“Our experience today reinforced that ASHAs (Accredited Social Health Activists) have the potential to revolutionize mental healthcare. Their interpersonal skills were heart-warming and their strong ties to the community form the needed foundation to deliver accessible, patient-centered care. These lessons are relevant across India but also the rest of the world including North America”
Daisy Singla, Ph.D., C.Psych, Clinician Scientist, Center of Addiction and Mental Health, University of Toronto, Lunenfeld Tanenbaum Research Institute
Depression is the leading mental health cause of the global burden of disease[i] and estimated global costs of untreated depression are up to 16 trillion US dollars.[ii] Brief psychological treatments are among the most effective and cost-effective interventions in medicine[iii] and recommended as the first line of care[iv] to address this global burden. The major supply-side barrier of inadequate numbers and inequitable distribution of mental health specialists has been addressed by global mental health practitioners by task-sharing of these treatments to NSPs—including community health workers, lay therapists, peers, nurses, and teachers. There is now a robust evidence base demonstrating that NSP can effectively deliver brief psychological treatments for depression and other common mental health problems in a wide range of contexts.[v],[vi] Dr. Anant Bhan, Site PI for Sangath Bhopal Hub, shared why it is so important to engage with NSPs in this work, particularly in India, “ASHAs are the backbone of the community healthcare India, and by extension, our work. It is indeed an honour to be able to work with these community health change agents with such levels of dedication, commitment and hard work. We believe that the involvement of frontline health workers such as ASHAS is crucial for integrating mental health into primary health care provision.”
Despite the availability of NSPs-delivered, effective and cost-effective psychological treatments, the treatment gap for mental disorders remains a big challenge to be addressed. From the service-delivery perspective, clinical supervision of NSP-delivered psychological treatments positively impact the therapist in training, therapy quality and patient outcomes and thus it essential to ensure the quality of the treatment delivered. Previous approaches to clinical supervision have focused on mental health expert-led, applying ungeneralizable metrics to supervise delivery. This is particularly relevant in India as our country has limited, adequately trained specialists in psychological treatments who are available to provide expert supervision.
This study, funded by Grand Challenges Canada, and led by Principal Investigator of the study is Dr. Daisy R Singla, Clinician Scientist, University of Toronto, Sinai Health System, Lunenfeld Tanenbaum Research Institute, seeks to address the barriers by scaling up measurement-based peer supervision, and innovation the study investigators have designed, piloted and evaluated over the past decade, using the digital platforms for supporting NSP-delivered care in global health. This peer-supervision study is a component of the overall EMPOWER project. EMPOWER is a priority work-stream of the GMH@Harvard Initiative with the goal of increasing health system capacity for the prevention and care of mental health problems across the life course, globally. Using digital training, supervision, and quality assurance tools for specific evidence-based psychosocial interventions EMPOWER will train, and supervise, frontline health workers to deliver these interventions with assured quality. Learn more about EMPOWER’s mission and programs at EMPOWER.care. “The field of global mental health has reached an inflection point where we have sufficient evidence about ‘what works’ but do not understand ‘how to make it work’.” reflects Dr. Abhijit Nadkarni, Site PI for Sangath Goa Hub, “Studies such as the GCC EMPOWER peer-supervision project allow us to answer this critical question which will help the scaling up evidence based psychosocial interventions so that they are accessible to those who need them the most”
This supervision component of the EMPOWER project seeks to address the barriers posed by the orthodox approach to supervision, a key pedagogical and quality assurance tool in treatment delivery which is known to positively impact the therapist in training,[vii],[viii],[ix] therapy quality [x] and patient outcomes.[xi],[xii] The Harvard Medical School Co-Investigators for the project are Professor Vikram Patel and Dr. John Naslund. The Investigators are collaborating with research teams at Dimagi and Sangath to adapt Dimagi’s well known CommCare digital platform for supporting NSP delivered care in global health.
In collaboration with projects based out of two Sangath hubs in Bhopal and Goa, the study will be conducted in primary care facilities in the Sehore district of Madhya Pradesh (14 facilities in rural settings), and the state of Goa (urban/peri-urban with 24 facilities). The NSPs will be trained to deliver a brief psychological treatment for depression called the Health Activity Program (HAP). In December 2021 the teams met in Hoshangabad district in Madhya Pradesh, India to test a beta version of Dimagi’s CommCare app for peer-supervision. There were 10 NSPs in total who attended the CommCare platform training consisting of five Accredited Social Health Activist (ASHA) supervisors and five ASHAs. “It was so inspiring, and humbling, to witness ASHAs, the formidable cadre of India’s public health workforce, demonstrate such commitment, motivation and comfort in learning to engage with cutting-edge technologies to support their new roles as mental health care providers”. Professor Vikram Patel shared about his time meeting with the ASHAs during the pilot testing. The NSPs travelled from 9 to 60 kilometres to participate in the training. This set of NSPs has a diverse variety of qualifications, ranging from high school to post-graduate studies, with eight NSPs having completed either secondary or post-secondary education. The rest held a bachelor’s degree (BA). The NSPs ages ranged from 30 to 50 years old. This particular group of NSPs owned a smartphone and were well-versed in the procedure.
Study team members who also attended the pilot testing and met with ASHA’s included:
[i] Ferrari AJ, Charlson FJ, Norman RE, et al. Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Med 2013; 10(11): e1001547.
[ii] Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development. The Lancet 2018; 392(10157): 1553-98.
[iii] Organization WH. Update of the Mental Health Gap Action Programme (mhGAP) guidelines for mental, neurological and substance use disorders, 2015: World Health Organization; 2015.
[iv] World Health Organization. Mental Health Global Action Programme Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological, and Substance Use Conditions in Humanitarian Emergencies. Geneva: WHO, 2015.
[v] Singla DR, Kohrt B, 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(1).
[vi] Van Ginneken N, Tharyan P, Lewin S, et al. Non‐specialist health worker interventions for the care of mental, neurological and substance‐abuse disorders in low‐and middle‐income countries. The Cochrane Library 2013.
[vii] Saxon D, Firth N, Barkham M. The relationship between therapist effects and therapy delivery factors: Therapy modality, dosage, and non-completion. Administration and Policy in Mental Health and Mental Health Services Research 2016: 1-11.
[viii] Fairburn CG, Allen E, Bailey-Straebler S, O’Connor ME, Cooper Z. Scaling Up Psychological Treatments: A Countrywide Test of the Online Training of Therapists. J Med Internet Res 2017; 19(6): e214.
[ix] Kühne F, Maas J, Wiesenthal S, Weck F. Empirical research in clinical supervision: a systematic review and suggestions for future studies. BMC psychology 2019; 7(1): 54.
[x] Weck F, Jakob M, Neng JM, Höfling V, Grikscheit F, Bohus M. The effects of bug‐in‐the‐ eye supervision on therapeutic alliance and therapist competence in cognitive‐behavioural therapy: A randomized controlled trial. Clinical psychology & psychotherapy 2016; 23(5): 386-96.
[xi] Saxon D, Barkham M, Foster A, Parry G. The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical psychology & psychotherapy 2017; 24(3): 575-88.
[xii] Singla DR, Hollon SD, Velleman R, et al. Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India. Psychological Medicine 2019: 1-9.
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