A mental health training program for community health workers in India: impact on knowledge and attitudes

Mental disorders are both disabling and costly for affected individuals, their families and the community. Mental disorders are increasingly recognised as a major contributor to the global health burden, including in low income countries (LICs), and they are often co-morbid with communicable and non-communicable diseases [1, 2]. Mental health remains a low priority in most LICs, and unmet needs for mental health treatment are pervasive [3–5]. Up to 90% of persons with mental disorders in low and middle-income countries do not receive even basic mental health care [4, 6]. This neglect continues despite overwhelming evidence that effective low-cost treatments (drugs, psychological treatments, and community based rehabilitation) are feasible, affordable and cost-effective for many mental disorders, and could be successfully delivered in primary health care (PHC) settings [1, 7–9].

In India, approximately 6% of the population have a mental disorder such as schizophrenia [7]. Suicide is a major public health problem, with over 100,000 suicides annually [10]. Mental disorders in India are not necessarily experienced and understood in the same way as in Western countries [11–15], and the vast majority of care is provided by the family. Many remain untreated, and those families who do seek treatment will often turn to non-allopathic providers including practitioners of Indian traditional medicine, religious healers, faith healers and astrologers [13, 14, 16]. The scarcity of mental health professionals, particularly in rural areas, places specialist psychiatric care out of the reach of most people [7, 10, 17].

The World Health Organization (WHO) advocates the need to integration of mental health into PHC as the optimal strategy for addressing the global burden of disease [7, 8]. In India, the National Mental Health Program also advocates the integration of mental health into PHC; however, there has been limited success in realising this policy in practice with only 24 of 600 districts currently covered by this program [7, 10, 18]. Due to the overlap between mental and physical health, people with mental disorders frequently present to PHC settings. For example, a survey in a Mumbai slum found that 28% of patients aged > 18 years attending a health centre suffered from psychiatric problems [12]. However, PHC staff lack the skills required to make an appropriate diagnosis and provide a reasonable standard of care when people present with such problems. Effective training programs are required to develop the mental health skills of generalist PHC staff [7].

If mental health is to be successfully integrated into PHC in low-income countries like India then grass-roots workers need to acquire relevant knowledge and skills so that they are able to recognise, refer and support people experiencing mental health disorders in their own communities. Task shifting of effective mental health interventions to non-specialist health workers has been proposed to increase the coverage of mental health care in both low and high-income settings [19–25].

Mental Health Literacy (MHL) is defined as 'knowledge and beliefs about mental disorders which aid their recognition, management and prevention' (p.396) [26]. Studies in India have indicated that knowledge and understanding of mental disorders is poor in many communities, including among community health workers [27–29]. Improved awareness of mental disorders among community health workers is likely to assist affected people to access treatment and improve the quality of the care they receive [26, 30]. Having the knowledge and skills to support people in the community who may be developing a mental disorder or experiencing a mental health crisis is referred to as Mental Health First Aid [31].

A small number of studies investigating various components of integrating mental health into PHC settings in India, have been conducted [26, 32–36] and this is creating an opportunity and momentum for achieving real changes in practice, leading to better outcomes for people with mental disorders. This study makes a contribution to this emerging body of evidence as it evaluates the effectiveness of a mental health training manual for grass-roots community health workers (CHWs). Mental health training was delivered to CHWs who had minimal knowledge about mental health, and the impact of the training on their level of MHL was evaluated. The hypothesis of the study was that community health workers would demonstrate improved MHL as assessed at completion of the training program and three months later.

The issue of providing practical mental health training for primary health care workers in low-income countries is of broad interest to many working in the field of global mental health. This study makes an important contribution to the related literature by conducting an evaluation of a training program for community health workers in rural India using an existing facilitator's mental health training manual [37].

The findings suggest that the mental health training program had mixed success in achieving its stated aims, but there were some encouraging outcomes. Importantly, there was only one participant out of seventy who did not complete the training program despite the extensive travel required for many participants to attend, and the considerable demands of participants' daily working and living duties.

The training increased the ability of the community health workers to recognize depression and psychosis in vignettes, and reduced their faith in unhelpful pharmacological interventions. There was evidence of a minor reduction in stigmatising attitudes, although the changes were very limited and largely isolated to the depression vignette. It was unclear if the training resulted in a change in the participant's faith in recovery.

The percentage of respondents correctly identifying the disorders in the vignettes in the baseline questionnaire was low relative to a previous survey of village health workers in a rural area of Maharashtra, India (depression, 56.7%) [28], and much lower than a sample of Australian community members trained in Mental Health First Aid (depression, 91.4%; psychosis 56.6%) [42]. The results suggest that the training increased the ability of the participants to recognise depression and psychosis in vignettes, yet despite this improvement, more than half of the participants were still unable to correctly identify either disorder at the three month follow-up. However, an evaluation of a mental health first aid training program conducted in Australia (delivered by an experienced mental health instructor) with a community sample of immigrants of Chinese-speaking background found results comparable to our study; recognition of depression and psychosis increased from 19.0% to 63.1% and 9.5% to 21.4% respectively immediately after the training (no three month follow-up was conducted) [44].

