Demographics of the 36 FCHVs trained on mCIDT are included in (Supplementary Table 1, Additional File 2). Of these 36 FCHVs, only 8 FCHVs 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 (Supplementary Table 2, Additional File 3). Over 3 months of implementation, 8 FCHVs registered and referred 8 cases through mCIDT: 4 depression, 2 psychosis, 1 epilepsy, and 1 antenatal depression. No FCHV registered more than 1 case in the study period. Of those 8 cases who were referred, 2 cases visited the health facility, 2 could not be contacted in the follow-up. Four cases stated they did not seek treatment because the government health facility was not staffed with health workers.
After piloting the technology for 3 months, a simulation exercise was held with the FCHVs (n=34) to determine their accuracy of using mCIDT (Figure 1b). Level of education was significantly higher and age was significantly lower for the FCHVs who were able to correctly use mCIDT in comparison to those who were not able (Supplementary Table 3, Additional File 4). Those who self-reported the ability to send an SMS and use the mCIDT Codebook were significantly more likely to correctly use mCIDT across all disorders.
Qualitative analysis of the KIIs, FGDs, field notes and observations by the research team elucidated the benefits of mCIDT, challenges, and recommendations to improve the program (See sample quotes from KIIs and FGDs in Table 1).
Table 1. Sample quotes from interviewees regarding use of mobile health Community Informant Detection Tool (mCIDT)
Theme
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Description
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Quote
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Perceived benefits
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Reduced travel burden for FCHVs when using mobile phone SMS for mCIDT
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“We don't have to go to the hospital time and again to ask about a patient. We don't have to ask the health worker. Previously we had to walk for 1 or 2 hours to reach the health institution but we can know about them if we send the message from our home. We can also find if the patient has gone for the treatment or not through messages.” – FCHV in FGD
“We got to know whether the patient went to hospital or not within a week after we had sent message despite the distance of patient's location. Otherwise, we need to go to the hospital to know if the patient went there or not. Now it is easy for us to go to patient’s home twice and ask about not going to the hospital.” – FCHV in FGD
“FCHVS are engaged in other programs such as Vitamin A distribution, visiting the pregnant and recent mothers and were very busy in these activities due to which they had neglected mental health initially. But later when they were oriented about the mobile, they had a sense that they should work on this otherwise.” - FCHV in FGD
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Feasibility
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Lack of feasibility for implementing mCIDT because FCHVs are overburdened
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“Because recently what we have been doing is the government has been mobilizing the FCHVs and we can see that FCHVs has been mobilized a lot. Because they have been engaging in programs related to maternal health, related to child health, and population statistics. And they have also been providing services regarding distribution of hygiene issues and home infestations so they’re quite busy so many times we have seen that they have not been referring the cases using CIDT due to the fact that they’re over-engaged and they have not been provided basic salary. Due to this fact I think if we can use other people, like teachers, or local clubs, or mothers’ groups I think there are a lot of mothers’ groups in the community, if we can mobilize them, we can better provide coverage to a large number of people. The FCHVs are overly busy with their schedule so if we can ease the burden of FCHVs on part and shift it to people to mothers group, teachers, and local leaders who have recently been elected, I think that can cause a huge impact and we might be getting a large number of referrals.” –KII with Mental Health Expert
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Lack of perceived need
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Some FCHVs did not see mental health care as a need for their communities
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“There aren’t many cases in my ward. I cannot register anyone who doesn’t have problem.” – FCHV in FGD
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Stigma
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Inability to use mCIDT because of MHDs stigma
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“When people hear the word manasik (mental), they feel different. They don't want to engage at all. May be because of such stigma in the community, the FCHVs might have had problems.” – KII with Government Health Official
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Perceived difficulty of mental health care
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Reluctance to work with mental health patients because of perceived difficulties
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“It’s difficult to work with manasik samasya (mental problems)? It's easy to work on other areas but for mental problems, it's quite difficult.” - FCHV in FGD
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Privacy concerns
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Reluctance to use mobile phones for mental health information
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“We need to create public awareness. Some patient has feeling that their illness is recorded in the phone and that information will be given to someone else.” - FCHV in FGD
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Low technological literacy
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Inability to use SMS function on mobile phones
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“Some of the FCHVs were finding it difficult to use the mobile phones and using the menu key.” –KII with Mental Health CIDT Trainer
“Another challenge would be difficulty in typing. We don't know how to type messages here. If it had been hand written, we could have written down some according to our capability but it is difficult to type it in the mobile.” - FCHV in FGD
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Supervision needs
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Recommendation from FCHVs for more regular supervision when introducing technology
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“You taught them today, and when you call them after a month, they will get embarrassed if they are not able to do it. They might think that you'll scold them if they can't do it. Because of that fear, they will learn by whatever way they can e.g. by asking children, or looking at books, and come. But, if you leave as it is, then they might not care about it. Even if you don't scold later, if you keep following up with them from time to time, they might feel that they will be embarrassed, which will urge them to learn. I think the monthly supervision will be very beneficial.”- FCHV in FGD
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Acceptability, Feasibility and Benefits
Among the FCHVs, HWs and mental health experts, the greatest benefit of mCIDT could be reducing the burden of work on FCHVs. 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 stated that maintaining patient confidentiality was not feasible.
Challenges
The simulation results showed how most FCHVs were unable to utilize mCIDT, this challenge was evident in the interviews as well. 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 [11]. This pointed to a lack of community awareness of the burden of mental illnesses. FCHVs mentioned that previously Home-Based Community Workers (HBCW) in the area were responsible for identification of mental health cases, and they had been paid by an international organization to implement CIDT after the earthquake.
FCHVs acknowledged that stigma towards mental health is persistent in the community. If an FCHV identified someone with a potential mental illness, 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 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 contributed. FCHVs said that community members were worried about breaches of confidentiality due to the use of a mobile phone.
FCHVs struggled to use the mobile phone for reasons ranging from poor eyesight among older FCHVs to lack of confidence using technology. 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 became a barrier when trying to type and send the structured SMS. A major challenge was transferring the visual information on paper-based CIDTs into 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. Interviewees, who were not FCHVs, discussed government challenges in the context of implementing a policy that would set an educational threshold for FCHVs.
FCHVs are also 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. Network instability was one technological challenge.
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.