https://orcid.org/0000-0002-1922-5715
Figures
Abstract
Workforce shortages represent a major bottleneck to delivering depression care, particularly in lower resource settings. This pilot study aimed to assess the acceptability and feasibility of a digital training program on developing knowledge and skills in the delivery of a brief behavioral activation intervention for depression among non-specialist providers (NSPs) in Gujarat, India. Participating NSPs, such as community health workers and other frontline providers without specialized training in mental health care, were provided access to a digital program covering the core skills and content necessary to deliver the Healthy Activity Program, an evidence-based behavioral activation intervention for depression. NSPs completed knowledge assessments before and after the digital training, followed by focus group discussions to gather their feedback about the program content and delivery format. Of 43 NSPs enrolled in this study, 67% (n = 29) were community health workers called Accredited Social Health Activists and 33% (n = 14) were frontline mid-level health providers called Community Health Officers. Most participants (n = 39; 91%) completed the full course. Knowledge assessment scores showed improvement from pre-training (mean = 29.96; 95% CI: 27.12–32.81) to post-training (mean = 34.62; 95% CI: 31.05–38.19; p = 0.0448). Focus group discussions revealed that participants appreciated the digital mode of training despite facing technical challenges while completing the course. This study further supports the feasibility and acceptability of digital approaches for training frontline providers to deliver brief psychological interventions for depression. With adequate resources and proper execution, digital training holds potential to serve as a key tool to build capacity of NSPs and expand the mental health workforce in India.
Citation: Brahmbhatt A, Rathod D, Joshi U, Khan A, Teja GS, Desai S, et al. (2024) Adapting and deploying a digital program for training non-specialist providers on a brief psychological intervention for depression in rural Gujarat, India. PLOS Glob Public Health 4(12): e0003967. https://doi.org/10.1371/journal.pgph.0003967
Editor: Ejemai Eboreime, Dalhousie University, CANADA
Received: May 30, 2024; Accepted: October 30, 2024; Published: December 5, 2024
Copyright: © 2024 Brahmbhatt et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: De-identified data are available as supplemental files.
Funding: The authors report no competing interests. This study was supported by funding from the Lakshmi Mittal and Family South Asia Institute at Harvard University enabled by a grant from the Tata Trusts (awarded to VP). This study was also supported by a grant from the National Institute of Mental Health (U19MH113211-01 awarded to VP and JAN). The funders had no role in the design of the review; collection, analysis, or interpretation of data; writing of the manuscript; or decision to submit the manuscript for publication.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Depression is a leading cause of morbidity affecting roughly 5% of the adult population globally [1]. This equates to approximately 280 million people living with depression, most of whom reside in lower income countries [1]. Over 75% of people living with depression in low-income and middle-income countries (LMICs) do not have access to any mental health care [1]. The World Health Organization (WHO) estimates that mental health conditions will contribute to economic losses exceeding 1.03 trillion USD from 2012–2030 [2]. Specifically, in India, it is estimated that 1 in 7 adults experience mild to severe psychiatric ailments [3], with lifetime prevalence and current prevalence of depressive disorders of 5.3% and 2.7%, respectively [4]. In Gujarat, the target setting for this study, the prevalence of depressive disorders has been reported between 1.2% [5] and 3.3% [3].
Although the Indian government has adopted new policies and legislations such as the National Mental Health Program (1982), the District Mental Health Program (1996), and the Mental Health Care Act (2017), ensuring accessibility and availability of mental health services remains a significant challenge [6, 7]. A large treatment gap persists due to inequities and inefficiencies in resource allocation [8]. There is also a chronic shortage of specialist mental health professionals and health care facilities equipped with skills in responding to the mental health needs of their patients. The few health facilities with available mental health services that do exist are typically concentrated in urban areas, leaving many individuals in rural areas without adequate access to mental health care [9]. Low health literacy, lack of health seeking behaviors, and negative attitudes around mental disorders in the form of stigma also play a role in preventing people from getting help [10, 11].
To mitigate these barriers, the delivery approach known as ‘task sharing’ has gained attention, where non-specialist community health workers are equipped with counselling skills necessary for responding to a range of mental disorders [12, 13]. The WHO recognizes task-sharing as the rational redistribution of tasks among health workforce teams [14]. This approach involves training and building capacity of frontline providers, who have not previously completed any specialized mental health training, to take on roles of delivering mental health care [12]. The delivery of effective psychosocial interventions for mental disorders can be assigned to non-specialist providers (NSPs) as a means to increase mental health care coverage in both low and high-income settings [15]. To successfully implement task-sharing models of mental health care delivery, it is necessary to first train and build capacity of NSPs. To date, conventional methods for training frontline NSPs pose challenges to achieving scale given the reliance on classroom-based instruction, which represents the most widely employed method of health worker training in LMICs. This approach is also costly given the continued need for mental health specialists to facilitate these trainings, travel costs of NSPs to reach the designated government health centers for attending the trainings, and additional logistical resources for coordinating the trainings. Therefore, training NSPs at scale represents a key bottleneck to implementing task-sharing models.
Digital tools (e.g., websites, mobile applications) may yield opportunities to overcome the logistical challenges of scaling up training and support for frontline health workers to facilitate task-sharing in low-resource settings. Broadly, there has been considerable interest in the ways digital technologies could be used to advance mental health care services in low-resource settings [16–19]. In India there have been numerous promising studies leveraging widely available digital technology to support and train frontline health workers [20–23]. Of relevance to the current study, the TeCHO platform has been used in Gujarat state since 2018 to improve comprehensive primary care services through real-time data entry and the generation of alerts for high-risk cases, supportive supervision, and report automation at multiple levels [24, 25]. Recent studies have also demonstrated that use of the TeCHO platform among frontline health workers has been successful in improving access to maternal and child healthcare services, as well as improved quality reporting and monitoring practices in Gujarat [26]. Furthermore, the cost-effectiveness of the TeCHO platform has been demonstrated, where the incremental costs are offset through averted disability attributed to the early identification of high-risk cases among pregnant women and children [27]. Such examples show the potential for mobile health (mHealth) tools to streamline and facilitate health care delivery processes.
