Factors affecting beneficiary attendance in a community youth mental health promotion program in Karnataka, India.

Background: Yuva Spandana is a unique community based Youth Mental Health Promotion program implemented across Karnataka. This program provides mental health promotion services like guidance and referral services for any issues related to youth. These services are provided through Youth Guidance centres established within every district stadium across Karnataka. We assessed factors affecting beneficiary attendance to these guidance centres across Karnataka. Methods: A conceptual framework was developed to understand the factors affecting beneficiary attendance through stakeholder consultation. First time beneficiaries attending guidance centres between 1st January 2017 and 31st December 2018 across 30 districts of Karnataka were considered study subjects. Requisite data were drawn from the computerized management information system (CMIS) specifically developed for the program. Multivariate Linear Regression was performed with factors affecting beneficiary attendance as outcome and a host of hypothesized variables within the conceptual framework as potential exposures that contribute towards beneficiary attendance. All variables significantly associated with outcome (p<0.10) in univariate and which changed the β-coefficient of atleast one preceding variable by 10% was retained in the multivariate model. Results: For every sensitization program where more than one issue was addressed, the beneficiary attendance increased by 84% (β =0.84; 95% CI=0.53-1.15). Reaching out to parent beneficiaries through sensitisation programs, increased beneficiary attendance at YSK by 79% (β =0.79; 95% CI=0.20-1.37). Referring clients to resource mapped organisations, significantly increased beneficiary attendance by 81% (β =0.81; 95% CI=0.34-1.28). For every percentage increase in reminder calls made to probable beneficiaries who sought support following a sensitization programme, beneficiary attendance increased by 2.18 times (β =2.18; 95% CI=0.52-3.83). Availability of internet connectivity at these guidance centres in 2017, increased beneficiary attendance by 18 times (β =18.00; 95% CI=5.86-30.13). Conclusions: This study provides important inputs towards increasing beneficiary attendance towards large scale youth mental health promotion programs. Addressing more than one issue during sensitisation programs among beneficiaries; conducting sensitization programs among parent groups; making reminder calls to beneficiaries who requested support through feedback forms to fix appointment at guidance centres; providing referrals to beneficiaries to seek services at resource mapped individuals/organizations and ensuring availability of internet in guidance centres increases beneficiary attendance.


Abstract Background: Yuva Spandana is a unique community based Youth Mental Health
Promotion program implemented across Karnataka. This program provides mental health promotion services like guidance and referral services for any issues related to youth. These services are provided through Youth Guidance centres established within every district stadium across Karnataka. We assessed factors affecting beneficiary attendance to these guidance centres across Karnataka.
Methods: A conceptual framework was developed to understand the factors affecting beneficiary attendance through stakeholder consultation. First time beneficiaries attending guidance centres between 1st January 2017 and 31st December 2018 across 30 districts of Karnataka were considered study subjects. Requisite data were drawn from the computerized management information system (CMIS) specifically developed for the program. Multivariate Linear Regression was performed with factors affecting beneficiary attendance as outcome and a host of hypothesized variables within the conceptual framework as potential exposures that contribute towards beneficiary attendance. All variables significantly associated with outcome (p<0.10) in univariate and which changed the β-coefficient of atleast one preceding variable by 10% was retained in the multivariate model.
Conclusions: This study provides important inputs towards increasing beneficiary attendance towards large scale youth mental health promotion programs.
Addressing more than one issue during sensitisation programs among beneficiaries; conducting sensitization programs among parent groups; making reminder calls to beneficiaries who requested support through feedback forms to fix appointment at guidance centres; providing referrals to beneficiaries to seek services at resource mapped individuals/organizations and ensuring availability of internet in guidance centres increases beneficiary attendance.

Background
India has the largest youth population in the world. Nearly 70% of the population is under the age of 35 years. 1 They are presumed to be healthy but, about 2.6 million young people between 10-24 years die each year. 2 Transition in traditional family systems, influenced by the rapid changes in economic, social and political scenarios globally, pose social, psychosocial, behavioural and mental health challenges amongst youth. Significant numbers of youth have issues related to alcohol, tobacco, lack of physical activity, unsafe sex and exposure to violence. 2 Considering these, youth and families need support to deal effectively with these challenges.
As a consequence, the Department of Youth Empowerment and Sports, Government Sensitization program is the first point of contact between probable beneficiary to YSK and the program service providers (YP/YSs). 4 After the sensitization program participants fill a feedback form to evaluate the program and seek support at YSKs.
The YPs segregate collected feedback forms into 'support required' and 'support not required' forms. All the feedback forms would be deposited to the YSKs within 2 days of sensitization program. Yuva Samalochakas at YSK make phone calls to all the beneficiaries who request support in feedback forms and fix appointment at YSKs. Yuva Samalochakas provide guidance to beneficiaries after s/he comes to YSK.
These steps are part of the standard operating procedures (SOPs) inbuilt into the program in-order to ensure beneficiary access services at YSKs. Process following a sensitization program has been presented here ( Figure I).
The program Yuva Spandana is in its sixth year of implementation. There has been a gradual and essential shift in the focus of the program. Initially, it was to establish Yuva Spandana Kendras across all the 30 districts within Karnataka. Now, with YSKs established in all the districts, the focus is on expanding coverage and ensuring quality of service seeking guidance at YSKs. With this shift in focus, an understanding of factors associated with beneficiaries attending YSK is important to undertake focused approach towards program activities that bring in beneficiaries to YSK. Thus, we aim to assess the factors affecting beneficiary attendance at YSKs in Karnataka.

