The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India

Abstract

BackgroundCare for schizophrenia in low and middle income countries is predominantly facility based and led by specialists, with limited use of non-pharmacological treatments. Although community based psychosocial interventions are emphasised, there is little evidence about their acceptability and feasibility. Furthermore, the shortage of skilled manpower is a major barrier to improving access to these interventions. Our study aimed to develop a lay health worker delivered community based intervention in three sites in India. This paper describes how the intervention was developed systematically, following the MRC framework for the development of complex interventions.MethodsWe reviewed the lierature on the burden of schizophrenia and the treatment gap in low and middle income countries and the evidence for community based treatments, and identified intervention components. We then evaluated the acceptability and feasibility of this package of care through formative case studies with individuals with schizophrenia and their primary caregivers and piloted its delivery with 30 families.ResultsBased on the reviews, our intervention comprised five components (psycho-education; adherence management; rehabilitation; referral to community agencies; and health promotion) to be delivered by trained lay health workers supervised by specialists. The intervention underwent a number of changes as a result of formative and pilot work. While all the components were acceptable and most were feasible, experiences of stigma and discrimination were inadequately addressed; some participants feared that delivery of care at home would lead to illness disclosure; some participants and providers did not understand how the intervention related to usual care; some families were unwilling to participate; and there were delivery problems, for example, in meeting the targeted number of sessions. Participants found delivery by health workers acceptable, and expected them to have knowledge about the subject matter. Some had expectations regarding their demographic and personal characteristics, for example, preferring only females or those who are understanding/friendly. New components to address stigma were then added to the intervention, the collaborative nature of service provision was strengthened, a multi-level supervision system was developed, and delivery of components was made more flexible. Criteria were evolved for the selection and training of the health workers based on participants' expectations.ConclusionsA multi-component community based intervention, targeting multiple outcomes, and delivered by trained lay health workers, supervised by mental health specialists, is an acceptable and feasible intervention for treating schizophrenia in India.

Technology-Based Interventions and Reducing the Burdens of Mental Illness: Perspectives and Comments on the Special Series

“…We know that lay individuals and counselors can effectively administer mental health (and physical health) services and that use of such individuals greatly expands the reach of these services (Kazdin & Rabbitt, 2013;WHO, 2008). For example, well-controlled studies have shown that lay individuals can deliver effective treatment for significant clinical problems (e.g., depression, anxiety, and schizophrenia; e.g., Balaji et al, 2012;Patel et al, 2010).…”

Global Mental Health: concepts, conflicts and controversies

“…Efforts have also been made to develop and outline suitable training programmes and desirable competencies for LHWs, as well as common deficiencies that need to be addressed (Fulton et al 2011;Balaji et al 2012). So far, growing evidence about effective taskshifting of psychosocial interventions to LHWs could be considered the major research finding of the GMH enterprise.…”

Effectiveness of knowledge translation of social interventions across economic boundaries: a systematic review

“…Studies identified by this review utilised task-shifting strategies to employ non-specialist, lay health workers (Balaji et al, 2012;Bass et al, 2006;Chatterjee et al, 2003;Patel et al, 2011;Petersen, Bhana, & Baillie, 2012;Petersen et al, 2011), reduce the size of caseloads and frequency of visits (Botha, Koen, Joska, Hering, & Oosthuizen, 2010) and operate temporary outreach camps in the community (Chatterjee et al, 2009). Task-shifting was also shown to increase job satisfaction and reduce feelings of isolation and burn out when staff were trained in new strategies (Uys & Zulu, 1996).…”