phone Supervision in Kenya: Qualitative Study

BACKGROUND

Task shifting is an effective model for increasing access to mental health treatment via lay counselors with less specialized training that deliver care under supervision. Mobile phones may present a low-technology opportunity to replace or decrease reliance on in-person supervision in task shifting, but important technical and contextual limitations must be examined and considered.

OBJECTIVE

Guided by human-centered design methods, we aimed to understand how mobile phones are currently used when supervising lay counselors, determine the acceptability and feasibility of mobile phone supervision, and generate solutions to improve mobile phone supervision.

METHODS

Participants were recruited from a large hybrid effectiveness implementation study in western Kenya wherein teachers and community health volunteers were trained to provide trauma-focused cognitive behavioral therapy. Lay counselors (n=24) and supervisors (n=3) participated in semistructured interviews in the language of the participants' choosing (ie, English or Kiswahili). Lay counselor participants were stratified by supervisor-rated frequency of mobile phone use such that interviews included high-frequency, average-frequency, and low-frequency phone users in equal parts. Supervisors rated lay counselors on frequency of phone contact (ie, calls and SMS text messages) relative to their peers. The interviews were transcribed, translated when needed, and analyzed using thematic analysis.

RESULTS

Participants described a range of mobile phone uses, including providing clinical updates, scheduling and coordinating supervision and clinical groups, and supporting research procedures. Participants liked how mobile phones decreased burden, facilitated access to clinical and personal support, and enabled greater independence of lay counselors. Participants disliked how mobile phones limited information transmission and relationship building between supervisors and lay counselors. Mobile phone supervision was facilitated by access to working smartphones, ease and convenience of mobile phone supervision, mobile phone literacy, and positive supervisor-counselor relationships. Limited resources, technical difficulties, communication challenges, and limitations on which activities can be effectively performed via mobile phone were barriers to mobile phone supervision. Lay counselors and supervisors generated 27 distinct solutions to increase the acceptability and feasibility of mobile phone supervision. Strategies ranged in terms of the resources required and included providing phones and airtime to support supervision, identifying quiet and private places to hold mobile phone supervision, and delineating processes for requesting in-person support.

CONCLUSIONS

Lay counselors and supervisors use mobile phones in a variety of ways; however, there are distinct challenges to their use that must be addressed to optimize acceptability, feasibility, and usability. Researchers should consider limitations to implementing digital health tools and design solutions alongside end users to optimize the use of these tools.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s43058-020-00102-9.

Scaling up community-delivered mental health support and care: A landscape analysis

Introduction

The mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up.

Methods

A narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features.

Results

The initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies.

Discussion

This landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

Factors affecting the sustainability of community mental health assets: A systematic review

Resources and activities offered by Voluntary, Community and Social Enterprise (VCSE) organisations could play a key role in supporting communities with their mental health. Whilst policy makers have become increasingly interested in using such asset-based approaches to improve mental health and well-being, the sustainability of these approaches remains underresearched. In this review, we explored the factors affecting the sustainability of community mental health assets. We conducted a systematic review of the literature using keywords based on three key terms: 'sustainability', 'mental health issues' and 'service provision'. Our search strategy was deployed in four electronic databases (MEDLINE, Web of Science, ASSIA and IBSS) and relevant websites were also searched. The literature search was conducted in November and December 2020 and yielded 2486 results. After title and abstract screening, 544 articles were subjected to full-text review. A total of 16 studies were included in a narrative synthesis. Studies included a broad range of community interventions and 30 factors affecting sustainability were identified across three sustainability levels: micro (individual), meso (organisational) and macro (local/national/global). Factors were discussed as barriers or facilitators to sustainability. A key barrier across all sustainability levels was funding (cost to individual participants, lack of available funding for VCSEs, economic uncertainty) whilst a key facilitator was connectedness (social connections, partnering with other organisations, linking with national public health systems). Nearly all articles included no definition of sustainability and the majority of factors identified here were at the meso/organisational level. As funding was found to be such a prevalent barrier, more research into macro level factors (e.g. government policies) is required.