Methods
Preparatory phase involved development of a conceptual framework to understand the factors affecting beneficiary attendance. A draft conceptual framework on factors affecting beneficiary attendance was developed by the investigators, keeping in mind the various program activities of Yuva Spandana that may contribute towards beneficiary attendance. Two stakeholder consultations namely one core team and one field team consultation workshops were held to finalize the conceptual framework, methodology of data collection and to list out potential exposure variables affecting beneficiary attendance ( Figure II).
First-time beneficiaries attending YSKs between 1st January 2017 and 31st December 2018 across 30 districts of Karnataka were considered as study subjects for the study. All the required data were drawn from the computerized management information system (CMIS) specifically developed for the program Yuva Spandana.
Registration and visit details of beneficiaries were considered. Further, the data related to sensitization programs, resource mapping, and phone call forms were also utilized. Data from monthly reports and training reports were also obtained.
Detailed information about the data used for the current study is depicted in table I & II.

Statistical analysis
Data from different sources were organized by district in the same order, assigning the same serial number across all databases. They were merged using the serial number for district as unique identifier. Descriptives and frequencies along with multivariate linear regression analysis were performed. Linear regression analysis was performed with number of beneficiaries registered in YSK during the study period as outcome. Factors within the conceptual framework for client attendance to YSK (Fig II and Table I & II) were hypothesized as exposure variables. All exposure variables significantly associated with outcome at 10% level (p < 0.10) in univariate analysis were eligible to be considered for multivariate analysis.
In multivariate linear regression analysis, each of the variables eligible to be included into the multivariate model was included one after the other using a forward stepping process. All variables that were significantly associated with the outcome at 5% levels (p < 0.05) and changed the β co-efficient of at-least one preceding variable by 10% was retained in the final model. Each model was compared with the preceding model using likelihood ratio-test with appropriate degrees of freedom. All statistical analyses were performed using Stata 12.1 software.

Results
Overall, there were 6895 beneficiaries with more than half (54.74%) of the beneficiaries being male. Mean age of male beneficiaries was 21.6 ± 8.3 years and female beneficiaries was 20.69 ± 7.1 years. About half of the beneficiaries were in the age group of 16-20 years and almost 3/4th of them (73.8%) had studied beyond high school. A majority of the beneficiaries were unmarried (87.2%) and were students (70%).
Univariate Simple Linear Regression analysis showed that there were 31 variables found eligible to be included into the final multivariate model (table V).
More than one issue addressed during a sensitisation program, reaching parent beneficiaries through sensitization programs, referrals to resource mapped services, proportion of reminder calls made to clients who sought support following sensitization programs and internet connection in YSK were associated with increased beneficiaries in YSK between 1st January 2017 to 31st December 2018 in Karnataka (table VI). For every sensitization program where more than one issue was addressed, the beneficiary attendance increased by 84% (β = 0.84; 95% CI = 0.53-1.15). Reaching out to parent beneficiaries through sensitisation programs, increased beneficiary attendance at YSK by 79% (β = 0.79; 95% CI = 0.20-1.37).