More recently there have been efforts to use digital technology for training community health workers (CHWs) in the delivery of mental health interventions [28, 29]. This includes the development of a digital program for training CHWs in Sehore district in Madhya Pradesh in the delivery of a brief psychological intervention for depression called the Healthy Activity Program (HAP) [30–34]. The HAP digital training focuses on the knowledge and skills required to deliver HAP, a counselling intervention for mild to moderate depression based on behavioral activation and adapted for use in India [35]. The acceptability and effectiveness of the digital training were reflected in a pilot study followed by a randomized controlled trial enrolling frontline health workers in Madhya Pradesh [32, 34]; yet, the training content has not been deployed in other regions or states in India, representing a critical next step towards achieving scale. Additionally, in other parts of India, technology has been successfully deployed for training primary care doctors in identifying and responding to mental health needs in rural settings [36, 37].
This study seeks to expand upon this recent work with the overall aim of adapting the HAP digital training program for depression care for use in primary health care settings in Gujarat. This study involved leveraging the established reach of the TeCHO platform in Gujarat to serve as the digital platform where frontline health workers could access the HAP digital training program. The HAP course was hosted on the Learning Management System (LMS) within the TeCHO platform which delivered the course through various videos and engaging quizzes. This involved taking the digital training content previously developed and deployed in Madhya Pradesh, translating the content for use in Gujarat, and then uploading it onto the TeCHO platform accessible through a smartphone app. The objective of this study was to assess the impact of the digital training program on participating health workers’ knowledge scores, as well as their satisfaction with the adapted digital training program in a new setting.
Methods
Ethics statement
Ethical approval was obtained from the Institutional Review Boards of Sangath and the Society for Education, Welfare and Action-Rural (SEWA-Rural). Sangath is a not-for-profit research organization that has been working in the field of mental health since 1996. SEWA-Rural, established in 1980, is a community-based organization that works to improve the health and welfare of people in the tribal block of Jhagadia in the southern part of Gujarat. All non-specialist providers (NSPs) in this study provided written informed consent according to procedures approved by the Institutional Review Boards of Sangath and SEWA-Rural.
Setting
This mixed-methods pilot study was conducted in the Jhagadia block of the Bharuch district in Gujarat, India. Gujarat is a state located on the western coast of India and has a population of over 60 million people, according to the 2011 census [38]. Bharuch is a predominantly rural district in southern Gujarat with over 1.5 million inhabitants of which roughly 66% reside in rural areas [39]. There are four psychiatric hospitals across the entire state of Gujarat, all of which specialize in long-term treatment of mental illnesses. Gujarat is also home to innovative community mental health programs including Dava-Dua, QualityRights, and Atmiyata [40–42]. Despite these community-based efforts, there remain many challenges around creating accessible mental health services at the primary health care level, driven largely by inadequate workforce capacity, and lack of specific training in delivery of proven mental health interventions.
Participants
This study conducted in Bharuch, Gujarat, employed a purposive sampling technique and the target sample consisted of non-specialist providers (NSPs) without any prior formal training in mental health care delivery, including CHWs referred to as Accredited Social Health Activists (ASHAs) and frontline mid-level health providers referred to as Community Health Officers (CHOs). The CHOs are more recently deployed mid-level health providers, introduced as part of India’s Comprehensive Primary Health Care reforms under the Ayushman Bharat program to enable delivery of an expanded range of comprehensive primary health care services within Health and Wellness Centers [43, 44]. Health and Wellness Centers are upgraded primary health facilities that offer preventive, promotive and curative health care services. CHOs, often primarily AYUSH or nurse practitioners who have undergone additional training, are deployed as the leaders of Health and Wellness Centers. The eligibility criteria for NSPs in this study included being 18 years or older, employed by the National Health Mission, and recommended by the state Ministry of Health and Family Welfare for participation in the study.
Study procedures
The list of eligible NSPs was provided by the Taluka Health Officer and approved by the Chief District Health Officer as per the directives of the National Health Mission in Gujarat. All nominated NSPs were invited for the recruitment information session and represented three distinct groups based on their cadre (i.e., type of health worker), and prior exposure to the TeCHO platform. The first group consisted of ASHAs who had Android mobile devices provided by the state health department and were using the TeCHO platform. The second group consisted of ASHAs who did not have any prior exposure to the TeCHO platform and were provided Android mobile devices from Sangath to use for the study duration. The final group consisted of the CHOs who owned their own Android mobile devices and were using the TeCHO platform. As part of the information session, interested NSPs could then choose to enroll in the study. All NSPs completed written informed consent according to procedures approved by the Institutional Review Boards of Sangath and SEWA-Rural prior to enrolling in the study. After completing informed consent, all participants attended an orientation for the training program, introduction to use of the TeCHO digital platform, and collection of baseline measures of knowledge. The group of ASHAs that did not have prior experience with the TeCHO platform received additional training on the use of digital devices to overcome potential digital literacy challenges and to facilitate their use of the digital training content. Participant recruitment and data collection was completed from May 1st, 2021 to August 31st, 2021.