At baseline, psychosocial interventions, including physical activity and listening, were widely viewed as helpful by participants, and there was moderately high endorsement of potentially inappropriate treatments like appetite stimulants, vitamins, tonics, herbal medicines, and sleeping pills. These findings are comparable to those from the rural Maharashtran MHL survey mentioned above [28]. The significant decrease in the endorsement of inappropriate pharmacological treatments among training participants is an important finding given that, whilst vitamins, tonics and herbal medicines may be relatively harmless, appetite stimulants and sleeping pills are of doubtful value and in some cases may be harmful. Similarly, the drop in endorsement for special diets is desirable given the lack of good evidence to support this as an intervention for depression or psychosis [47]. While psychiatric medications were not asked about explicitly, the increasing endorsement of the "other pharmacological" category suggests an improvement in awareness of appropriate psychiatric medication options that have an important role to play in recovery, particularly from severe mental illness.

Less than half the participants believed that, with appropriate help, the persons described in the vignettes could fully recover without further problems. Additionally, belief in full recovery with no further problems decreased in the case of the psychosis vignette, however, it appeared that the significant decrease happened after the training (i.e. between post-course measurement and three month follow-up) making it difficult to directly attribute this change to the training intervention itself. In any case, these negative outcome expectations are concerning and have the potential to impede access to potentially effective treatments. The result may also reflect the local context of the study setting where there are no local psychiatrists or highly skilled mental health practitioners. Additionally, the training intervention itself did not focus on evidence for the effectiveness of treatments for mental disorders. This is an important consideration given that there is evidence indicating that belief in the effectiveness of treatments can help to reduce stigmatising attitudes towards people with mental disorders [48, 49].

The training had a small impact on stigmatising attitudes towards people with mental disorders. Perhaps most importantly, after participation in the training fewer participants thought that the mental disorder described in the depression vignette was a sign of personal weakness, and only a small percentage agreed that it is best to avoid the person described in this vignette.

The concepts of stigma and discrimination in the context of mental disorders have been well documented [50, 51]. Stigma is linked to experiences of discrimination by people with mental disorders [52], including biases in the receipt of healthcare [53]. Stigma (as expressed by mental health professionals and the general public) contributes to under-use of mental health services, a delay in accessing mental health treatment, and an impeded recovery process [48, 54–56]. The negative effects of stigma can outweigh the impact of disability due to the disorder [57].

Culture influences the experience, expression and determinants of stigma, and the effectiveness of different approaches to stigma reduction, and further research on attitudes toward mental illness is required in India and other non-Western cultures. Results from a study on patients with schizophrenia and their caregivers in Bangalore [58] indicated that stigma motivated families to contain the patient at home in an effort to conceal the condition and the perceived causes of the condition (e.g. sins and bad deeds), resulting in a delay in receiving timely treatment. Families and patients experiencing a high level of stigma would attempt to avoid the social disapproval anticipated from seeking allopathic care.

The content of the mental health training manual in this study incorporated a brief educational activity regarding the topic of stigma and discrimination that was focused on exploring the impact of stigma and identifying some common stigmatising attitudes. Our findings indicate that the effectiveness of the training in relation to stigma reduction was limited, and that it would be worthwhile exploring opportunities to have a greater impact in this area.

Research has highlighted the importance of contact with people experiencing mental disorders as a strategy for changing stigmatising attitudes about mental illness [51, 59–65]. A study using a community sample from America [66] found that direct contact with people who have (or have had) mental health problems had the greatest impact on attitudes, in comparison to education challenging myths which yielded only a modest positive impact. Involving people who have previously experienced mental disorders as co-facilitators has the potential to reduce stigmatising attitudes of participants, as does contact with consumers who have had positive (and realistic) experiences of mental health care, and who are employed and socially included in their communities [48]. While the training manual evaluated in this study can be modified to more actively promote the inclusion of consumers as facilitators/presenters, it must be acknowledged that there are still substantial barriers to be overcome in order to consistently achieve this. In a country such as India, people with mental disorders most frequently remain hidden and are not mobilised precisely because of the stigma experienced by affected individuals and families.

A second useful strategy for improving stigmatising attitudes as identified by Corrigan et al [48] is to provide more information about the effectiveness of treatments. There is an association between confidence in treatment and stigmatising attitudes [49]. This approach could be complemented by discussions that explore approaches for building trust in allopathic mental health care within the community, and increasing contact with people with mental disorders so that participants can be exposed to positive consumer stories about recovery.

The mental health training facilitator's manual demonstrated potential to be an effective way to improve some aspects of mental health literacy among community health workers, including the recognition of mental disorders in vignettes and the perceived helpfulness of inappropriate pharmacological interventions. The training had a limited positive impact on attitudes towards people with mental disorders. Strategies for improving the training could include facilitating contact with consumers of mental health services, including stories of recovery, and providing information on the effectiveness of interventions for mental disorders.