Discussion
The programme Yuva Spandana is the first ever state-level mental health promotion program in India, developed in-line with the National Youth Policy-2012. The current paper aimed at understanding factors which contribute to increase clientele to Yuva Spandana Kendras. As a result, we identified factors that enable service utilization by the beneficiaries in the community. Our study revealed that it is essential to address more than one issue for which the services are available within the program while sensitizing beneficiaries; conduct more sensitization programs to parents groups; make reminder calls to beneficiaries who requested support through feedback forms, to fix appointment at YSK; provide referral letter to beneficiaries to seek services at resource mapped individual/organizations and ensure internet availability in YSK in order to increase beneficiary attendance at YSKs In this study, a systematic, objective assessment of factors affecting client attendance was done by developing a conceptual framework through stakeholder consultations. Our study utilized program data collected utilizing a specifically developed computerized management information system (CMIS) that captures data in real time. This study utilized program data from multiple sources. Data quality is Coordinator and Field Liaison Officers closely monitor all data entered in CMIS on a day-to-day basis. Program Coordinator and Principal Investigator of the program supervise this process of data monitoring regularly. All these ensure real-time data collection with minimal errors in data entry.
Activities conducted to develop the conceptual framework were scientific and comprehensive thus; the results of the study can be generalized to all Yuva Spandana Kendras across Karnataka. In addition, stakeholder involvement in designing the study is likely to ensure stakeholder participation. It is likely to facilitate the field team to utilize these results and own future interventions based on these results. Intervening on these factors could improve client attendance for the program in future.
One of the factors affecting beneficiary attendance in YSKs in Karnataka was addressing multiple issues during a sensitisation program. Addressing multiple issues ensures that there is something for every beneficiary at YSK. During these sensitization programs, YPs broadly address 6 issues covering the entire gamut of youth issues. 4 Hence, when YPs address multiple issues as part of sensitization programs, youth with any issue/s are sensitized about their issue and encouraged to visit YSK thereby increasing beneficiary attendance.
YPs conduct sensitization program at field level for different groups such as youth clubs, students, parents, teachers etc. 4 It was observed that, conducting sensitization programs for parents increase beneficiaries to YSKs. In the Indian context, parents are the key decision makers in the family. Although it seems that the youth are independent, when it is the question of seeking support or care, the youth are under the control of their parents or caretakers in India. Hence, focusing on sensitising parents would bring their children to YSKs. 5 YPs collect feedback forms from participants after the sensitization program. Our study found that making reminder calls to schedule appointments to YSK following sensitization program increases beneficiary attendance. This helps in rapport and confidence building among potential beneficiaries. For the beneficiary, receiving a reminder call post sensitization program is likely to reinforce the fact that "there is somebody who is willing to listen to me and help me with my problems" -a message that is shared as part of the sensitization program. Usage of technology for increasing service utilization of programs is the need of the hour. 6,7 Yuva Samalochakas provide guidance to beneficiaries who come to YSKs and refer them to an appropriate referral institution for further help. Our results reveal that referrals to resource mapped services bring beneficiaries to YSKs. This process provides an opportunity to showcase services available at YSK through beneficiaries themselves and thereby promoting cross referrals. It also provides evidence to resource mapped organisations about an ongoing successful program.
It was observed that having internet connection during 2017 is a significant factor affecting client attendance. Having internet connection in YSK ensures that district teams at YSK are well supported by core team at NIMHANS enabling the district teams to confidently handle clients at YSK.
Univariate Simple Linear Regression analysis showed 27 variables to be significant.
However, only 5 factors were found to be statistically significant in multivariate analysis. The variables which were significant in univariate analysis might seem to be less important compared to the five factors significant in multivariate analysis in increasing clients. However, this might not be true. Logically, given the robust monitoring and supervision in-built into the program, an analysis done as part of the routine monitoring and evaluation in July 2017 8 revealed that availability of YSs in YSK; potential beneficiaries agreeing to visit YSK during phone call following sensitisation programs; focusing on teachers and youth in sensitisation programs; and sensitisation programs and friends as source of referral increased beneficiary attendance. 8 Other sources of information and challenges and difficulties faced during sensitisation programs decreased client attendance. Learning from this previous evaluation, helped us intervene (Eg-focussing on teachers through sensitization program) on these factors. These might have made these program components/ exposure variables insignificant at this stage of the program. This is known to happen as part of evolution of the program. However, these would still be relevant as activities of the program and needs to be part of the routine monitoring and supervision along with a special focus on the five factors identified in this study.
This study is not without limitations. Other relevant factors affecting beneficiary attendance such as quality aspects of sensitization programs, guidance and client satisfaction levels are not considered in the current study. Since, majority of programs are focussed on student population, it is obvious that majority of the beneficiaries attending YSKs are students. Hence the generalisability of the results to other beneficiaries is questionable.

Conclusion
This study provides important inputs on what brings beneficiaries into such large community-based youth mental health promotion programs. Utilising this evidence; the program team can plan for evidence-based implementation of the program.
Henceforth, YPs would be strengthened to address all the 6 issues in the sensitization programs conducted for any group 4 . This would be monitored to conduct more programs for parent groups. Referring of beneficiaries to referral institution/individuals would be continued and further efforts would be made to strengthen the networking between those organizations/individuals. Emphasizing the importance of making reminder phone calls to those who had sought support through feedback forms is another factor to be vigorously monitored by the program. Finally, ensuring availability of functional internet in the centre in order to monitor and supervise on daily basis.
We believe that the findings and the conduct of this study provides important insight for program managers, implementers, policy makers and funders on factors that need to be looked into while developing and implementing large community-

Consent for Publication:
Written consent was obtained from each participant before collecting data from them Availability of data and materials: The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.        Figure 1 Process following a sensitization program Figure 2 Final version of conceptual framework to assess factors affecting client attendance