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

From: SMART Mental Health Project: process evaluation to understand the barriers and facilitators for implementation of multifaceted intervention in rural India

Key components from Andersen’s model Prior SMART Mental Health Intervention Scenario Intervention and processes implemented Participants’ perception about the intervention (barriers, facilitators and recommendations from participants to improve the programme)
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
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