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To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary-care settings in Goa, India. Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary-care facilities. Subjects were randomly assigned to an intervention or a control arm. Eligible subjects in the intervention arm were given psycho-education, case management, interpersonal psychotherapy and/or antidepressants by lay health workers. Subjects in the control arm were treated by physicians. The use of health-care resources, the disability of each subject and degree of psychiatric morbidity, as measured by the Revised Clinical Interview Schedule, were determined at 2, 6 and 12 months. Complete data, from all three follow-ups, were collected from 1243 (75.4%) and 938 (81.7%) of the subjects enrolled in the study facilities from the public and private sectors, respectively. Within the public facilities, subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm. Time costs were also significantly lower in the intervention arm than in the control arm, whereas health system costs in the two arms were similar. Within the private facilities, however, the effectiveness and costs recorded in the two arms were similar. Within public primary-care facilities in Goa, the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving.

Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511. 16 clusters were assigned to intervention (23 353 households, 12 391 total births) and control groups (23 768 households, 11 443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12 028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000; risk ratio [RR] 0·79, 95% CI 0·68–0·92; p=0·006). The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups (RR 0·85, 0·76–0·96; p=0·02). Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential. WHO; Saving Newborn Lives Program of Save the Children USA, funded by the Bill & Melinda Gates Foundation.

Background and objective One of the strategies for enhancing the mental health literacy of the community could be capacity building in the field of mental health first aid (MHFA) training among health ambassadors, who serve as volunteers between health service providers and families. The present study aims to investigate the effectiveness of MHFA training packages for depression prevention using critical thinking methods on the depression literacy (as a key component of mental health literacy) of health ambassadors to assist in the early identification and timely referral of individuals with depressive disorders. Depressive disorders are among the most prevalent mental health conditions, yet many individuals delay or avoid seeking treatment due to stigma and limited awareness. Improving mental health literacy is therefore essential to promote early recognition and timely help-seeking. Health ambassadors, as community volunteers linking families to health services, are uniquely positioned to support this goal. This study applies a culturally adapted MHFA training package for depression, delivered through critical thinking and role playing, in improving the depression literacy (as a key component of mental health literacy) of health ambassadors. The trial seeks to determine whether this approach enhances their ability to recognize symptoms, provide initial support, and facilitate referral to professional care. Methodology This is a study protocol for a cluster-randomized controlled trial conducted in 10 comprehensive health service centers (CHSCs) in Islamshahr, Iran. A computer-generated random sequence will assign five centers to the intervention group and five to the control group. The allocation sequence will be prepared and concealed by an independent epidemiologist not involved in recruitment or intervention delivery. From each center, 25 eligible health ambassadors (women aged 25–45 years with ≥ 2 years of experience) will be randomly selected, yielding a total sample of 250 participants. The intervention group will receive an eight-session, culturally adapted MHFA training package delivered using problem-based learning and role-playing methods. Depression literacy (as a key component of mental health literacy) will be assessed at baseline and 2 months post-intervention using the questionnaire developed by Reavley et al. (2014). For statistical inference, analysis of covariance (ANCOVA) will be employed to examine group differences, and multivariate linear regression will be applied to adjust for potential confounders, using SPSS software version 24. A p -value of < 0.05 will be considered statistically significant. Discussion This protocol describes a trial designed to evaluate whether mental health first aid (MHFA) training with a critical thinking approach can improve depression literacy (as a key component of mental health literacy) among health ambassadors. Findings from this study may provide evidence to guide future mental health promotion strategies, particularly for the early identification and referral of individuals with depression and the prevention of suicide. Trial registration Iran Randomized Clinical Trial Center IRCT20231225060521N1. Registered on 21 January 2024 (current status: ongoing).