Secondary trauma, burnout and resilience among mental health professionals from India: A review of research

While globally there has been growing research interest in the negative psychological consequences faced by helping professionals, literature among Indian Mental Health Professionals (MHPs) is sparse, and predominantly focussed on health care workers. This systematic review aims to synthesize and summarize current Indian literature on burnout, secondary traumatic stress and resilience among Indian MHPs. The review explores 14 research studies published in peer-reviewed journals between January 2005 to January 2022. Studies in the areas of secondary traumatic stress, burnout, vicarious trauma, compassion fatigue, and resilience have been included in the review. The term resilience within this paper includes compassion satisfaction, vicarious post-traumatic growth, well-being, coping, and stress management. The mental health professionals considered were psychiatrists, psychiatric nurses, psychiatric social workers, clinical psychologists, psychotherapists and counsellors. Studies were reviewed for their methodological considerations, the mental health population being studied, and the primary outcomes. Data related to sociodemographic variables, psychological impacts, risk and protective factors that influence burnout, secondary trauma and resilience among mental health professionals in India have been reported. The review summarizes conceptual, methodological, and analytical gaps and generates recommendations that contribute to theoretical and practice-based improvements in this area of research and practice.

Mental Health Interventions among Adolescents in India: A Scoping Review

Early adolescence is the period of the emergence of most mental disorders contributing significantly to the mental health burden globally, including India. The major challenges in India are early identification of mental health problems, treatment gap, lack of professionals, and interventions that address the same. Our review aimed to assess the effectiveness of mental health interventions among adolescents in India. We systematically searched PubMed, PsycINFO, and Cochrane databases and used cross-referencing to review the interventions published from 2010 to 2020. Eleven interventions were included in this review; nine were school-based, one community, and one digital. Most of the school-based programs used a life skills curriculum. Additionally, coping skills and resilience curricula showed improvement in depressive symptoms, cognitive abilities, academic stress, problem-solving, and overall mental well-being. The multi-component whole-school intervention was quite promising and helped in improving the overall school climate and various other mental health outcomes. Hence, school-based programs should be implemented as an entry point for screening mental health problems. However, there is a need for a more comprehensive mental health program in the country for adolescents. Additionally, there is a need to address the gap by conducting more interventions for early and out-of-school adolescents.

Addressing Mental Health Stigma in Low-Income and Middle-Income Countries: A New Frontier for Digital Mental Health

BACKGROUND

Mental health stigma is a major barrier to seeking help, and leads to poor quality of life and social withdrawal for individuals living with mental illness. These concerns are especially severe in low-income and middle-income countries (LMICs) that face a disproportionate share of the global burden of mental illnesses. With growing access to digital technologies in LMICs, there may be new opportunities to address mental health stigma. This review considers the potential for emerging digital technologies to advance efforts to challenge mental health stigma in LMICs.

METHODS

Promising digital strategies to reduce mental health stigma were identified through searching the peer-reviewed literature. Drawing from the Mental Illness Stigma Framework, these studies of digital strategies were grouped into three categories: 1) protest; 2) education, and 3) contact.

RESULTS

These three categories align with established stigma reduction programs. Digital strategies could expand the reach of or complement existing efforts. There are challenges with digital stigma reduction strategies, including the need for cultural adaptation of these programs to diverse contexts and settings, consideration of reliable measurement of mental health related stigma, and risks that digital media could perpetuate the spread of misinformation and exacerbate concerns pertaining to mental health stigma.

CONCLUSION

This review highlights the promise of technology for addressing mental health stigma in LMICs. This is imperative in the face of growing demand for mental health services owing to the economic and social impacts of the COVID-19 pandemic, and the increasing reliance on digital platforms among individuals in most countries.

Perceptions of ASHA workers in the HOPE collaborative care mental health intervention in rural South India: a qualitative analysis

OBJECTIVE

The main objective of this exploratory study was to investigate the overlooked perspectives and beliefs of Accredited Social Health Activists (ASHA workers) regarding a collaborative care mental health intervention (HOPE: Healthier Options through Empowerment), mental illness and the health of their rural communities.

DESIGN

Semi-structured, one-on-one, qualitative interviews.

SETTING

Seven primary health centres (PHCs) in rural Karnataka, India. All PHCs had previously completed the HOPE study.

PARTICIPANTS

15 ASHA workers, selected via purposive sampling. ASHAs are high school-educated village women trained as community health workers. ASHAs were included if they had previously participated in the HOPE intervention, a collaborative-care randomised controlled trial that aimed to integrate mental healthcare into existing primary care systems in rural Karnataka.

INTERVENTIONS

No interventions were introduced.

RESULTS

ASHA workers mostly had positive interactions with patients, including encouraging them to attend sessions, helping to explain the topics and techniques, and checking on the patients frequently. ASHA workers were able to identify key barriers to treatment and facilitators to treatment. ASHAs claimed that their knowledge about mental illness improved because of the HOPE study, though gaps remained in their understanding of aetiology and treatment. Several expressed interest in receiving additional mental health training. Overall, ASHAs viewed the HOPE study as a necessary and effective intervention, and requested that it expand.

