Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India

Abstract

BackgroundAvailability of basic mental health services is limited in rural areas of India. Health system and individual level factors such as lack of mental health professionals and infrastructure, poor awareness about mental health, stigma related to help seeking, are responsible for poor awareness and use of mental health services. We implemented a mental health services delivery model that leveraged technology and task sharing to facilitate identification and treatment of common mental disorders (CMDs) such as stress, depression, anxiety and suicide risk in rural areas of the state of Andhra Pradesh, India. The intervention was delivered by lay village health workers (Accredited Social Health Activists – ASHAs) and primary care doctors. An anti-stigma campaign was implemented prior to this activity. This paper reports the process evaluation of the intervention using mixed methods.MethodsA mixed methods pre-post evaluation assessed the intervention using quantitative service usage analytics from the server, and qualitative interviews with different stakeholders. Barriers and facilitators in implementing the intervention were identified.ResultsHealth service use increased significantly at post-intervention, ASHAs could followup 78.6% of those who had screened positive, and 78.6% of the 1243 Interactive Voice Response System calls made, were successful. Most respondents were aware of the intervention. They indicated that knowledge received through the intervention empowered them to approach ASHAs and share their mental health symptoms. ASHAs and doctors opined that EDSS was useful and easy to use. Medical camps organized in villages to increase access to the doctor were received positively by all. However, some aspects or facilitators of the intervention need to be improved, including network connectivity, booster training, anti-stigma campaigns, quality of mental health services provided by doctors, provision of psychotropic medications at primary health centers and frequency of health camps.ConclusionThe respondents’ views helped to understand the barriers and facilitators for improving the likely effectiveness of the intervention using Andersen’s Modified Behavioral Model of Health Services Use, and identify the mechanisms by which those factors affected mental health services uptake in the community.Trial registrationThe study is registered with Clinical Trials Registry India (Applied - 16/07/14-Ref2014/07/007256; registration received - 04/10/17-CTRI/2017/10/009992).Electronic supplementary materialThe online version of this article (10.1186/s12888-017-1525-6) contains supplementary material, which is available to authorized users.

Health care use and treatment-seeking for depression symptoms in rural India: A descriptive cross-sectional analysis

“…Firstly, we found no evidence that those with lower levels of self-stigma, exposure to mental health communications, or indicators of higher mental health literacy were more likely to seek treatment for depression. This contrasts with the conclusions of previous Indian studies, which have implicated these factors as barriers to treatment-seeking (13,61). This may be because in the current study research workers referred to specific symptoms of depression, rather than to mental illness or psychiatric treatment, and some evidence suggests that symptoms of common mental disorders are not associated with mental illness in India (41).…”

“…Secondly, while a majority of participants felt that cost and distance barriers are important, in line with previous research (13,61,63), those who reported these barriers were no less likely to seek treatment for depression. We also found little evidence to support differences in treatment-seeking by socio-economic status.…”

Implementation outcomes and strategies for depression interventions in low- and middle-income countries: a systematic review

“…Other implementation strategies commonly tested included facilitating the relay of clinical data to providers (n = 3; 14.3%) and conducting ongoing training (n = 3; 14.3%). For example, Tewari et al (2017) reported the acceptability, feasibility, and fidelity of a community-based electronic decision-support implementation strategy to facilitate the relay of clinical depression data from the community to primary care providers in India. Gureje et al (2015) reported fidelity associated with the conducting ongoing training of primary healthcare workers in the WHO Mental Health Gap Action Programme Intervention Guide to integrate depression treatment with primary care in Nigeria.…”

“…Yet, even with this widespread recognition of MNS disordersand depression in particularas key drivers of global disability, the gap between knowledge of evidence-based prevention and treatment approaches in the literature and its application in community settings is large. In high-income settings, only one in five patients with depression receive minimally-adequate treatment, with gaps increasing to one in nine in upper-middle-income countries and 1 in 27 for lower-middle-income countries (Thornicroft et al, 2017). Others have written that a comprehensive 'mental health care gap' would likely be much larger, as it would include the biomedical treatment gap, combined with the psychosocial care gap as well as the physical health care gap (Pathare et al, 2018).…”

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

“…The process evaluation from the set of 30 villages indicates that the intervention is acceptable, feasible and can be scaled up. It has identified a set of barriers and facilitators which need to be addressed 22 . Future randomised controlled studies can address these issues, add to the evidence and provide data on cost effectiveness so that this methodology could then be applied across similar settings after suitable adaptations.…”