Digital training program and adaptation for use in Gujarat
A digital training program covering the HAP content was originally developed for use in Madhya Pradesh by adapting and transforming in-person instruction approaches, such as role-plays, into digital content that could be accessed from a smartphone app. This process of developing the digital training has been previously described in detail [30, 45]. HAP is a brief psychological intervention for depression that is delivered over 6–8 sessions and centers around behavioral activation as the core psychological framework with added emphasis on problem-solving strategies and the activation of social networks [35, 46]. The digital course includes 18 modules with roughly 100 videos, presentations, reading materials, engagement quizzes, and assessment questions, requiring about 50–60 hours to complete [30].
In the current study, this existing digital training program was adapted for use in Gujarat. This involved translating the content into the local language, Gujarati, and adapting the digital content so that it could be hosted onto the TeCHO smartphone app via a boutique newly developed Learning Management System (LMS) integrated into the application. Argusoft India Ltd, who had developed the TeCHO App also developed the LMS for TeCHO. TeCHO is a mobile and web-based application that enables data entry by the person providing services at the time and place of service delivery [24]. The digital course for our study was developed through the contextualization and adaptation of the existing HAP course in Hindi, previously developed and tested among NSPs in Madhya Pradesh [30]. Contextualization of the course content for use in Gujarat involved translation, adaptation, and fidelity checks. The entire HAP manual along with all other resources and video scripts were first translated into Gujarati, the local language. A research team member with knowledge of both the local language and content cross-checked and approved the final version of the course content. Stakeholder workshops were convened, consisting of small groups of 3–5 health workers, initially after translation of all materials and then again after the instructional videos were filmed. Stakeholder feedback primarily concerned the clarity of terms used, the need for correct use of local language, and modifying the context in role-play scenarios. These recommendations were incorporated into the program and the final content was reviewed by the research team prior to being uploaded to the digital training LMS platform, which was then shared with the NSPs.
Participants had 21 days (3 weeks) to complete the digital training. The research team provided technical support to participants as needed throughout the training, primarily through regular check-ins and by being available for troubleshooting by phone or over WhatsApp. The process for accessing the training on the TeCHO app is outlined in Fig 1. The research team tracked the progress of all the participants with the help of a dashboard accessible only to the research team. This highlighted the participants with slow or no progress. Those participants were contacted by the research team via calls and were offered encouragement to complete the course along with support with troubleshooting various technical challenges faced, if any. A WhatsApp group among participants and the research team also helped to facilitate regular communication, and to share updates, and supporting mitigation of any potential challenges.
Outcome assessment
The main outcomes were the acceptability and feasibility of the adapted digital training program, assessed based on completion rates of the training, completion of a post-training satisfaction questionnaire, and feedback provided through in-depth qualitative focus group discussions. Additionally, we assessed the preliminary effectiveness of the adapted training program by measuring change in scores on a written competency assessment among participants. Data collection occurred at baseline (pre-training) and endline (post-training). Demographic characteristics were also collected at baseline for all participants.
Knowledge assessment questionnaire
The primary effectiveness outcome was assessed with a validated knowledge questionnaire consisting of 26 multiple-choice questions [47]. The questionnaire evaluates change in participants’ applied knowledge and skills about the HAP intervention after completion of the digital training program. The questionnaire uses short-case vignettes followed by multiple-choice questions, and was developed and adapted for use in Madhya Pradesh [47, 48]. This measure was translated into Gujarati, and each correct answer is considered one point, meaning higher scores indicate greater knowledge of the HAP intervention for depression. The scores were then converted to 0–100 scale to facilitate interpretation. This measure was collected pre- (baseline) and post-training (endline).
Attitudes about mental illness
The Knowledge, Attitudes and Behaviors (KAB) questionnaire captures participants views about mental illness, and has been used previously with health workers in India [49, 50]. The KAB measure was translated into Gujarati and was collected pre- (baseline) and post-training (endline).
Satisfaction questionnaire
The satisfaction questionnaire was adapted from the MUSIC model [51], a measure composed of 26 questions, and was translated into Gujarati. The measure captures data on various key constructs pertaining to acceptability of the digital training, including empowerment (i.e., the individual has control over his/her learning environment in the course), usefulness (i.e., the course content is useful for his/her future), success (i.e., he/she can succeed at completing the digital course), interest (i.e., the instruction and course content is interesting), and caring (i.e., the instructor cares about whether students succeed in completing the course) (Jones 2019). Participants rate each item on a Likert scale, ranging from 1–6, where 1 is the lowest and 6 is the highest score. The items are scored across each of the key constructs, and this measure was collected post-training.
Qualitative focus group discussions
Participants were invited to join focus group discussions after completing the training. Three focus group discussions were conducted based on participants familiarity with TeCHO as a means to collect targeted feedback, and ensure all participants would have the chance to share their views about the program. The first group consisted of ASHAs who were using TeCHO in their routine work, a second group consisted of ASHAs without any experience of using TeCHO, and the third group included CHOs. Participants shared their insights about their experiences with the training, with emphasis on the acceptability of the digital platform and course content and offering recommendations for improvement. The focus group discussions lasted about 60 minutes and were audio-recorded and transcribed for thematic analysis.