CONCLUSIONS

This paper discusses the perspectives of ASHAs who participated in a novel effort to extend the collaborative care model to their own communities. ASHA workers help maintain relationships with patients that encourage participation, and the efforts of ASHAs often aid in mitigating common barriers to treatment. ASHA workers' beliefs and knowledge regarding mental illness can be changed, and ASHAs can become effective advocates for patients. Future collaborative care interventions would likely benefit from involving ASHA workers in community outreach efforts.

A Local Community-Based Social Network for Mental Health and Well-being (Quokka): Exploratory Feasibility Study

BACKGROUND

Developing healthy habits and maintaining prolonged behavior changes are often difficult tasks. Mental health is one of the largest health concerns globally, including for college students.

OBJECTIVE

Our aim was to conduct an exploratory feasibility study of local community-based interventions by developing Quokka, a web platform promoting well-being activity on university campuses. We evaluated the intervention's potential for promotion of local, social, and unfamiliar activities pertaining to healthy habits.

METHODS

To evaluate this framework's potential for increased participation in healthy habits, we conducted a 6-to-8-week feasibility study via a "challenge" across 4 university campuses with a total of 277 participants. We chose a different well-being theme each week, and we conducted weekly surveys to (1) gauge factors that motivated users to complete or not complete the weekly challenge, (2) identify participation trends, and (3) evaluate the feasibility of the intervention to promote local, social, and novel well-being activities. We tested the hypotheses that Quokka participants would self-report participation in more local activities than remote activities for all challenges (Hypothesis H1), more social activities than individual activities (Hypothesis H2), and new rather than familiar activities (Hypothesis H3).

RESULTS

After Bonferroni correction using a Clopper-Pearson binomial proportion confidence interval for one test, we found that there was a strong preference for local activities for all challenge themes. Similarly, users significantly preferred group activities over individual activities (P<.001 for most challenge themes). For most challenge themes, there were not enough data to significantly distinguish a preference toward familiar or new activities (P<.001 for a subset of challenge themes in some schools).

CONCLUSIONS

We find that local community-based well-being interventions such as Quokka can facilitate positive behaviors. We discuss these findings and their implications for the research and design of location-based digital communities for well-being promotion.

Attitudes Toward the Environment and Use of Information and Communication Technologies to Address Environmental Health Risks in Marginalized Communities: Prospective Cohort Study

BACKGROUND

Information and communication technologies, including mobile health (mHealth), can help isolated communities address environmental health challenges. The Puerto Rican island of Culebra has faced multiple sociopolitical and economic factors that have distressed the island's environment and health. Culebrenses are technologically engaged and have demonstrated a use of technology that transcends socioeconomic barriers. As a result, technological interventions could potentially help manage environmental risks on the island.

OBJECTIVE

This study aims to test and evaluate the potential benefits of an mHealth tool, termed ¡mZAP! (Zonas, Acción y Protección), for engaging communities with environmental risks through technology.

METHODS

Participants using ¡mZAP! (N=111) were surveyed. Bivariate analyses were used to examine associations of mHealth use with sociodemographics, technology use, an adapted environmental attitudes inventory, and the multidimensional health locus of control. Logistic regression was used to examine associations between attitudes toward environmental health risks and mHealth use.

RESULTS

Higher positive attitudes toward the environment were significantly associated with the use of ¡mZAP! (odds ratio 5.3, 95% CI 1.6-17.0). Environmental attitudes were also associated with the multidimensional health locus of control powerful others subscale (P=.02), indicating that attitudes toward the environment become more negative as feelings controlled by others increase. Participants felt that the authorities would resolve the challenges (63/111, 56.7%).

CONCLUSIONS

Perceived lack of control could present barriers to collective actions to address salient environmental health challenges in communities. The ongoing dependency on government-based solutions to community problems is worrisome, especially after the hurricane experiences of 2017 (which may potentially continue to be an issue subsequent to the more recent 2020 earthquakes).

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India

BACKGROUND

Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level.

AIMS

To describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India.

METHOD

This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention.

RESULTS

Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50-0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15).

CONCLUSIONS

To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.

