Development of a Digital Program for Training Community Health Workers in the Detection and Referral of Schizophrenia in Rural India

Vidhi Tyagi, Azaz Khan, Saher Siddiqui, Minal Kakra Abhilashi, Pooja Dhurve, Deepak Tugnawat, Anant Bhan, John A Naslund, Vidhi Tyagi, Azaz Khan, Saher Siddiqui, Minal Kakra Abhilashi, Pooja Dhurve, Deepak Tugnawat, Anant Bhan, John A Naslund

Abstract

This study aimed to develop and assess the acceptability of a digital program for training community health workers (CHWs) in the detection and referral of patients with schizophrenia in community settings in rural India. An iterative design process was employed. First, evidence-based content from existing community programs for schizophrenia care was incorporated into the curriculum, and reviewed by experts to ensure clinical utility and fidelity of the adapted content. Second, CHWs provided feedback on the appropriateness of language, content, and an initial prototype of the digital training program to ensure relevance for the local context. Focus group discussions were then used to understand the acceptability of the digital training prototype and to inform modifications to the design and layout. Qualitative data was analysed using a rapid thematic analysis approach based on predetermined topics pertaining to acceptability of the training content and digital platform. Development of the initial prototype involved content review by 13 subject matter experts with clinical expertise or experience accessing and receiving mental health services, and engagement of 23 CHWs, of which 11 provided feedback for contextualization of the training content and 12 participated in focus group discussions on the acceptability of the prototype. Additionally, 2 service-users with lived experience of schizophrenia contributed to initial testing of the digital training prototype and offered feedback in a focus group discussion. During contextualization of the training content, key feedback pertained to simplifying the language and presentation of the content by removing technical terms and including interactive content and images to enhance interest and engagement with the digital training. During prototype testing, CHWs shared their familiarity with similar symptoms but were unaware of schizophrenia as a treatable illness. They shared that training can help them identify symptoms of schizophrenia and connect patients with specialized care. They were also able to understand misconceptions and discrimination towards people with schizophrenia, and how to address these challenges by supporting others and spreading awareness in their communities. Participants also appreciated the digital training, as it could save them time and could be incorporated within their routine work. This study shows the acceptability of leveraging digital technology for building capacity of CHWs to support early detection and referral of schizophrenia in community settings in rural India. These findings can inform the subsequent evaluation of this digital training program to determine its impact on enhancing the knowledge and skills of CHWs.

Keywords: Community health workers; Digital technology; Global mental health; Schizophrenia; Severe mental disorders; Task-sharing.

Conflict of interest statement

The authors declare no competing interests.

© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

Figures

Fig. 1
Fig. 1
Overview of the stepwise process for developing and contextualizing the training content
Fig. 2
Fig. 2
Sample content from the SARATHA training program manual
Fig. 3
Fig. 3
Sample content from the video-based instructional materials for the SARATHA digital training program