Data analysis
Participant demographic characteristics were summarized using descriptive statistics. The primary effectiveness outcome was the multiple-choice measure of applied knowledge, where pre-post changes scores were analyzed using paired t tests. Wilcoxon sign paired rank test was used to test the null hypothesis that the post-training knowledge scores will be higher than pre-training knowledge scores. Pre-post differences in scores on the secondary KAB measure was analyzed using the non-parametric test (Wilcoxon sign paired rank test). The satisfaction questionnaire responses were tabulated and summarized in a table. All statistical analyses were completed using Stata version 17.0 and p<0.05 was considered statistically significant. Qualitative data on program acceptability and feasibility obtained from the focus group discussions were analyzed thematically. Focus group discussions were coded based on pre-defined themes pertaining to benefits, challenges, and recommendations for improving the training program, allowing for flexibility for additional themes to emerge from the codes [52]. An external researcher who was not part of the development or delivery of the digital training led the thematic analysis to minimize risk of bias [52]. One individual read and coded the transcripts, and then the research team met to review the codes and key themes, which offered a chance to resolve any disagreements and reach consensus.
Results
In total, 45 non-specialist providers (NSPs) were nominated by the district, of which 43 consented and enrolled in the study to complete the digital training. Table 1 lists the demographic characteristics of participating NSPs, consisting of 28 ASHAs, 1 ASHA Facilitator (a senior ASHA worker, who supervises around 20 ASHAs each along with providing community care), and 14 CHOs. Participants’ mean age was 33.3 (SD = 7.9) years, and most participants were female (93%). Nearly all (98%) participants reported having used a smartphone previously, with most (86%) indicating that they owned a smartphone. A total of 39 participants (91%) completed the entire course, requiring between 12 and 21 days of time. We did not observe any statistically significant differences in training completion rates or outcomes between participants with prior experience using the TeCHO platform compared to those without prior experience using the TeCHO platform.
Preliminary effectiveness of the digital training
Improvements in applied knowledge scores were observed from pre-training (mean = 29.96; 95% CI: 27.12–32.81) to post-training (mean = 34.62; 95% CI: 31.05–38.19). Based on the Wilcoxon sign paired rank test, the pre-post change observed in the competency test score was statistically significant (p = 0.045).
Attitudes about mental illness
Participants’ median score was 42 pre-training on the KAB measure, and increased to 43 at the post-training assessment, though this change was not statistically significant based on the Wilcoxon sign paired rank test (p = 0.74). These results are outlined in Table 2.
Satisfaction questionnaire
The satisfaction questionnaire responses were generally quite high, with most key constructs on the measure scoring at least 5 or greater out of a 6-point Likert scale. Specifically, the empowerment (mean = 5.02; 95% CI 4.76–5.29), usefulness (mean = 5.29; 95% CI 5.04–5.53), success (mean = 5.03; 95% CI 4.78–5.27), interest (mean = 5.02; 95% CI 4.83–5.21), and caring (mean = 5.00; 95% CI 4.75–5.24) components of the measure each scored 5 or greater.
Acceptability and feasibility of the digital training
Thematic analysis from the focus group discussions revealed 5 broad themes, including: satisfaction with the training program; benefits of the training program; challenges faced and what participants did not like about the training program; navigation issues with using the training app; and recommendations for improving the training and the digital training app. These broad themes, sample codes, and representative quotes are summarized in Table 3.
Participants shared positive views about the digital training and commented on aspects they appreciated including convenience of time, feasibility, and the video-based content. Participants enjoyed the visual and audio quality of the videos and found that they could easily understand the issues discussed as it was in Gujarati. Participants preferred the video format over reading material; yet, the reading material was viewed as important understanding and reviewing difficult concepts. They also highlighted that HAP would be useful in their communities and for themselves (mental health self-care). Participants expressed appreciation for the digital training in comparison to face-to-face conventional training programs. They also highlighted a few key benefits of the digital training including, feasibility in terms of flexibility to take course at a time of their choice, saving of resources for travel to central training facilities, and self-paced learning that facilitates more retention and makes it possible to revisit the content at their own leisure. Participants also highlighted challenges they faced during the training, such as technical errors due to application insufficiencies and internet bandwidth issues. In terms of navigating the content in the app, participants explained that they got used to it after a point of time. While mostly enjoying the videos, some participants remarked that some videos seemed lengthy or repetitive, and they offered suggestions about videos that should be shortened.
Participants suggested having an in-person orientation before beginning the digital training to address technical issues and become familiar with the app. Participants also emphasized the importance of completing the training and mentioned the value of having family support to enable them to do the training. These participants mentioned that help with household chores and childcare that family members offered could free up more time to enable them to finish the training as typically they took the course during morning or evening hours. Several ASHAs highlighted the role of having a supervisor to assist with responding to the needs of patients. The CHOs’ suggestions were more inclined towards the technical aspects, as they shared recommendations to make the videos available offline to address low bandwidth, and taking care of connectivity and platform issues such as refreshing and downloading the content.
Discussion
This study assessed the acceptability and preliminary effectiveness of a digital program for training frontline health workers to deliver a brief psychological intervention for depression adapted for use in Gujarat, India. Participants showed improvement in their scores on a validated measure of applied knowledge, suggesting the training was successful in teaching NSPs the skills and applied knowledge necessary for delivering the intervention. Participants showed no change in their attitudes about mental illness, suggesting that perhaps these health workers were sensitive towards mental health before enrolling in the study, and therefore, held fewer misconceptions about mental health concerns. In terms of qualitative feedback, through focus group discussions, participants highlighted their satisfaction with the training, and how the training was helpful, and expressed their preference for digital compared to conventional in-person training. They also commented on various challenges they faced when using the digital platform and provided constructive suggestions for improving the program.