Making mental health more accessible in light of COVID-19: Scalable digital health with digital navigators in low and middle-income countries

The rapid spread of COVID-19 and the devastating consequences to economies and healthcare systems around the world has highlighted the exigent need for accessible mental health support. Increasing use of mobile devices in Lower Middle-Income Countries (LMIC) such as India offers novel opportunity to expand treatment options and reach underserved populations. Prior efforts have utilized technology to redistribute or supplement clinical care but measurable outcomes of this research are limited. In this paper, we explain the structural barriers that prevent access to care and build on prior research to demonstrate how technology can be utilized to offer treatment if it is aided by education and technical support.

Bibliometric Analysis and Methodological Review of Mobile Health Services and Applications in India

PURPOSE

The purpose of this research is to analyze the literature published on mobile health (mHealth) in the Indian context. It also reviews the most important research works and presents various methodologies adopted by the researchers in this domain.

DESIGN/METHODOLOGY/APPROACH

The SciVerse SCOPUS database was used for extracting the literature on mobile health. The study used articles published between January 2008 to 28^th June 2019. The keyword used is 'mHealth' and journal articles with studies or interventions carried out in India were selected for bibliometric analysis and methodological review.

FINDINGS

For the keyword search, a total of 7,874 documents have been extracted, of which only 158 have been considered for the analysis. There is an exponential increase in the number of publications from the year 2015 to 2019. The keywords used for representing their articles have been grouped as mobile health devices, gender and age groups, system and software, health and disease condition, management, evidence-based practices (outcome), methods, and importance of the study. The journal PLOS One (87) has the highest number of citations, followed by The Lancet (63). The bibliometric analysis of the literature revealed seven clusters classified as individual's individual's mobile health applications adoption characteristics, need for mobile health and its governance, mobile phone application with the internet of things based framework for healthcare monitoring, mobile health for primary healthcare systems, authentication and security protocol for mobile healthcare, development and experimentation of mobile health application, and development and mobile health for adherence support intervention.

ORIGINALITY/VALUE

The study contributes in analyzing the bibliometrics and provides a methodological review for the journal articles published on mobile health. Previous articles considered systematic analysis of the bibliometric for mHealth, and mobile technology but less adequately discussed specifically towards Indian context which this study has embraced.

Digital Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression in Primary Care in India: Findings from a Randomized Pilot Study

Introduction: Task sharing holds promise for scaling up depression care in countries such as India, yet requires training large numbers of non-specialist health workers. This pilot trial evaluated the feasibility and acceptability of a digital program for training non-specialist health workers to deliver a brief psychological treatment for depression. Methods: Participants were non-specialist health workers recruited from primary care facilities in Sehore, a rural district in Madhya Pradesh, India. A three-arm randomized controlled trial design was used, comparing digital training alone (DGT) to digital training with remote support (DGT+), and conventional face-to-face training. The primary outcome was the feasibility and acceptability of digital training programs. Preliminary effectiveness was explored as changes in competency outcomes, assessed using a self-reported measure covering the specific knowledge and skills required to deliver the brief psychological treatment for depression. Outcomes were collected at pre-training and post-training. Results: Of 42 non-specialist health workers randomized to the training programs, 36 including 10 (72%) in face-to-face, 12 (86%) in DGT, and 14 (100%) in DGT+ arms started the training. Among these participants, 27 (64%) completed the training, with 8 (57%) in face-to-face, 8 (57%) in DGT, and 11 (79%) in DGT+. The addition of remote telephone support appeared to improve completion rates for DGT+ participants. The competency outcome improved across all groups, with no significant between-group differences. However, face-to-face and DGT+ participants showed greater improvement compared to DGT alone. There were numerous technical challenges with the digital training program such as poor connectivity, smartphone app not loading, and difficulty navigating the course content-issues that were further emphasized in follow-up focus group discussions with participants. Feedback and recommendations collected from participants informed further modifications and refinements to the training programs in preparation for a forthcoming large-scale effectiveness trial. Conclusions: This study adds to mounting efforts aimed at leveraging digital technology to increase the availability of evidence-based mental health services in primary care settings in low-resource settings.

Digital Mental Health: The Answer to the Global Mental Health Crisis?

Digital mental health interventions are often touted as the solution to the global mental health crisis. However, moving mental health care from the hands of professionals and into digital apps may further isolate individuals who need human connection the most. In this commentary, we argue that people, our society's greatest resource, are as ubiquitous as technology. Thus, we argue that research focused on using technology to support all people in delivering mental health prevention and intervention deserves greater attention in the coming decade.

Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally

Workforce shortages pose major obstacles to delivering adequate mental health care and scaling up services to address the global treatment gap. Mounting evidence demonstrates the clinical effectiveness of having nonspecialist health workers, such as community health workers, lay health workers, midwives, or nurses, deliver brief psychosocial treatments for common mental disorders in primary care settings. With rapidly increasing access to, and use of, digital technology worldwide, new opportunities are available to leverage these emerging digital technologies to support nonspecialist health workers and increase mental health workforce capacity. This Perspectives article considers the potential that digital technology holds for supporting nonspecialist health workers in delivering evidence-based mental health care. Specifically, from our search of the academic literature, we identified seven promising examples from primary care settings in different low- and middle-income countries (India, Pakistan, Zimbabwe, Peru, China, and Nigeria) where digital platforms are being used to support delivery of mental health care from a variety of nonspecialist providers by offering training, providing digital tools for diagnosis, guiding treatment, facilitating supervision, and integrating services. We summarize these examples and discuss future opportunities to use digital technology for supporting the development of a trained, effective, and sustainable mental health workforce. We also consider the potential to leverage these technologies for integrating mental health care into existing health systems in low-resource settings.

Innovative mental health initiatives in India: A scope for strengthening primary healthcare services

Mental health burden is a major health concern worldwide. In the last few decades, we are witnessing innovations that are successfully addressing gaps in the mental health service delivery in Indian context. This is an opportune time to explore existing innovative mental health initiatives in the country and integrate viable interventions to primary healthcare facilities to strengthen public mental healthcare delivery. The descriptive review of literature on innovative mental health programs in India was carried out. The initial search from google scholar and PubMed database yielded 1152 articles, of which 1114 were excluded that did not meet inclusion criteria. Full texts of 38 articles were reviewed and finally 22 studies were included for the study. Based on the review, most innovations are broadly summarized into five categories: (1) quality improvement mental health programs; (2) community-based mental health programs; 3) non-specialist mental health programs, 4) mobile-technology based mental health programs, 5) tele-mental health programs. These promising innovations in treatment and care can be customized as per the context for scale up and integrated into the primary healthcare system through District Mental Health Programme. The innovative approach not only makes mental health services more accessible and affordable but also empowering in nature by encouraging community members in early detection, prevention of mental illness and appropriate treatment referral to existing primary health care services.

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD).

METHODS

The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project.

DISCUSSION

Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries.

TRIAL REGISTRATION

The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Feasibility and acceptability of a novel community-based mental health intervention delivered by community volunteers in Maharashtra, India: the Atmiyata programme

BACKGROUND

Many community-based intervention models for mental health and wellbeing have undergone robust experimental evaluation; however, there are limited accounts of the implementation of these evidence-based interventions in practice. Atmiyata piloted the implementation of a community-led intervention to identify and understand the challenges of delivering such an intervention. The goal of the pilot evaluation is to identify factors important for larger-scale implementation across an entire district in India. This paper presents the results of a feasibility and acceptability study of the Atmiyata intervention piloted in Nashik district, Maharashtra, India between 2013 and 2015.

METHODS

A mixed methods approach was used to evaluate the Atmiyata intervention. First, a pre-post survey conducted with 215 cases identified with a GHQ cut-off 6 using a 3-month interval. Cases enrolled into the study in one randomly selected month (May-June 2015). Secondly, a quasi-experimental, pre-post design was used to conduct a population-based survey in the intervention and control areas. A randomly selected sample (panel) of 827 women and 843 men age between 18 to 65 years were interviewed to assess the impact of the Atmiyata intervention on common mental disorders. Finally, using qualitative methods, 16 Champions interviewed to understand an implementation processes, barriers and facilitators.

RESULTS

Of the 215 participants identified by the Champions as being distressed or having a common mental disorder (CMD), n = 202 (94.4%) had a GHQ score at either sub-threshold level for CMD or above at baseline. Champions accurately identified people with emotional distress and in need of psychological support. After a 6-session counselling provided by the Champions, the percentage of participants with a case-level GHQ score dropped from 63.8 to 36.8%. The second sub-intervention consisted of showing films on Champions' mobile phones to raise community awareness regarding mental health. Films consisted of short scenario-based depictions of problems commonly experienced in villages (alcohol use and domestic violence). Champions facilitated access to social benefits for people with disability. Retention of Atmiyata Champions was high; 90.7% of the initial selected champions continued to work till the end of the project. Champions stated that they enjoyed their work and found it fulfilling to help others. This made them willing to work voluntarily, without pay. The semi-structured interviews with champions indicated that persons in the community experienced reduced symptoms and improved social, occupational and family functioning for problems such as depression, domestic violence, alcohol use, and severe mental illness.