References

    1. Charlson FJ, et al. Global epidemiology and burden of schizophrenia: findings from the global burden of disease study 2016. Schizophr Bull. 2018;44(6):1195–203. doi: 10.1093/schbul/sby058.
    1. Harvey PD, et al. Functional impairment in people with schizophrenia: focus on employability and eligibility for disability compensation. Schizophr Res. 2012;140(1–3):1–8. doi: 10.1016/j.schres.2012.03.025.
    1. Morgades-Bamba CI, Fuster-Ruizdeapodaca MJ, Molero F. The impact of internalized stigma on the well-being of people with Schizophrenia. Psychiatry Res. 2019;271:621–7. doi: 10.1016/j.psychres.2018.12.060.
    1. Drake RE, Bond GR, Essock SM. Implementing evidence-based practices for people with schizophrenia. Schizophr Bull. 2009;35(4):704–13. doi: 10.1093/schbul/sbp041.
    1. Mueser KT, et al. Psychosocial treatments for schizophrenia. Ann Rev Clin Psychol. 2013;9:465–97. doi: 10.1146/annurev-clinpsy-050212-185620.
    1. Lora A, et al. Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low-and middle-income countries. Bull World Health Organ. 2012;90(1):47–54B. doi: 10.2471/BLT.11.089284.
    1. Gautham MS et al. The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. International Journal of Social Psychiatry, 2020. 66(4): p. 361–372.
    1. Kermode M, et al. Community beliefs about causes and risks for mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Int J Soc Psychiatry. 2010;56(6):606–22. doi: 10.1177/0020764009345058.
    1. Kermode M, et al. Community beliefs about treatments and outcomes of mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Public Health. 2009;123(7):476–83. doi: 10.1016/j.puhe.2009.06.004.
    1. Kermode M, et al. Attitudes to people with mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol. 2009;44(12):1087–96. doi: 10.1007/s00127-009-0031-7.
    1. Morin L, Franck N. Rehabilitation interventions to promote recovery from schizophrenia: a systematic review. Front Psychiatry. 2017;8:100. doi: 10.3389/fpsyt.2017.00100.
    1. Asher L, Patel V, De Silva MJ. Community-based psychosocial interventions for people with schizophrenia in low and middle-income countries: systematic review and meta-analysis. BMC Psychiatry. 2017;17(1):1–15. doi: 10.1186/s12888-017-1516-7.
    1. Kulhara P, et al. Needs of indian schizophrenia patients: an exploratory study from India. Soc Psychiatry Psychiatr Epidemiol. 2010;45(8):809–18. doi: 10.1007/s00127-009-0126-1.
    1. Dutta M, et al. Factors responsible for delay in treatment seeking in patients with psychosis: a qualitative study. Indian J Psychiatry. 2019;61(1):53.
    1. O’Connell N, et al. Early intervention in psychosis services: a systematic review and narrative synthesis of the barriers and facilitators to implementation. Eur Psychiatry. 2022;65(1):e2. doi: 10.1192/j.eurpsy.2021.2260.
    1. Singla DR, et al. Psychological treatments for the world: Lessons from low- and middle-income countries. Ann Rev Clin Psychol. 2017;13:149–81. doi: 10.1146/annurev-clinpsy-032816-045217.
    1. Raviola G, et al. Innovative models in mental health delivery systems: task sharing care with non-specialist providers to close the mental health treatment gap. Curr psychiatry Rep. 2019;21(6):1–13. doi: 10.1007/s11920-019-1028-x.
    1. Barbui C, et al. Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review. The Lancet Psychiatry. 2020;7(2):162–72. doi: 10.1016/S2215-0366(19)30511-5.
    1. Chatterjee S, et al. Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India. Br J Psychiatry. 2009;195(5):433–9. doi: 10.1192/bjp.bp.108.057596.
    1. Chatterjee S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. The Lancet. 2014;383(9926):1385–94. doi: 10.1016/S0140-6736(13)62629-X.
    1. Asher L, et al. Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): results of a 12-month cluster-randomised controlled trial. The Lancet Global Health. 2022;10(4):e530–42. doi: 10.1016/S2214-109X(22)00027-4.
    1. Hanlon C, et al. Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial. The Lancet Psychiatry. 2022;9(1):59–71. doi: 10.1016/S2215-0366(21)00384-9.
    1. Naslund JA, Shidhaye R, Patel V. Digital technology for building capacity of non-specialist health workers for task-sharing and scaling up mental health care globally. Harv Rev Psychiatry. 2019;27(3):181. doi: 10.1097/HRP.0000000000000217.
    1. Naslund JA, et al. Digital innovations for global mental health: opportunities for data science, task sharing, and early intervention. Curr Treat options psychiatry. 2019;6(4):337–51. doi: 10.1007/s40501-019-00186-8.
    1. O’Donovan J, et al. 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. doi: 10.1136/bmjopen-2017-021467.
