Thirty-six FCHVs were trained on the mCIDT (See Supplementary Table 1, Additional File 2). Of these 36 FCHVs, only 8 successfully implemented mCIDT, defined as referring someone. Several error messages including typos, missing spaces, wrong disorder codes and incorrect sequencing were recorded in the system (See Supplementary Table 2, Additional File 3). Over three months of implementation, 8 FCHVs registered and referred 8 cases through mCIDT: 4 depression, 2 psychosis, 1 epilepsy and 1 antenatal depression. Of those 8 referred cases, 2 cases visited the health facility, 2 could not be contacted in the follow-up and other 4 refused visiting the health facility as they knew that no HW was assigned to that particular health facility at the time.
After piloting the technology for 3 months, a simulation exercise was held with the FCHVs (n=34) to determine their accuracy of using the technology (Figure 2). Fisher’s exact test was used to compare differences of self-reported characteristics between FCHVs who correctly referred using mCIDT and those who did not (See Supplementary Table 3a, Additional File 4). Level of education was significantly higher for the FCHVs who were able to correctly use mCIDT in comparison to those who were not able to for all vignettes. Those who self-reported the ability to send an SMS and use the mCIDT Codebook were significantly more likely to be able to correctly use mCIDT across all disorders. T-tests with Wilcoxon test statistics were run to look at differences amongst age. For each disorder, the median age was significantly higher in FCHVs who incorrectly used the mCIDT.
Qualitative analysis of the key informant interviews, focus group discussions, field notes and observations by the research team elucidated the benefits of mCIDT, challenges faced by participants, and recommendations to improve the program.
Acceptability, Feasibility and Benefits of mCIDT
There was good agreement among the FCHVs, HWs and mental health experts familiar with the CIDT that the greatest benefit of mCIDT could be reducing the burden of work on FCHVs (See sample quotes in Table 1). Secondary benefits included the potential for better communication between HWs and FCHVs. Mental health and mHealth experts were wary of the FCHVs ability to use the mobile phones and expressed concern about maintaining patient privacy.
Numerous challenges to mCIDT were mentioned by all interviewees. We summarized these challenges in 5 domains: Community, Participant, Facility, Program, and Technological.
The most prominent challenges were mentioned at the community level. FCHVs repeatedly said no mental health cases were present in the community, which is inconsistent with assessments finding high rates of mental health and psychosocial problems in the area . This pointed to a lack of community awareness of the burden of MHD. FCHVs mentioned that previously Home-Based Community Workers (HBCW) in the area were responsible for identification of mental health cases. FCHVs acknowledged that stigma towards mental health is persistent in the community. At times if an FCHV identified someone with a potential MHD, it was difficult to gain support from the family to get the patient to care. FCHVs were aware that AUD cases resided in the communities, but they were uncomfortable interacting with the patient fearing s/he was violent or thinking the patient cannot get better. FCHVs particularly felt discomfort dealing with male patients citing their gender roles. The fact that these FCHVs lived in the same community and they did not want to have potential conflict also added on this. Though no interviews with community members were done, FCHVs did bring up that community members were worried about breaches of privacy due to the use of a mobile phone.
FCHVs struggled to use the mobile phone for a myriad of reasons ranging from poor eyesight among older FCHVs to lack of self-confidence in the use of a mobile phone. Lack of technological literary was the most frequent issue observed during training sessions. It was also noted by trainers that the need to focus on how to use a mobile phone was unanticipated.
Low literacy rates also became a barrier when trying to type and send the structured SMS. The biggest challenges were in translating the visual aids of the paper-based CIDTs into the appropriate syntax for the structured SMS. Lack of literacy also became an issue when receiving error messages and the inability to read and respond with the correction. Lastly, FCHVs are highly overburdened through engagement in many parts of the health sector. Absenteeism of HW at the health post discouraged one FCHV whose referred case had to return without services. Financial incentives were brought up by most FCHVs as a way to increase motivation for them to engage in the mental health sector.
Technological and government challenges were not as frequently discussed in the interviews. Network instability was mentioned as the greatest technological challenge. Other interviewees except FCHVs talked about government level challenges in the context of implementing a policy that would set an educational threshold for FCHVs.
Suggested Recommendations from Participants
The main recommendations centered around more supervision for the FCHVs and increasing the level of awareness about mental health in the community.