CONCLUSIONS

This study shows that community-led interventions using volunteers from rural neighbourhoods can serve as a locally feasible and acceptable approach to facilitating access social welfare benefits, as well as reducing distress and symptoms of depression and anxiety in a low and middle-income country context. The intervention draws upon social capital in a community to engage and empower community members to address mental health problems. A robust evaluation methodology is needed to test the efficacy of such a model when it is implemented at scale.

The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990-2017

BACKGROUND

Mental disorders are among the leading causes of non-fatal disease burden in India, but a systematic understanding of their prevalence, disease burden, and risk factors is not readily available for each state of India. In this report, we describe the prevalence and disease burden of each mental disorder for the states of India, from 1990 to 2017.

METHODS

We used all accessible data from multiple sources to estimate the prevalence of mental disorders, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by these disorders for all the states of India from 1990 to 2017, as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We assessed the heterogeneity and time trends of mental disorders across the states of India. We grouped states on the basis of their Socio-demographic Index (SDI), which is a composite measure of per-capita income, mean education, and fertility rate in women younger than 25 years. We also assessed the association of major mental disorders with suicide deaths. We calculated 95% uncertainty intervals (UIs) for the point estimates.

FINDINGS

In 2017, 197·3 million (95% UI 178·4-216·4) people had mental disorders in India, including 45·7 million (42·4-49·8) with depressive disorders and 44·9 million (41·2-48·9) with anxiety disorders. We found a significant, but modest, correlation between the prevalence of depressive disorders and suicide death rate at the state level for females (r²=0·33, p=0·0009) and males (r²=0·19, p=0·015). The contribution of mental disorders to the total DALYs in India increased from 2·5% (2·0-3·1) in 1990 to 4·7% (3·7-5·6) in 2017. In 2017, depressive disorders contributed the most to the total mental disorders DALYs (33·8%, 29·5-38·5), followed by anxiety disorders (19·0%, 15·9-22·4), idiopathic developmental intellectual disability (IDID; 10·8%, 6·3-15·9), schizophrenia (9·8%, 7·7-12·4), bipolar disorder (6·9%, 4·9-9·6), conduct disorder (5·9%, 4·0-8·1), autism spectrum disorders (3·2%, 2·7-3·8), eating disorders (2·2%, 1·7-2·8), and attention-deficit hyperactivity disorder (ADHD; 0·3%, 0·2-0·5); other mental disorders comprised 8·0% (6·1-10·1) of DALYs. Almost all (>99·9%) of these DALYs were made up of YLDs. The DALY rate point estimates of mental disorders with onset predominantly in childhood and adolescence (IDID, conduct disorder, autism spectrum disorders, and ADHD) were higher in low SDI states than in middle SDI and high SDI states in 2017, whereas the trend was reversed for mental disorders that manifest predominantly during adulthood. Although the prevalence of mental disorders with onset in childhood and adolescence decreased in India from 1990 to 2017, with a stronger decrease in high SDI and middle SDI states than in low SDI states, the prevalence of mental disorders that manifest predominantly during adulthood increased during this period.

INTERPRETATION

One in seven Indians were affected by mental disorders of varying severity in 2017. The proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990. Substantial variations exist between states in the burden from different mental disorders and in their trends over time. These state-specific trends of each mental disorder reported here could guide appropriate policies and health system response to more effectively address the burden of mental disorders in India.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Ethical issues in the design and conduct of stepped-wedge cluster randomized trials in low-resource settings

Background

Stepped-wedge cluster randomized trials (SW-CRTs) are increasingly popular in health-related research in both high- and low-resource settings. There may be specific ethical issues that researchers face when designing and conducting SW-CRTs in low-resource settings. Knowledge of these issues can help to improve the ethical conduct of SW-CRTs in a global health context.

Methods

We performed an ethical analysis of two studies using SW-CRT designs in low-resource settings: the Que Vivan Las Madres study conducted from 2014 to 2017 in Guatemala and the Atmiyata study conducted from 2017 to 2018 in rural parts of India. For both case studies, we identified and evaluated the classification of the study as research or nonresearch and the ethical issues regarding the justification of the design, including the delayed rollout of an intervention that had a promising effect.

Results

In our case studies, some minor ethical issues surfaced about the registration and stakeholder pressure on the order of randomization, but both included good justification for the design and delayed rollout. Our analysis did, however, demonstrate that careful consideration of the role of randomization and registration of the trials is important.

Discussion

SW-CRTs can provide an opportunity for rigorous evaluation of interventions destined to be rolled out on the basis of limited evidence. Furthermore, in SW-CRTs, the underlying objective is often to provide a robust evaluation of the effectiveness for generalized dissemination, and this makes the SW-CRT no less a research study than any other form of cluster randomized trial.

