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.

Atif Rahman,Najia Atif,Zille Huma,Iftikhar Uddin,Huma Nazir,Siham Sikander,Parveen Akhtar,Joanna Maselko,Syed Usman Hamdani,Anum Nisar,Shamsa Zafar

doi:10.1017/gmh.2019.7

Abstract

The Thinking Healthy Programme (THP) is an evidence-based psychological intervention endorsed by the World Health Organization, tailored for non-specialist health workers in low- and middle-income countries. However, training and supervision of large numbers of health workers is a major challenge for the scale-up of THP. We developed a 'Technology-Assisted Cascaded Training and Supervision system' (TACTS) for THP consisting of a training application and cascaded supervision delivered from a distance. A single-blind, non-inferiority, randomized controlled trial was conducted in District Swat, a post-conflict area of North Pakistan. Eighty community health workers (called Lady Health Workers or LHWs) were randomly assigned to either TACTS or conventional face-to-face training and supervision by a specialist. Competence of LHWs in delivering THP post-training was assessed by independent observers rating a therapeutic session using a standardized measure, the 'Enhancing Assessment of Common Therapeutic factors' (ENACT), immediately post-training and after 3 months. ENACT uses a Likert scale to score an observed interaction on 18 dimensions, with a total score of 54, and a higher score indicating greater competence. Results indicated no significant differences between health workers trained using TACTS and supervised from distance v. those trained and supervised by a specialist face-to-face (mean ENACT score M=24.97, s.d.=5.95 v. M=27.27, s.d.=5.60, p=0.079, 95% CI 4.87-0.27) and at 3 months follow-up assessment (M=44.48, s.d.=3.97 v. M=43.63, s.d.=6.34, p=0.53, CI -1.88 to 3.59). TACTS can provide a promising tool for training and supervision of front-line workers in areas where there is a shortage of specialist trainers and supervisors.

Highlights

The Thinking Healthy Programme (THP) is an evidence-based psychological intervention endorsed by the World Health Organization, tailored for non-specialist health workers in low- and middle-income countries
While most low- and middle-income countries (LMICs) including Pakistan have vastly underdeveloped specialist facilities for mental health, a number of trials from LMICs show that non-specialists can deliver them effectively (Rahman et al 2008, 2016b; Patel et al 2010; Chibanda et al 2016)
We developed and tested a technology-assisted training and supervision system for community health workers (CHWs) to be trained in an evidence-based intervention for perinatal depression in a post-conflict area of Pakistan to establish whether it can be an alternative to conventional specialist-led face-to-face training and supervision

Summary

Introduction

The Thinking Healthy Programme (THP) is an evidence-based psychological intervention endorsed by the World Health Organization, tailored for non-specialist health workers in low- and middle-income countries. Results indicated no significant differences between health workers trained using TACTS and supervised from distance v. Rates of perinatal depression in low- and middle-income countries (LMICs) range from 18% to 25% (Fisher et al 2012), while in Pakistan, rates of 28–38% have been reported (Rahman et al 2003 ; Khan et al 2015). The Thinking Healthy Programme (THP), developed in Pakistan, is a cognitive behavior therapy (CBT)-based intervention for perinatal depression, delivered by lay community health workers (CHWs). The THP is the first psychological intervention to be incorporated into the WHO’s flagship Mental Health Gap Action Programme (mhGAP) (World Health Organization, 2016)

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Discussion

Conclusion