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ESSENCE Hub Project Summary


DR. NASLUND: Hi, my name is John Naslund, and I'm really delighted to be here today to present on behalf of the ESSENCE hub, really pleased to be at this Scale Up Hubs: Lessons Learned and Conversations meeting, and to present on behalf of our team.

Our hub is called the Enabling Translation of Science to Service to Enhance Depression Care, and I'm going to present our work. We're one of the ten NIMH-funded U19 scale up hubs. So we’re really grateful for the funding from NIMH that has supported all of these hubs and this work focused on addressing challenges to implementation and scale up of evidence-based mental health services in low-resource settings.

I think this is pretty well known in this audience, but just really to emphasize that not only access to mental health care, but in particular access to brief psychological treatments is very low in virtually every setting globally. We know that these are potent treatments for addressing a wide range of mental disorders, and we know that very, very few people have access to these in routine care settings. This really represents one of the biggest challenges in terms of scaling up mental health care globally that we face today.

So this is really the emphasis of our work, and I present this pathway basically to deliver a psychological treatment for depression, thinking of the pathway for the provider. So starting with training, through ongoing support and quality assurance, and then having this integrated within the broader health system. So this pathway is really key in order to successfully deliver these treatments and to ensure that they're delivered with high quality and high fidelity to achieve the outcomes that we know that these treatments can result in for patients.

We also have an incredible opportunity, and our work as part of the ESSENCE hub really tries to leverage these different factors. We know that mental health is now -- it's become an increasingly recognized urgent public health priority. This is certainly the case in India, where our work is based.

We know that there's a very robust evidence base demonstrating the effectiveness of brief psychological treatments, and then there's also significant amount of research from many of our colleagues from other hubs as well as our own collaborators in India, demonstrating that non-specialist providers can deliver these treatments with a high degree of fidelity. So basically, the idea of task sharing is now well-established in the literature and has really resulted in a paradigm shift about how mental health care can be delivered. Yet there are still many barriers to implementation and achieving this at scale.

We also have new innovative models around peer-to-peer supervision and support in the actual delivery of these services for ensuring quality assurance, and then we also have new digital tools, which I'll speak to as another tool and another method for improving scale up and quality assurance.

So our program, the ESSENCE program, has really got two major parts. Most of my emphasis today will be on part one, as this is the component of the program that has been completed and we have results now, and then also our second component, which is the implementation piece, is still ongoing.

Our first component really is focused on the training. So how to train non-specialists, health workers, so community health workers, lay health workers, really how to train them to ensure competency to support their delivery of these brief psychological treatments in primary care.

The second component is really then thinking about how to actually establish the infrastructure within the primary care setting in order to effectively deliver these treatments at scale.

When we think of the implementation, I know all of the work that we're doing is really focused around how to address key barriers to implementation and practice, and the first major implementation challenge that our program seeks to address is really how to build workforce capacity and how to do this at scale. So really thinking about how to train community health workers in the delivery of a brief psychological treatment and then also how to ensure the necessary skills and competencies in order to do this confidently and effectively in practice.

I'm going to introduce our program, our main collaborator in India. Sangath is a leading NGO, has really been a pioneer in global mental health research, has led many of the largest trials in global mental health over the last several decades, and our team is based in Bhopal in Madhya Pradesh, which is in the center of India, and this is one of the hubs from Sangath. So Sangath was originally established in Goa, and then the Bhopal hub was established just over 10 years ago now, and really is in a very different part of the country, which I'll speak to in a moment.

When we think of Bhopal, I always like to try to introduce where exactly our work is taking place. It's a predominantly rural part of the country, but also an area where there's a great deal of cultural heritage and many national parks. It's also part of the country with many tigers and many historical sites, but as I mentioned, it's also very rural, and it's one of the more underdeveloped states in India. So it ranks much lower on the human development index. It's much less industrialized than other parts of the country. And this creates challenges when thinking about how do you deliver high quality mental health care and do this at scale, when there isn't the same level of resources or infrastructure as other parts of the country.

So this really leads to our first major part of the project, the development of this digital training program I mentioned, and thinking about how to use technology to train community health workers. This work really started with a significant amount of formative research, really trying to understand the perspectives of the community health workers, better understanding their perspectives about treating depression, whether this is something they recognize in their work, and then also thinking about the role of technology to support them.