Conclusion

The design and conduct of stepped-wedge cluster randomized trials raises at least two ethical issues that need special consideration in both high- and low-resource settings: the justification for using the design, specifically the delayed rollout of the intervention to the control group, and the classification of the study as research or nonresearch. In our case studies, these issues did not seem to raise special ethical scrutiny in low-resource settings. Further ethical evaluation will hopefully result in specific ethical guidelines for the use of SW-CRTs in both high- and low-resource settings to contribute to responsible functioning of these trials and adequate protection of participants.

Digital Innovations for Global Mental Health: Opportunities for Data Science, Task Sharing, and Early Intervention

PURPOSE

Globally, individuals living with mental disorders are more likely to have access to a mobile phone than mental health care. In this commentary, we highlight opportunities for expanding access to and use of digital technologies to advance research and intervention in mental health, with emphasis on the potential impact in lower resource settings.

RECENT FINDINGS

Drawing from empirical evidence, largely from higher income settings, we considered three emerging areas where digital technology will potentially play a prominent role: supporting methods in data science to further our understanding of mental health and inform interventions, task sharing for building workforce capacity by training and supervising non-specialist health workers, and facilitating new opportunities for early intervention for young people in lower resource settings. Challenges were identified related to inequities in access, threats of bias in big data analyses, risks to users, and need for user involvement to support engagement and sustained use of digital interventions.

SUMMARY

For digital technology to achieve its potential to transform the ways we detect, treat, and prevent mental disorders, there is a clear need for continued research involving multiple stakeholders, and rigorous studies showing that these technologies can successfully drive measurable improvements in mental health outcomes.

Women's freedom of movement and participation in psychosocial support groups: qualitative study in northern India

BACKGROUND

Depression, the world's leading cause of disability, disproportionately affects women. Women in India, one of the most gender unequal countries worldwide, face systemic gender disadvantage that significantly increases the risk of common mental disorders. This study's objective was to examine the factors influencing women's participation in psychosocial support groups, within an approach where community members work together to collectively strengthen their community's mental health.

METHODS

This community-based qualitative study was conducted from May to July 2016, across three peri-urban sites in Dehradun district, Uttarakhand, Northern India. Set within an NGO-run mental health project, data were collected through focus group discussions with individuals involved in psychosocial support groups including women with psychosocial disabilities as well as caregivers (N = 10, representing 59 women), and key informant interviews (N = 8) with community members and mental health professionals. Data were analyzed using a thematic analysis approach.

RESULTS

The principal barrier to participating in psychosocial support groups was restrictions on women's freedom of movement. Women in the community are not normally permitted to leave home, unless going to market or work, making it difficult for women to leave their home to participate in the groups. The restrictions emanated from the overall community's attitude toward gender relations, the women's own internalized gender expectations, and most significantly, the decision-making power of husbands and mothers-in-law. Other factors including employment and education shaped women's ability to participate in psychosocial support groups; however, the role of these additional factors must be understood in connection to a gender order limiting women's freedom of movement.

CONCLUSIONS

Mental health access and gender inequality are inseparable in the context of Northern India, and women's mental health cannot be addressed without first addressing underlying gender relations. Community-based mental health programs are an effective tool and can be used to strengthen communities collectively; however, attention towards the gender constraints that restrict women's freedom of movement and their ability to access care is required. To our knowledge, this is the first study to clearly document and analyze the connection between access to community mental health services in South Asia and women's freedom of movement.

A structured review of psychiatric rehabilitation for individuals living with severe mental illness within three regions of the Asia-Pacific: Implications for practice and policy

INTRODUCTION

Psychiatric rehabilitation can provide and support recovery-oriented care by assisting individuals living with severe mental illness to lead full lives. Despite a well-established evidence-base, implementation and access to these interventions in clinical practice for people with severe mental illness in the Asia-Pacific region is low. We therefore aimed to evaluate prominent themes impacting on clinical practice, policy, and the implementation of psychiatric rehabilitation across the Asia-Pacific region.

METHODS

A comprehensive review of relevant literature on psychiatric rehabilitation of three regions within the Asia-Pacific was conducted using a structured search of PubMed and other databases. Eligible articles were selected which focussed on how psychiatric rehabilitation is defined and implemented across the Asia-Pacific region, as well as the associated successes and challenges. Common themes were generated.