Our study adds to emerging evidence showing that digital technology can support health worker training in LMICs [53]. In terms of gaining the necessary applied knowledge and skills to deliver brief psychological interventions, digital training appears to be as effective as traditional classroom or face-to-face training [32, 54, 55]. Consistent with prior studies, we found that participants favored the digital mode of training as it is more convenient, and found the digital training [31] content to be a new and interesting to learn. Furthermore, participants appreciated the flexibility and convenience of the digital training in terms of time, place, and avoiding the need for transportation to designated classroom-based facilities. In a recent study, training videos were also considered useful as they offer an audio-visual demonstration of psychological concepts [28]. Use of captivating clip-art images in videos and quizzes, with the addition of interactive role-plays, proved useful techniques as they were quickly accepted and helped participants to learn the new material and concepts. Participants also mentioned that the addition of the printed materials was also valuable for learning the different concepts. These findings are consistent with prior research showing that interactive, rich media can encourage participant engagement with training materials [56].
ASHAs’ limited prior experience using smartphones, length of the videos, poor internet connectivity, limited device storage space, certain navigation features of the TeCHO app, and technical glitches posed challenges in accessing and completing the training. Some participants were not pleased with certain mandatory features of the app requiring them to watch videos. Similar technological drawbacks were observed in a previous study [57]. For participants who were not well versed with smartphones, it was a challenging task to navigate the app, highlighting the need for orientation and targeted assistance. This kind of issue was noted in a prior study with frontline health workers in Ethiopia [57]. Importantly, our team has since modified the training content to better function in settings with lower bandwidth, by reducing the length of the video-based content, and ensuring smaller file sizes to avoid delays with loading [30]. Furthermore, since launching this study, there have been significant advances in terms of the access and quality of digital devices, particularly in rural settings in India. This is reflected by the improved connectivity and bandwidth in rural areas, increasing access to smartphones among frontline health workers that was further accelerated in the aftermath of the pandemic, and greater familiarity with using digital devices for engaging in training and supporting other work-related activities [58–60]. Therefore, while we noted a range of technical challenges in this study, these do not represent insurmountable barriers to employing the use of digital training for building workforce capacity among rural frontline health workers at scale.
Participants offered suggestions, including the need to reduce the length of several videos, pre-download the video files to the devices to address buffering issues, make technical support available, and improve the functioning of the app to make the digital training more user-friendly. Consistent with prior research, there is a need to engage end users early in the design to promote adoption and use of digital interventions to manage NCDs such as depression [61]. Prior similar efforts have studied task-shifting and mobile technology-based electronic decision support systems as approaches for enhancing the skills and abilities of primary care health workers. One study trained frontline providers to provide evidence-based mental health care for stress, depression, and suicidal risk in 30 remote villages in the Indian state of Andhra Pradesh [62]. Participants in this prior study found the digital training satisfactory and informative as it helped them to understand the fundamentals of mental health in an interactive way. Consistent with the current study, the digital training appeared to equip frontline providers with the skills to screen and identify individuals from their communities struggling with mental illness. Another study showed that frontline health workers can play an essential role in providing psychological interventions in the community [63].
The COVID-19 pandemic was a major driving factor for the adoption of digital technology [58, 60], even in rural India. The Health and Wellness Centers are now expected to use technology to address healthcare delivery and staff shortages. Due to drug shortages, travel restrictions, and financial hardships, many patients experiencing mental health concerns were unable to receive necessary care. Teleconsultations enabled healthcare providers to ensure continuity of care. The Indian government’s launch of the eSanjeevani OPD during the COVID-19 pandemic was critical and timely; yet, patients’ main challenges appeared to be related to their low levels of education and computer literacy, and language barriers [64], highlighting the need for connection with community-based providers for delivery of mental health services. As the National Health Authority considers expanding digitization of healthcare services across India through the Ayushman Bharat Digital Mission [65], it is important for the state to invest in internet availability at the sub-center and primary care center level, where the need for tele-services is even more salient. It may also be advisable, until universal broadband penetration is received, to design tools that allow for asynchronous, offline, operations. Furthermore, programs at the health system-level aimed at equipping frontline health workers with digital tools to support them in their work represent key opportunities to support the uptake of digital training programs and to ensure the sustainability of such efforts [19, 66, 67]. Our findings indicate that digital training in rural and underserved areas, which if scaled up, can be a potentially sustainable and time-saving solution for building capacity in the delivery of evidence-based mental health services. Efforts to leverage digital training program not only hold promise for training and supporting NSPs, but could support cost-effective and scalable approaches for training other health care providers, including primary care doctors and nurses [36, 37].
This pilot study is limited in terms of generalizability as it was conducted in one block of a rural district of Gujarat and a purposive sampling technique was used to identify participants. The sample size was small, with a total of 43 participants, which makes it difficult to draw conclusions about the broad impact of the training. With the small sample size, it was also not possible to determine if any participant characteristics might have influenced study outcomes, such as digital literacy or prior exposure to the TeCHO digital platform. Technical problems encountered during the digital training, including poor internet connectivity, application server issues, and storage limitations on the digital devices represented key issues to address to scale up such training efforts. The COVID-19 pandemic posed challenges during the training implementation, requiring adoption of enhanced safety protocols for data collection [68]. Lastly, this study is limited because it did not involve collecting data on the newly trained NSPs’ quality of HAP delivery in routine care settings, thereby highlighting a critical next step for advancing this work. Furthermore, this study did not include longer-term follow up to better understand whether the knowledge gained from completing the training had other impacts on the day-to-day work activities and performance of the participating NSPs. Future studies are needed to consider how digital training programs like the one evaluated in this study may result in changes in practice or application of new knowledge in the field among frontline NSPs.
Conclusion
This study adds to mounting evidence on the acceptability and effectiveness of digital programs for training NSPs in the delivery of proven mental health interventions, such as HAP. These findings highlight that the digital training content can be adapted for different settings and hosted on diverse digital learning management system platforms, in this case the TeCHO platform, demonstrating the potential to scale this training program across different regions of India and globally. This digital training program holds potential to help build capacity of NSPs in India and make mental health care more accessible in underserved areas [69].