One thing that's consistently come up across dozens of interviews with many, many different community health workers is really the clear understanding that depression is something that does exist in their work, a clear recognition that this is a serious issue, something that they see in their villages, something that they see in their patients, and something that they often feel helpless in addressing in their work, simply because they aren't sure what to do and don't feel that they have the skills to address these concerns.

So this was really something that was critical for starting the development of a digital training program, was really -- this idea that there's high recognition and high demand for training around depression care. So this really helped set the stage and really offered the motivation for moving forward with this work, with this particular group of health workers, which in our context, they're ASHA workers, which are a community health worker in India called Accredited Social Health Activists, and they really represent the backbone of the health system in India, delivering the vast majority of primary care services in rural settings, and really represent a critical community health worker workforce, actually one of the largest workforce of community health workers globally. They number over a million across the country, and now mental health care is one of the things that they are -- it's part of their mandate now is they've increasingly shifted towards more addressing care for noncommunicable diseases, and mental health care being one of them.

So our goal was really to take this evidence-based treatment for depression called the Healthy Activity Program and then to adapt this for training the ASHA workers that I just mentioned and then to digitize this content so that the training could be delivered on a smartphone so that it could be easily scaled up.

This drastically oversimplifies this process, because if we think of it, these are very academic manuals. They're grounded in the psychological sciences. Think of a paper-based manual, and how do you convert that to a smartphone app that is both simple, engaging, but also achieves the target goals, training goals. So this process involved a considerable amount of engagement with community health workers through storyboarding activities and focus groups, really thinking about how to develop content that would be both interesting and engaging.

Then also determining whether there's recognition of this being an important tool for supporting training, and many of the ASHA workers we talked to felt that digital training would actually be very convenient for them and something that they found would be supportive for achieving the training goals, simply out of convenience, but then also not requiring travel to attend training in facilities and then they could also do it on their own pace at their own leisure.

So we engaged in a systematic process for developing the training. This rigorous process of developing first the blueprints, the drafting scripts, and then really digitizing this content for uploading onto a digital platform. We have described this process in detail in manuscripts.

We went with a platform called Moodle, because this platform could work well in settings with low bandwidth, could work well in settings with low internet access, and really trying to think about how to make sure content could be accessed from a platform without necessarily having a strong wireless connection.

So the course was designed using a variety of graphics, simple icons, many of these again just to make sure that it could be easily accessible in an environment with low connectivity, but then also using video-based content. This was partly one of the recommendations from the community health workers, was this interest in video-based content because they could very easily relate to the videos, but then also felt like this would be an opportunity to see the content firsthand and the delivery of care. This involved a combination of lecture videos, as well as roleplays demonstrating practice, delivery of care in different settings.

So this led to our next trial, with the results of an evaluation of comparing this digital training to the standard conventional face-to-face training, and this large trial involved recruiting about 339 community health workers and randomizing them to these three different arms, comparing the conventional and the gold standard face-to-face to digital training and then a third arm involving training enhanced with remote coaching support, largely because the coach was seen as being really critical to support engagement with the technology. This was something that we learned in our formative research that using simply a digital app may not achieve high enough engagement levels, but the addition of a remote coach through basically telephone or WhatsApp-based support could offer that additional motivation and encouragement to complete the training.

So this involved recruiting the group of community health workers I mentioned, the ASHAs. We enrolled 339 in the study, randomized them to these three different arms, had very, very high retention rates through the trial with most of the ASHAs completing; retention was around 95 percent retention in the study. So very high, but again, these community health workers enrolled in a training program to help them in developing their own skills.

Just briefly, the results from this trial. So it was set up as a noninferiority trial, which means that basically our goal was to demonstrate that the digital training would be as good as the face-to-face training, and we hypothesized that it would be about the equivalent and then we also hypothesized that the digital plus the coaching would be superior to the digital alone.

So our hypotheses were validated in this study. We found that in fact all three arms, there were no significant differences between the three different training conditions. So this was an important finding, but what also was really important for us is we found that essentially pre-post scores on a competency measure, basically assessing skills needed to deliver -- knowledge and skills needed to deliver the training, but essentially we found that all three conditions showed pre-post improvement. So basically, from the beginning to the end, so before the training and after the training, all the conditions showed improvement.

But what's really critical here is that actually the digital plus coaching and the face-to-face training performed better than the digital training alone. So what this tells us is that it looks like the face-to-face training performed better than the digital, but that difference was not significant. But we did find that both the face-to-face and the digital with coaching appeared about equivalent.