RESULTS

Six themes emerged: the impact of policy, legislation, and human rights; access difficulties; the important role of family; the significance of culture, religion, and spiritual beliefs; the widespread impact of stigma; and the indigenous models of excellence being developed.

DISCUSSION

Consideration of the six themes and their implications should help raise awareness of the issues involved in the provision of psychiatric rehabilitation in the Asia-Pacific region and may improve outcomes for people living with severe mental illness. Suggested strategies include: developing a shared understanding of psychiatric rehabilitation; establishing quality legislation that's well implemented; adapting evidence-based models to develop culturally appropriate services; implementing stigma reduction and empowerment-based interventions; and, ensuring coordinated action among all stakeholders, combined with effective leadership.

Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap

PURPOSE OF REVIEW

Most people do not have access to adequate mental health care, and lack of skilled human resources is a major factor. We provide a narrative review of approaches to implementing task sharing-engaging non-specialist providers-to deliver mental health care.

RECENT FINDINGS

There is strong evidence both for the effectiveness of task sharing as a means of delivering care for a range of conditions across settings and for the effectiveness of non-specialist providers and health workers in delivering elements of culturally adapted psychosocial and psychological interventions for common and severe mental disorders. Key approaches to facilitate task sharing of care include balanced care, collaborative care, sustained training and supervision, use of trans-diagnostic interventions based on a dimensional approach to wellness and illness, and the use of emerging digital technologies. Non-specialist providers and health workers are well positioned to deliver evidence-based interventions for mental disorders, and a variety of delivery approaches can support, facilitate, and sustain this innovation. These approaches should be used, and evaluated, to increase access to mental health services.

Longitudinal assessment of an anti-stigma campaign related to common mental disorders in rural India

BACKGROUND

Stigma related to mental health and lack of trained mental health professionals is a major cause for an increased treatment gap, particularly in rural India. The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project delivered a complex intervention involving task sharing, an anti-stigma campaign and use of technology-based, decision-support tools to empower primary care workers to identify and manage depression, anxiety, stress and suicide risk.AimsThe aim of this article is to report changes in stigma perceptions over three time points in the rural communities where the anti-stigma campaign was conducted.

METHOD

A multimedia-based anti-stigma campaign was conducted over a 3-month period in the West Godavari district of Andhra Pradesh, India. Following that, the primary care-based mental health service was delivered for 1 year. The anti-stigma campaign was evaluated in two villages and data were captured at three time points over a 24-month period (N = 1417): before and after delivery of the campaign and after completion of the health services delivery intervention. Standardised tools captured data on knowledge, attitude and behaviour towards mental health as well as perceptions related to help seeking for mental illnesses.

RESULTS

Most knowledge, attitude and behaviour scores improved over the three time points. Overall mean scores on stigma perceptions related to help seeking improved by -0.375 (minimum/maximum of -2.7/2.4, s.d. 0.519, P &lt; 0.001) during this time. Loss to follow-up was 10%.

CONCLUSIONS

The data highlight the positive effects of an anti-stigma campaign over a 2-year period.Declaration of interestNone.

Scaling-up psychological interventions in resource-poor settings: training and supervising peer volunteers to deliver the 'Thinking Healthy Programme' for perinatal depression in rural Pakistan

BACKGROUND

There is a scarcity of specialist trainers and supervisors for psychosocial interventions in low- and middle-income countries. A cascaded model of training and supervision was developed to sustain delivery of an evidence-based peer-delivered intervention for perinatal depression (the Thinking Healthy Programme) in rural Pakistan. The study aimed to evaluate the model.

METHODS

Mixed methods were employed as part of a randomised controlled trial of the intervention. Quantitative data consisted of the peers' competencies assessed during field training and over the implementation phase of the intervention, using a specially developed checklist. Qualitative data were collected from peers and their trainers through 11 focus groups during the second and third year of intervention rollout.

RESULTS

Following training, 43 peers out of 45 (95%) achieved at least a 'satisfactory' level of competency (scores of ⩾70% on the Quality and Competency Checklist). Of the cohort of 45 peers initially recruited 34 (75%) were retained over 3 years and showed sustained or improved competencies over time. Qualitatively, the key factors contributing to peers' competency were use of interactive training and supervision techniques, the trainer-peer relationship, and their cultural similarity. The partnership with community health workers and use of primary health care facilities for training and supervision gave credibility to the peers in the community.

CONCLUSION

The study demonstrates that lay-workers such as peers can be trained and supervised to deliver a psychological intervention using a cascaded model, thus addressing the barrier of scarcity of specialist trainers and supervisors.