Background Hypertension is a major risk factor for cardiovascular disease, a leading cause of premature death and disability in India. Since access to health services is poor in rural India and Accredited Social Health Activists (ASHAs) are available throughout India for maternal and child health, a potential solution for improving hypertension control is by utilising this available workforce. We aimed to develop and implement a training package for ASHAs to identify and control hypertension in the community, and evaluate the effectiveness of the training program using the Kirkpatrick Evaluation Model. Methods The training program was part of a cluster randomised feasibility trial of a 3-month intervention to improve hypertension outcomes in South India. Training materials incorporated details on managing hypertension, goal setting, facilitating group meetings, and how to measure blood pressure and weight. The 15 ASHAs attended a five-day training workshop that was delivered using interactive instructional strategies. ASHAs then led community-based education support groups for 3 months. Training was evaluated using Kirkpatrick’s evaluation model for measuring reactions, learning, behaviour and results using tests on knowledge at baseline, post-training and post-intervention, observation of performance during meetings and post-intervention interviews. Results The ASHAs’ knowledge of hypertension improved from a mean score of 64% at baseline to 76% post-training and 84% after the 3-month intervention. Research officers, who observed the community meetings, reported that ASHAs delivered the self-management content effectively without additional assistance. The ASHAs reported that the training materials were easy to understand and useful in educating community members. Conclusion ASHAs can be trained to lead community-based group educational discussions and support individuals for the management of high blood pressure. Trial Registration The feasibility trial is registered with the Clinical Trials Registry - India (CTRI) CTRI/2016/02/006678 (25/02/2016).

Mental health task shifting is a potential way to address the burgeoning treatment gap for mental illness. Easily available and accessible digital technology can be utilised to continuously engage grassroot level health workers (for example, Accredited Social Health Activists (ASHAs). However, the impact of such a strategy is not yet systematically evaluated. In this randomised controlled trial, longitudinal hybrid training of ASHAs [1 day in-person classroom training and seven online sessions (ECHO model), aimed to screen and refer to commonly prevalent mental health issues in communities] was compared with traditional one-day in-person classroom training. ASHAs (n = 75) from six Primary Health Centres in Ramanagara district, Karnataka, India were randomized into study (SG-ASHAs) and control (CG-ASHAs) groups. After excluding drop-outs, 26 ASHAs in each group were included in the final analysis of the scores on their Knowledge, attitude, and practices (KAP) in mental health. Two house-to-house surveys were conducted by both groups to identify and refer possible cases. The number of screen positives (potential persons with mental illnesses) and the KAP scores formed the outcome measures. Online sessions for SG-ASHAs were completed over 18 months, the COVID-19 pandemic being the main disruptor. SG-ASHAs identified significantly higher number of persons with potential alcohol use disorders [n = 873 (83%); p ≤ 0.001] and common mental disorders [n = 96(4%); p = 0.018], while CG-ASHAs identified significantly higher number of those with potential severe mental disorders [n = 61(61.61%); p ≤ 0.001]. As regards KAP, after controlling for baseline scores, the time effect in RMANOVA favoured SG-ASHAs. Mean total KAP score increased from 16.76 to18.57 (p < 0·01) in SG-ASHAs and from 18.65 to 18.84 (p = 0.76) in CG-ASHAs. However, the Time-group interaction effect did not favour either (F = 0.105; p = 0.748). Compared to traditional training, mentoring ASHAs for extended periods is more impactful. Easily accessible digital technology makes the latter feasible. Scaling up such initiatives carry the potential to considerably improve treatment access for those in need.

Maternal post-natal depression is a global public health problem. Parenting interventions targeting children's development may also bring benefits to mothers, but few parenting interventions have been studied thoroughly. The study aimed to measure the effect of a parenting intervention using culturally appropriate and locally made toys, along with nutrition education and unconditional cash, on maternal depressive symptoms (MDS) and quality of life (QoL). The study was a cluster randomised controlled trial with two arms: i) intervention: parenting with nutrition education and unconditional cash and ii) comparison: unconditional cash in an urban setting in Bangladesh. Twenty clusters were randomised to either the intervention or control group. Community Health Workers (CHWs) delivered parenting and nutrition education sessions fortnightly in households for one year. The participants were mother-child (6-16 months) dyads. The MDS and QoL were measured using the Self-Reporting Questionnaire-20 and a brief version of the QoL questionnaire. Linear regression analysis was used to assess the treatment effects. After one year of intervention, 547 mothers (93%) completed the study. The mothers in the intervention group had lower MDS [Regression coefficient (β)=-1.53, Confidence interval (95% CI)=-2.28, -0.80] and higher QoL scores in physical health [β = 4.21 (95% CI = 1.71, 6.73)], psychological health [β = 3.14 (95% CI = 1.10, 5.19)], social relationships [β = 3.21 (95% CI = 0.76, 5.66)] and environment [β = 3.40 (95% CI = 1.37, 5.44)] compared with the comparison group. Parenting interventions including nutrition education and unconditional cash, aimed at improving children's development, resulted in a reduction in maternal depressive symptoms and improvement in quality of life.