This an important finding, because it shows us that with the use of a digital training program, enhanced with remote coaching, that we can achieve training outcomes that are comparable to face-to-face training, which is the more costly gold standard to training community health workers across the globe.

So this really has led to our implementation trial, which was the second major component of ESSENCE, of the ESSENCE program, and really now thinking of trying to address this major challenge of basically, well, now that we've trained a community health worker workforce to deliver depression care, how do we then make sure that the primary care facilities are able to adopt basically the care pathways needed to identify positive cases of depression, refer these cases of depression to receive care, and then initiate treatment delivered by the community health workers? So how do we basically establish all of these care processes and care pathways within primary health care centers?

The second component is really focused on implementation, really focused on how do we support facilities in implementing the depression care package, the basically how to screen and refer cases of depression, based on the mhGAP, so the WHO program for depression care, and then determining whether this improves referral of cases and the initiation of treatment, but then also outcomes among patients.

In this study, it's a cluster randomized trial. Our unit of randomization is the primary health care centers. They're referred to as PHCs, and there's 14 that we're enrolling in this study, but basically comparing two forms -- determining whether an enhanced implementation support would be superior to the routine implementation support, and what that means is basically facilities already in the health system engage in what's called routine implementation support.

So any time a new practice is delivered -- in this we're drawing from the delivery of noncommunicable disease care, so their NCD program -- they do have a system of supporting facilities' delivery of new practices. So that's the routine implementation support. What we're looking at is whether an enhanced implementation support, grounded in the implementation science literature, can offer an advantage in supporting these facilities in the uptake of depression care.

So basically, what does that look like? This is our team serving as a remote coaching support team, basically supporting facilities that are randomized to the enhanced support arm in adopting the depression care package. So this involves a combination of one-on-one remote technical assistance sessions. So there would be kind of similar to a meeting over Zoom or via the telephone if needed, basically to walk the facility teams through the steps needed to adopt the depression care package, and how basically to ensure that they're screening, referring, and following up with patients who screen positive for depression.

Also ongoing support through WhatsApp, this very scalable and also highly effective way to check in and to address any kind of challenges as they arise, and then also thinking of the use of a virtual learning collaborative, basically to think of how can the facilities randomize to this arm. So seven facilities in this arm, how can they support each other as they proceed in the uptake and delivery of depression care?

So this diagram is really just to give an idea of how we would get depression care into practice. So really thinking of all the referral pathways and then working with the facilities to make sure that they're able to support this at each of the key steps. This is really the goal of our coaching team is to think of how to support the different facility staff. So whether it's the medical officers, the nurses, and then how to support them in ensuring referral of patients to receive care delivered by the ASHA workers.

Across each of these steps, leveraging a model for implementation, this is really a guiding framework for the coaching model is really thinking of the Plan, Do, Study, Act cycles, and really thinking of problem-solving and working with the facility teams in addressing any barriers that come up and then how to focus on determining strategies to overcome these different challenges.

So basically, this is applied to a framework of coaching the facilities, determining if they're reaching their targets. So whether they're reaching screening targets, referral targets, and then if they're not, how do you work with the facilities to help them to achieve these goals?

So as I mentioned, this trial is under way, but the ultimate goal is really to think about how to help facilitate this entire continuum along the delivery of psychological treatment for depression. So really thinking about the overall delivery of depression care, beginning with ensuring that there's the workforce capacity, then moving on to the ongoing quality assurance, and then thinking of how does this integrate into the broader system to support the identification of cases and then the referral to receive high quality care.

This is also part of a broader picture that our ESSENCE program is now linked to is thinking about the overall progression of community health workers from gaining the skills needed to then become skilled providers and then to help support a continuum where then they can also support the next cohort of community health workers as they learn these materials through the digital platform, but then become competent and skilled providers through ongoing supervision and support.

This has led to an exciting effort called EMPOWER, essentially how do we leverage the digital solutions that I've presented here through the ESSENCE program to do this at scale and to support this rollout more broadly in India, but then also thinking of other parts around the world, including here in the United States.

I'd like to just recognize our team, and everyone who has contributed to this work, and basically thinking of all of our many, many collaborators here in the United States and also globally, and then importantly, our team in India and many collaborators across India, and also again, really recognizing and acknowledging the funding from the NIMH that has really made this program possible and has helped support additional smaller projects that have helped build on this and really thinking of how to scale up mental health care in India and globally.

Thank you very much for your attention today and looking forward to the rest of the meeting.