    1. Winters N, 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. doi: 10.1136/bmjgh-2019-001421.
    1. Carter H, et al. 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. J Psychiatr Res. 2021;133:223–46. doi: 10.1016/j.jpsychires.2020.12.016.
    1. Naslund JA, 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. doi: 10.1016/S2215-0366(17)30096-2.
    1. Khan A, 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. J Technol Behav Sci. 2020;5(4):402–15. doi: 10.1007/s41347-020-00154-7.
    1. Muke SS, 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.
    1. Muke SS, 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. Int J Environ Res Public Health. 2020;17(17):6368. doi: 10.3390/ijerph17176368.
    1. Naslund JA, 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. Contemp Clin Trials. 2021;102:106267. doi: 10.1016/j.cct.2021.106267.
    1. Naslund JA, et al. Schizophrenia Assessment, Referral and Awareness Training for Health Auxiliaries (SARATHA): protocol for a mixed-methods pilot study in rural India. Int J Environ Res Public Health. 2022;22:14936. doi: 10.3390/ijerph192214936.
    1. Suryanarayana MH, Agrawal A. and K. Seeta Prabhu. Inequality-adjusted Human Development Index for India’s States 2011. 2011 [cited 4/1/2019.
    1. Menon P, Deolalikar A. Ndia State Hunger Index: comparisons of Hunger Across States. New Delhi: International Food Policy Research Institute; 2009.
    1. Kokane A, et al. Mental health issues in Madhya Pradesh: insights from national mental health survey of India 2016. In Healthcare. MDPI; 2019.
    1. Agarwal S, et al. The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study. Hum Resour health. 2019;17(1):1–13. doi: 10.1186/s12960-019-0402-4.
    1. Scott K, George AS, Ved RR. Taking stock of 10 years of published research on the ASHA programme: examining India’s national community health worker programme from a health systems perspective. Health Res policy Syst. 2019;17(1):1–17. doi: 10.1186/s12961-019-0427-0.
    1. Saprii L, et al. Community health workers in rural India: analysing the opportunities and challenges accredited Social Health activists (ASHAs) face in realising their multiple roles. Hum Resour health. 2015;13(1):1–13. doi: 10.1186/s12960-015-0094-3.
    1. Bhatia K. Community health worker programs in India: a rights-based review. Perspect public health. 2014;134(5):276–82. doi: 10.1177/1757913914543446.
    1. Angell BJ, et al. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: overcoming the challenges of stewardship and governance. PLoS Med. 2019;16(3):e1002759. doi: 10.1371/journal.pmed.1002759.
    1. Patel M, Misra S. Capacity building of “Accredited social health activist” under rural health training center regarding mental health: an interventional study. Indian J Community Med. 2022;47(2):240–3. doi: 10.4103/ijcm.ijcm_726_21.
    1. Sivakumar T, et al. Community-based rehabilitation for persons with severe mental illness in a rural community of Karnataka: methodology of a randomized controlled study. Indian J Psychol Med. 2020;42(6suppl):S73–9. doi: 10.1177/0253717620971203.
    1. 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 J Psychiatry. 2018;60(2):163. doi: 10.4103/psychiatry.IndianJPsychiatry_304_18.
    1. Rasaily S, Sharma IL, Ongmoo K. Capacity building and community process in DMHP implementation in Gyalshing District, Sikkim: Two year report (13–14) The Journal of Medical Research, 2017. 3(3): p. 169–171.
    1. Mishra A. The role of the Accredited Social Health Activists in effective health care delivery: evidence from a study in South Orissa. in BMC Proceedings. 2012. BioMed Central.
    1. Basavaraju V, et al. Care at door-steps for persons with severe mental disorders: a pilot experience from Karnataka district mental health program. Int J Soc Psychiatry. 2022;68(2):273–80. doi: 10.1177/0020764020983856.
    1. Chatterjee S. A Manual for Working with People with Schizophrenia and their Families. COPSI: Community Care for People with Schizophrenia in India 2012 [cited 2022 June 20]; Available from:
    1. Chatterjee S, et al. Collaborative community based care for people and their families living with schizophrenia in India: protocol for a randomised controlled trial. Trials. 2011;12(1):1–14. doi: 10.1186/1745-6215-12-12.
    1. Department of Empowerment of Persons with Disabilities (Divyangjan). Department of Empowerment of Persons with Disabilities (Divyangjan). 2022 [cited 2022 September 30].
    1. Chowdhary N et al. The Premium Counselling Relationship Manual. 2013 [cited 2021 October 5]; Available from:
    1. Basavarajappa C, et al. Nuts and bolts of starting and running Psychiatric Rehabilitation Services. Bengaluru, India: National Institute of Mental Health and Neurosciences (NIMHANS); 2016.