Supporting information
S1 Checklist. Inclusivity in global research questionnaire.
https://doi.org/10.1371/journal.pgph.0003967.s001
(PDF)
References
- 1.
World Health Organization. Depressive Disorder (depression) Geneva, Switzerland: WHO; 2023 [cited 2024 February 3]. Available from: https://www.who.int/news-room/fact-sheets/detail/depression.
- 2.
World Health Organization. Mental Health Geneva, Switzerland: WHO; 2022 [cited 2024 February 3]. Available from: https://www.who.int/india/health-topics/mental-health.
- 3. Sagar R, Dandona R, Gururaj G, Dhaliwal R, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020;7(2):148–61. pmid:31879245
- 4. Murthy RS. National mental health survey of India 2015–2016. Indian journal of psychiatry. 2017;59(1):21. pmid:28529357
- 5. Arvind BA, Gururaj G, Loganathan S, Amudhan S, Varghese M, Benegal V, et al. Prevalence and socioeconomic impact of depressive disorders in India: multisite population-based cross-sectional study. BMJ open. 2019;9(6):e027250. pmid:31253618
- 6.
Directorate General of Health Services. National Mental Health Programme New Delhi, India: Ministry of Health & Family Welfare, Government of India; 2017 [cited 2024 February 3]. Available from: https://dghs.gov.in/content/1350_3_NationalMentalHealthProgramme.aspx#:~:text=Background%3A,to%20the%20Program%20in%201996.
- 7. Singh OP. District Mental Health Program-Need to look into strategies in the era of Mental Health Care Act, 2017 and moving beyond Bellary Model. Indian Journal of Psychiatry. 2018;60(2):163. pmid:30166670
- 8. van Ginneken N, Maheedhariah MS, Ghani S, Ramakrishna J, Raja A, Patel V. Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes. PloS one. 2017;12(6):e0178954. pmid:28582445
- 9. Shankardass MK. Mental health issues in India: Concerns and response. Indian Journal of Psychiatric Nursing. 2018;15(1):58–60.
- 10. Ogorchukwu JM, Sekaran VC, Nair S, Ashok L. Mental health literacy among late adolescents in South India: What they know and what attitudes drive them. Indian journal of psychological medicine. 2016;38(3):234–41. pmid:27335519
- 11. Naslund JA, Deng D. Addressing mental health stigma in low-income and middle-income countries: A new frontier for digital mental health. Ethics, Medicine and Public Health. 2021;19:100719. pmid:35083375
- 12. Raviola G, Naslund JA, Smith SL, Patel V. Innovative models in mental health delivery systems: task sharing care with non-specialist providers to close the mental health treatment gap. Current psychiatry reports. 2019;21:1–13.
- 13. Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V. Psychological treatments for the world: Lessons from low-and middle-income countries. Annual review of clinical psychology. 2017;13:149–81. PubMed Central PMCID: PMC5506549. pmid:28482687
- 14. Organization WH. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. 2007.
- 15. Armstrong G, Kermode M, Raja S, Suja S, Chandra P, Jorm AF. A mental health training program for community health workers in India: impact on knowledge and attitudes. International journal of mental health systems. 2011;5(1):1–11.
- 16. Carter H, Araya R, Anjur K, Deng D, Naslund JA. The emergence of digital mental health in low-income and middle-income countries: A review of recent advances and implications for the treatment and prevention of mental disorders. Journal of psychiatric research. 2021;133:223–46. pmid:33360867
- 17. Naslund JA, Shidhaye R, Patel V. Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally. Harvard review of psychiatry. 2019:1–12.
- 18. Naslund JA, Aschbrenner KA, Araya R, Marsch LA, Unützer J, Patel V, et al. Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. The Lancet Psychiatry. 2017;4(6):486–500. pmid:28433615
- 19. Naslund JA, Gonsalves PP, Gruebner O, Pendse SR, Smith SL, Sharma A, et al. Digital innovations for global mental health: opportunities for data science, task sharing, and early intervention. Current treatment options in psychiatry. 2019;6:337–51. pmid:32457823
- 20. Jindal D, Gupta P, Jha D, Ajay VS, Goenka S, Jacob P, et al. Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings. Global Health Action. 2018;11(1):1517930. pmid:30253691
- 21. Kaphle S, Matheke-Fischer M, Lesh N. Effect of performance feedback on community health workers’ motivation and performance in Madhya Pradesh, India: a randomized controlled trial. JMIR public health and surveillance. 2016;2(2):e3381.
- 22. Prabhakaran D, Jha D, Prieto-Merino D, Roy A, Singh K, Ajay VS, et al. Effectiveness of an mHealth-based electronic decision support system for integrated management of chronic conditions in primary care: the mWellcare cluster-randomized controlled trial. Circulation. 2019;139(3):380–91. pmid:30586732
- 23.
Singla DR, Fernandes L, Savel K, Shah A, Agrawal R, Bhan A, et al. Scaling up the task-sharing of psychological therapies: A formative study of the PEERS smartphone application for supervision and quality assurance in rural India. Cambridge Prisms: Global Mental Health. 2024.
- 24. Saha S, Kotwani P, Pandya A, Patel C, Shah K, Saxena D, et al. Addressing comprehensive primary healthcare in Gujarat through mHealth intervention: early implementation experience with TeCHO+ programme. Journal of Family Medicine and Primary Care. 2020;9(1):340. pmid:32110616
- 25. Saha S, Kotwani P, Pandya A, Saxena D, Puwar T, Desai S, et al. TeCHO+ program in Gujarat: a protocol for health technology assessment. BMJ Innovations. 2020;6(4):209–14.
