Table 3 Identifying barriers and facilitators of mental health services use based on Anderson’s Modified Behavioural Model of health services use

Environmental

Healthcare system

Mental health care was not available at PHC

ASHAs lacked knowledge on CMD and skills for interview people on mental health issues

Primary care doctors did not have proper knowledge and skills to identify and manage CMD

Patients required to travel to distantly located PHCs, leading to financial loss

41 ASHAs and 6 doctors were trained on using the mobile technology-based application

12 Field staff were trained to communicate with ASHAs and doctors and implement the programme and supervise the process

ASHAs screened 22,046 community members for CMDs using algorithm based EDSS. Among these, 900 community members were screened positive and referred to PHC for treatment

Doctors used this training to manage CMD using mhGAP-IG based EDSS

About 104 Health camps organized in villages to facilitate the easier access to doctors and treatment

IVRS calls were sent for a period of 1 year to 41 ASHAs, 6 PHC doctors and the screen positives in the community at different intervals and different frequency on a case-to-case basis, to remind screen positive individuals about treatment and to ASHAs about their pending screenings and follow ups

In all, 14,849 calls were placed during intervention period; 13,400 call placed to community members;1449 calls placed to ASHAs and doctors;8046 calls to patients

Community members, ASHAs, primary care doctors appreciated the programme and perceived it as valuable in enhancing the knowledge of community members on mental health

ASHAs reported that training enhanced their confidence level and interview skills

Doctors appreciated the usage of EDSS, as it provided some prior information of the patient and consume less time

Almost all ASHAs, and doctors mentioned that poor signal and network connectivity was a barrier on using the applications

Training sessions helped ASHAs, doctors and field staff to operate the tablets

Distance, lack of public transport facility and financial burden were demotivating factors to access the care

Health camps within the locality were appreciated as they reduced time and money spent in visiting the PHC

ASHAs paid repeated visits to enquire about health and to motivate them to visit the doctor for treatment

Few participants were aware of the IVRS sent to them on their mobile phones

Family members owned only one phone set, kept at home

Phone sets were owned by their family members, husbands or their children’s; and most of them were illiterate

Some people simply assumed that the messages were from service provider and did not even show interest to check these messages at all

Population characteristics

Predisposing characteristics

Limited awareness about mental health among community members

Social issues like poverty, unemployment, and caste system exist in villages

Organized awareness campaign on mental health using several strategies

Brochures and pamphlets were used in the door-to-door campaign and community meetings to raise mental health awareness and discuss issues related to stigma; this was repeated 3–4 times in each village

A promotional video where a local film actor speaks about mental health and stigma was screened

A video of a person with mental disorder to talk about his/her experience was screened and discussed during the campaign

Staging a drama by a local theatre group on domestic violence, mental disorder and the need for getting treated

Door-to-door campaign was a key strategy to approach people for face- to face interaction and motivate them for treatment, if required

The drama was received very well and there was good participation at all the villages

Domestic violence, family restrictions, preoccupation with work were the other reasons which prevented people from visiting the doctors

ASHAs were scared to enter in some houses belonged to economically well-off people or to the higher caste

Community leaders shared that in some families, the elders did not allow daughters/daughters-in-law to go out for seeking treatment, specifically for mental illness

Alcohol addiction and loneliness were perceived as reasons for mental illness

Stigma is associated with mental illness, and were highly prevalent

Enabling resources

No pre-existing mental health services in villages

Community members were not oriented towards identifying CMD

Local administration and village leaders were informed about the project at each phase

ASHAs and doctors used to provide care and treatment

Field staff were trained using standard operational procedures and their activities monitored regularly

Field staff monitored ASHAs regularly and ensured the quality of data collected by them; supervisors followed up with doctors regularly to check for any problems that they might be facing with the application

Health camps in villages enabled patients with CMD to seek care from doctors closer to home

Village leaders reported that people suffering from mental illness needed some support, which they received through this programme

Peer learning and sharing of experiences encouraged people to seek health care

Need

Perceived need to seek care for CMDs was negligible as there was no awareness about CMDs

ASHAs and doctors were not trained to identify or manage the CMD

Screening of the whole population by ASHAs led to increase in help seeking

Participants suggested more training programs for doctors and ASHAs

Most participants recommended that communities need to be more educated about the facts pertaining to mental illness

Personal health practices

Stigma related to mental health was highly prevalent

Poor knowledge about CMDs amongst community members and health workers

A campaign was organized to increase mental health awareness and reduce stigma

All participants reported the campaign was beneficial

Project increased the awareness about CMDs and the need to seek care

Outcomes

Use of health services

There was no treatment for CMDs in PHCs

The intervention had a focus on increasing mental health services use for CMDs

Task shifting was used to enable mental health care for the rural population

Technology driven platforms were used to facilitate provision of mental health services

A system developed to ensure follow up by ASHAs and doctors

Out of 900 patients, 731 visited the doctor at least once. The doctors were able to deliver the healthcare effectively

104 Health camps organized in villages to facilitate the easier access to doctors and treatment

Programme should be implemented through PHCs, and in collaboration with 104s (ambulance services in the rural areas), assisting them to have access to the nearest treatment facilities

Perceived health status

A comprehensive mental health intervention implemented

The intervention was well received and appreciated in the community

Consumer satisfaction

A pre-post evaluation of the project provided objective assessment of the outcomes

Community members were satisfied with SMART mental health intervention as it led to increase in the knowledge of CMDs in the community