    1. Coderre S, Woloschuk W, Mclaughlin K. Twelve tips for blueprinting. Med Teach. 2009;31(4):322–4. doi: 10.1080/01421590802225770.
    1. Joshi U, 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 J psychiatry. 2021;63:102750. doi: 10.1016/j.ajp.2021.102750.
    1. Bondre AP, et al. A qualitative exploration of perceived needs and barriers of individuals with schizophrenia, caregivers and clinicians in using mental health applications in Madhya Pradesh, India. SSM-Mental Health. 2022;2:100063. doi: 10.1016/j.ssmmh.2022.100063.
    1. Beebe J. Rapid qualitative inquiry: a field guide to team-based assessment. Rowman & Littlefield; 2014.
    1. Gale RC, et al. Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the Veterans Health Administration. Implement Sci. 2019;14(1):1–12. doi: 10.1186/s13012-019-0853-y.
    1. Hamilton AB, Finley EP. Qualitative methods in implementation research: an introduction. Psychiatry Res. 2019;280:112516. doi: 10.1016/j.psychres.2019.112516.
    1. National Health Mission. Update on ASHA Programme. 2017 [cited 2022 September 22]; Available from:
    1. Keshavan MS, Shrivastava A, Gangadhar BN. Early intervention in psychotic disorders: Challenges and relevance in the indian context. Indian J psychiatry. 2010;52(Suppl1):S153. doi: 10.4103/0019-5545.69228.
    1. Tewari A, et al. SMART Mental Health Project: process evaluation to understand the barriers and facilitators for implementation of multifaceted intervention in rural India. Int J mental health Syst. 2021;15(1):1–18. doi: 10.1186/s13033-021-00438-2.
    1. Maulik PK et al. 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).
    1. Rahul P, et al. Accredited Social Health activist (ASHA) and her role in district mental health program: Learnings from the COVID 19 pandemic. Commun Ment Health J. 2021;57(3):442–5. doi: 10.1007/s10597-021-00773-1.
    1. Patel V, et al. EMPOWER: toward the global dissemination of Psychosocial Interventions. Focus. 2022;20(3):301–6. doi: 10.1176/appi.focus.20220042.
    1. Merchant R, et al. Digital Technology for management of severe Mental Disorders in low-and Middle-Income Countries. Curr Opin Psychiatry. 2020;33(5):501.
    1. Nirisha PL 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, 2022: p.1–10.
    1. Rahman A 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.
    1. Narayanan K. Digital Health in India. 2021 [cited 2022 June 20]; Available from:
    1. National Health Authority. Ayushman Bharat Digital Mission. 2022 [cited 2022 June 20]; Available from:
    1. Rodriguez-Villa E, et al. Making mental health more accessible in light of COVID-19: scalable digital health with digital navigators in low and middle-income countries. Asian J psychiatry. 2020;54:102433. doi: 10.1016/j.ajp.2020.102433.
    1. Rodriguez-Villa E et al. Smartphone Health Assessment for Relapse Prevention (SHARP): a digital solution toward global mental health.BJPsych Open, 2021. 7(1).
    1. Rodriguez-Villa E et al. Cross cultural and global uses of a digital mental health app: results of focus groups with clinicians, patients and family members in India and the United States.Global Mental Health, 2021.8.
    1. Lakhtakia T, et al. Smartphone digital phenotyping, surveys, and cognitive assessments for global mental health: initial data and clinical correlations from an international first episode psychosis study. Digit Health. 2022;8:1–18.
    1. Kapanee ARM, et al. Mental health orientation among ASHAs: a study from Karnataka State, India. J Family Med Prim Care. 2021;10(10):3748. doi: 10.4103/jfmpc.jfmpc_764_21.
    1. Bansal S, Srinivasan K, Ekstrand M. Perceptions of ASHA workers in the HOPE collaborative care mental health intervention in rural South India: a qualitative analysis. BMJ open. 2021;11(11):e047365. doi: 10.1136/bmjopen-2020-047365.
    1. Rössler W. The stigma of mental disorders: a millennia-long history of social exclusion and prejudices. EMBO Rep. 2016;17(9):1250–3. doi: 10.15252/embr.201643041.
    1. Hofmann-Broussard C, et al. A mental health training program for community health workers in India: impact on recognition of mental disorders, stigmatizing attitudes and confidence. Int J Cult Mental Health. 2017;10(1):62–74. doi: 10.1080/17542863.2016.1259340.
    1. Armstrong G, et al. A mental health training program for community health workers in India: impact on knowledge and attitudes. Int J mental health Syst. 2011;5(1):1–11. doi: 10.1186/1752-4458-5-17.
    1. Asher L, et al. Like a doctor, like a brother”: achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia. PLoS ONE. 2021;16(2):e0246158. doi: 10.1371/journal.pone.0246158.

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