- 26. Saha S, Quazi ZS. Does digitally enabling frontline health workers improve coverage and quality of maternal and child health services? Findings from a mixed methods evaluation of TECHO+ in Gujarat. Frontiers in Public Health. 2022;10:856561. pmid:35958841
- 27. Saha S, Pandya A, Raval D, Saxena D. Cost-Effectiveness of mHealth Intervention (TeCHO+) for Improving Maternal and Child Health Indicators in Gujarat, India. Indian Journal of Community Medicine. 2022;47(4):549–54. pmid:36742961
- 28. Kapanee ARM, Meena KS, Nattala P, Manjunatha N, Sudhir PM. Design and development of a training video for Accredited Social Health Activists (ASHAs) on brief psychological intervention for depression. Journal of Family Medicine and Primary Care. 2022;11(7):3862–7. pmid:36387707
- 29. Nirisha PL, Malathesh BC, Kulal N, Harshithaa NR, Ibrahim FA, Suhas S, et al. Impact of Technology Driven Mental Health Task-shifting for Accredited Social Health Activists (ASHAs): Results from a Randomised Controlled Trial of Two Methods of Training. Community Mental Health Journal. 2023;59(1):175–84. pmid:35779139
- 30. Khan A, Shrivastava R, Tugnawat D, Singh A, Dimidjian S, Patel V, et al. Design and Development of a Digital Program for Training Non-specialist Health Workers to Deliver an Evidence-Based Psychological Treatment for Depression in Primary Care in India. Journal of Technology in Behavioral Science. 2020. pmid:34150992
- 31. Muke S, Shrivastava R, Mitchell L, Khan A, Murhar V, Tugnawat D, et al. Acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural India. Asian Journal of Psychiatry. 2019;45:99–106. pmid:31557716
- 32. Muke SS, Tugnawat D, Joshi U, Anand A, Khan A, Shrivastava R, et al. 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. International journal of environmental research and public health. 2020;17(17):6368. pmid:32883018
- 33. Naslund JA, Tugnawat D, Anand A, Cooper Z, Dimidjian S, Fairburn CG, et al. Digital training for non-specialist health workers to deliver a brief psychological treatment for depression in India: Protocol for a three-arm randomized controlled trial. Contemporary clinical trials. 2021;102:106267. pmid:33421650
- 34. Tugnawat D, Singh A, Anand A, Bondre A, Chandke D, Dhurve P, et al. ESSENCE: An Implementation Research Program to Scale Up Depression Care in Rural Communities. Psychiatric Services. 2024;75(2):167–77. pmid:37904491
- 35. Patel V, Weobong B, Weiss HA, Anand A, Bhat B, Katti B, et al. The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial. The Lancet. 2017;389(10065):176–85. PubMed Central PMCID: PMC5236064.
- 36. Manjunatha N, Kumar CN, Math SB, Thirthalli J. Designing and implementing an innovative digitally driven primary care psychiatry program in India. Indian journal of psychiatry. 2018;60(2):236–44. pmid:30166682
- 37. Manjunatha N, Sadh K, Shashidhara HN, Manjunatha B, Shashank H, Ashwatha KP, et al. Establishing performance indicators of telemedicine-based “On-Consultation Training” of primary care doctors: an innovation to integrate psychiatry at primary care. Indian Journal of Community Medicine. 2021;46(1):75–9. pmid:34035581
- 38.
Office of the Registrar General & Census Commissioner. Population Finder 2011 New Delhi, India: Ministry of Home Affairs, Government of India; 2011 [cited 2024 February 3]. Available from: https://censusindia.gov.in/census.website/data/population-finder.
- 39.
Population Census. Bharuch District—Population 2011–2024 2011 [cited 2024 February 3]. Available from: https://www.census2011.co.in/census/district/202-bharuch.html.
- 40. Saha S, Chauhan A, Hamlai M, Saiyad V, Makwana S, Shah K, et al. Unique collaboration of modern medicine and traditional faith-healing for the treatment of mental illness: Best practice from Gujarat. Journal of Family Medicine and Primary Care. 2021;10(1):521. pmid:34017781
- 41. Pathare S, Funk M, Bold ND, Chauhan A, Kalha J, Krishnamoorthy S, et al. Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India. The British Journal of Psychiatry. 2021;218(4):196–203. pmid:31218972
- 42. Pathare S, Joag K, Kalha J, Pandit D, Krishnamoorthy S, Chauhan A, et al. Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India. Plos one. 2023;18(6):e0285385. pmid:37289730
- 43. Desai S, Bishnoi RK, Punjot P. Community health officer: the concept of mid-level health care providers. Int J Community Med Public Health. 2020;7(4):1610.