To design and test the usability of case-based HIV microlearning lessons using WhatsApp groups. This paper reports on effectiveness and uptake. South Africa has the largest antiretroviral treatment program globally. National guidelines are regularly updated. Ongoing training of healthcare workers is vital but complicated by infrastructural, financial and human resource shortages. Innovative solutions are needed. A pragmatic, mixed methods, parallel group, cluster randomised trial. Nurses and community health workers (CHWs) at 50 clinics in the Eastern Cape were invited to participate. Online questionnaires tested knowledge and retention of knowledge; retrospective folder reviews measured changes in patient care. Patient folders were sampled purposively pre-/post-intervention for clinical points learned. Descriptive and inferential analyses were performed. Uptake and participation were good: 232 (79 %) nurses and 207 (76 %) CHWs participated. 96 % of nurses and 88 % of CHWs read the lessons within two weeks. There was a significant intervention effect on knowledge, based on the online questionnaires: nurses (0.5 units; 95 % CI 0.11–1.0; p = 0.0499) and CHWs (0.7 units; 95 % CI 0.2–1.3; p = 0.004). 1083 patient folders were reviewed to compare changes in patient care between the study arms. Adjusting for pre-care differences between the arms, the intervention increased correct patient care by 21 % ( 95 % CI 10 %-32 %; p < 0.001) in the year after the training. WhatsApp-based microlearning improves knowledge and patient care. This, with the companion paper’s data showing that it is well received and accepted, makes it a valuable option for simple, accessible, scalable continuing medical education for HCWs.

Background Comprehensive sexuality education (CSE) has been introduced in many sub-Saharan African countries, but limited political interest and insufficient funding have resulted in many CSE initiatives being dependent on donor funding or non-governmental organisations (NGOs) supporting its implementation. This has created concerns about the sustainability of the programmes. The objective of this study was to explore factors affecting the sustainability of CSE delivered through a youth club organized after school hours in Zambia. Methods We interviewed teachers and community health workers (CHWs) who had implemented CSE as part of an after-school youth club set up as part of a cluster randomized controlled trial. The trial evaluated the effectiveness of economic support for adolescent girls, CSE and community dialogue meetings on adolescent childbearing. Teachers and CHWs in 63 schools were trained to facilitate the CSE youth clubs, and they were given economic incentives during the trial´s two-year intervention period to organize meetings every fortnight. Two years after the external support for the youth clubs ended, we conducted qualitative interviews with the facilitators in 15 of the 63 schools, interviews with some head teachers, and focus group discussions with guardians of adolescent girls. Results Whereas CHWs were generally supportive of teaching adolescents about contraception, some of the teachers stressed that abstinence was the most effective method to avoid pregnancy and diseases. The respondents’ diverging points of view did not affect their willingness to continue teaching CSE, including contraception. However, the youth club meetings were only continued in a few schools after the external support period ended. This was attributed to transfers of trained teachers and a lack of training among the remaining staff; lapse of moral support, resources and incentives; limited involvement of the school management in the CSE initiative; and attention shifting to other projects. Conclusion To ensure the sustainability of CSE initiatives for adolescents, emphasis should be placed on training several teachers in each school, and continued moral support and encouragement also appeared essential. Trial registration : ISRCTN (ISRCTN12727868). Plain Language Summary This study looked at the sustainability of Comprehensive Sexuality Education (CSE) in Zambia, delivered through after-school youth clubs. These clubs were part of a larger project that also provided economic support to adolescent girls and organized community meetings. The clubs were run by a teacher and a community health worker (CHW), who were trained and given financial incentives to hold meetings every two weeks. Two years after the project ended, interviews were conducted with various stakeholders. While CHWs were generally in favor of teaching about contraception, some teachers emphasized abstinence as the best way to avoid pregnancy and diseases. Despite these differing views, all were willing to continue teaching CSE, including contraception. However, only a few schools continued the youth club meetings after the project ended. This was due to trained teachers being transferred, lack of training for remaining staff, loss of support and resources, limited school management involvement in the CSE initiative, and the need to focus on other projects. To ensure the sustainability of CSE initiatives, more teachers in each school should be trained, and continued support and encouragement should be provided.