- 44. Purohit N, Goyal A, Rairker AB, Balasubramanya M, Kotwal A, Prinja S. Strengthening Comprehensive Primary Health Care through Ayushman Bharat: Role of Demand and Supply-side Interventions. Indian Journal of Public Health. 2023;67(4):568–74. pmid:38934822
- 45. Black CJ, Berent JM, Joshi U, Khan A, Chamlagai L, Shrivastava R, et al. Applying Human-Centered Design in Global Mental Health to Improve Reach Among Underserved Populations in the United States and India. Global Health: Science and Practice. 2023;11(1). pmid:36853639
- 46. Chowdhary N, Anand A, Dimidjian S, Shinde S, Weobong B, Balaji M, et al. The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation. The British journal of psychiatry. 2016;208(4):381–8. pmid:26494875
- 47. Restivo JL, Mitchell L, Joshi U, Anand A, Gugiu PC, Hollon SD, et al. Assessing health worker competence to deliver a brief psychological treatment for depression: development and validation of a scalable measure. Journal of Behavioral and Cognitive Therapy. 2020;30(4):253–66. pmid:33409505
- 48. Joshi U, Haney JR, Sequeira M, Singla DR, Patel V, Bhan A, et al. Adaptation and translation of a scalable measure for assessing health worker competence to deliver a brief psychological intervention: A case study from central India of its comparison to a performance-based measure. Psychiatric Quarterly. 2022:1–15. pmid:36536268
- 49. Maulik PK, Devarapalli S, Kallakuri S, Tewari A, Chilappagari S, Koschorke M, et al. Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychological medicine. 2017;47(3):565–75. pmid:27804895
- 50. Maulik PK, Devarapalli S, Kallakuri S, Tripathi AP, Koschorke M, Thornicroft G. Longitudinal assessment of an anti-stigma campaign related to common mental disorders in rural India. The British Journal of Psychiatry. 2019;214(2):90–5. pmid:30681052
- 51.
Jones BD. User guide for assessing the components of the MUSIC® Model of Motivation Blacksburg, Virginia: The MUSIC® Model of Motivation; 2017 [cited 2018 November 15]. Available from: https://www.themusicmodel.com/.
- 52.
Alhojailan MI, editor Thematic analysis: a critical review ofits process and evaluation. WEI international European academic conference proceedings, Zagreb, Croatia; 2012: Citeseer.
- 53. Long L-A, Pariyo G, Kallander K. Digital technologies for health workforce development in low-and middle-income countries: a scoping review. Global Health: Science and Practice. 2018;6(Supplement 1):S41–S8. pmid:30305338
- 54. Rahman A, Akhtar P, Hamdani SU, Atif N, Nazir H, Uddin I, et al. Using technology to scale-up training and supervision of community health workers in the psychosocial management of perinatal depression: a non-inferiority, randomized controlled trial. Global Mental Health. 2019;6. pmid:31157115
- 55. Mathur S, Weiss HA, Neuman M, Leurent B, Field AP, Shetty T, et al. Developing knowledge-based psychotherapeutic competencies in non-specialist providers: A pre-post study with a nested randomised controlled trial of a coach-supported versus self-guided digital training course for a problem-solving psychological intervention in India. Cambridge Prisms: Global Mental Health. 2023;10:e87. pmid:38161749
- 56. Florez-Arango JF, Iyengar MS, Dunn K, Zhang J. Performance factors of mobile rich media job aids for community health workers. Journal of the American Medical Informatics Association. 2011;18(2):131–7. pmid:21292702
- 57. Medhanyie AA, Little A, Yebyo H, Spigt M, Tadesse K, Blanco R, et al. Health workers’ experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia. Human resources for health. 2015;13(1):1–10. pmid:25588973
- 58. Stein DJ, Naslund JA, Bantjes J. COVID-19 and the global acceleration of digital psychiatry. The Lancet Psychiatry. 2022;9(1):8–9. pmid:34921798
- 59. Rodriguez-Villa E, Naslund J, Keshavan M, Patel V, Torous J. Making mental health more accessible in light of COVID-19: Scalable digital health with digital navigators in low and middle-income countries. Asian journal of psychiatry. 2020;54:102433. pmid:33271713
- 60. Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. The Lancet Psychiatry. 2021;8(6):535–50. pmid:33639109
- 61. Gudi N, Yadav UN, John O, Webster R. Challenges and opportunities in employing digital health to address self-management needs of people with NCDs in India. BMJ innovations. 2021:bmjinnov-2020-000620.
- 62. Maulik PK, Kallakuri S, Devarapalli S, Vadlamani VK, Jha V, Patel A. Increasing use of mental health services in remote areas using mobile technology: a pre–post evaluation of the SMART Mental Health project in rural India. Journal of global health. 2017;7(1):010408. pmid:28400954
- 63. Mutamba BB, van Ginneken N, Smith Paintain L, Wandiembe S, Schellenberg D. Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review. BMC health services research. 2013;13(1):1–11. pmid:24119375
- 64. Singh V, Sarbadhikari SN, Jacob AG, John O. Challenges in delivering primary care via telemedicine during COVID-19 pandemic in India: a review synthesis using systems approach. Journal of family medicine and primary care. 2022;11(6):2581. pmid:36119291
- 65.
National Health Authority. Ayushman Bharat Digital Mission New Delhi, India: Government of India; 2022 [cited 2022 June 20]. Available from: https://ndhm.gov.in/.
- 66. Winters N, Langer L, Nduku P, Robson J, O’Donovan J, Maulik P, et al. Using mobile technologies to support the training of community health workers in low-income and middle-income countries: mapping the evidence. BMJ global health. 2019;4(4):e001421. pmid:31413872
- 67. O’Donovan J, O’Donovan C, Kuhn I, Sachs SE, Winters N. Ongoing training of community health workers in low-income and middle-income countries: a systematic scoping review of the literature. BMJ open. 2018;8(4):e021467. pmid:29705769
- 68. Joshi U, Khan A, Muke S, Choubey S, Tugnawat D, Naslund JA, et al. Development and implementation of COVID-19 safety protocols for conducting a randomized trial in global mental health: Field report from Central India. Asian Journal of Psychiatry. 2021;63:102750. pmid:34304030
- 69. Patel V, Naslund JA, Wood S, Patel A, Chauvin JJ, Agrawal R, et al. EMPOWER: toward the global dissemination of psychosocial interventions. Focus. 2022;20(3):301–6. pmid:37021040