Background Suicidal ideation may lead to deliberate self-harm which increases the risk of death by suicide. Globally, the main cause of deliberate self-harm is depression. The aim of this study was to explore prevalence of, and risk factors for, suicidal ideation among men and women with common mental disorder (CMD) symptoms attending public clinics in Zimbabwe, and to determine whether problem solving therapy delivered by lay health workers can reduce common mental disorder symptoms among people with suicidal ideation, using secondary analysis of a randomised controlled trial. Methods At trial enrolment, the Shona Symptom Questionnaire (SSQ) was used to screen for CMD symptoms. In the intervention arm, participants received six problem-solving therapy sessions conducted by trained and supervised lay health workers, while those in the control arm received enhanced usual care. We used multivariate logistic regression to identify risk factors for suicidal ideation at enrolment, and cluster-level logistic regression to compare SSQ scores at endline (6 months follow-up) between trial arms, stratified by suicidal ideation at enrolment. Results There were 573 participants who screened positive for CMD symptoms and 75 (13.1%) reported suicidal ideation at baseline. At baseline, after adjusting for confounders, suicidal ideation was independently associated with being aged over 24, lack of household income (household income yes/no; adjusted odds ratio 0.52 (95% CI 0.29, 0.95); p  = 0.03) and with having recently skipped a meal due to lack of food (adjusted odds ratio 3.06 (95% CI 1.81, 5.18); p  < 0.001). Participants who reported suicidal ideation at enrolment experienced similar benefit to CMD symptoms from the Friendship Bench intervention (adjusted mean difference − 5.38, 95% CI −7.85, − 2.90; p  < 0.001) compared to those who had common mental disorder symptoms but no suicidal ideation (adjusted mean difference − 4.86, 95% CI −5.68, − 4.04; p  < 0.001). Conclusions Problem-solving therapy delivered by trained and supervised lay health workers reduced common mental disorder symptoms among participants with suicidal thoughts who attended primary care facilities in Zimbabwe. Trial registration pactr.org ldentifier: PACTR201410000876178

To determine the usability of WhatsApp-based HIV microlearning for healthcare workers. This paper reports acceptability and feasibility. HIV guidelines are regularly updated making ongoing training essential. Distance, infrastructure, human and financial resource constraints are challenges to training in South Africa. Innovative, accessible, scalable and sustainable training is needed. The country has 100 % mobile phone penetration; 93 % WhatsApp use. A pragmatic, mixed-methods, parallel-group cluster-randomised trial, conducted in 50 clinics, with intervention and control groups receiving training at different times. 233 nurses and 206 community health workers participated. Short case-based lessons were held in WhatsApp groups. Uptake, feasibility, accessibility, changes in knowledge and patient care were measured with analysis of online questionnaires, WhatsApp interactions, focus groups and folder reviews. Focus group sampling was purposive and convenience. Twelve focus groups and one interview were held, with 21 nurses and 42 community health workers. Qualitative data were analysed using template analysis. Overall sentiment was positive, with 98 % of participants saying they would participate if the training were held weekly throughout the year. Three themes described sentiment: (1) ‘WhatsApp group is best’ – training was effective and interesting; easy and enjoyable; live group learning, with trainer access was appreciated; and further training was wanted; (2) Challenges – infrastructural/technology-based; language barriers/jargon; and message fatigue; (3) Recognition, appreciation and empowerment. Participants expressed satisfaction, with 98.6 % of nurses and 95.2 % of CHWs finding the training useful. WhatsApp-based microlearning for healthcare workers is feasible and well-received. Future research should explore application at scale.