The NALAM study: Village workers promoting mental health

Innovation summary

Poverty directly contributes to an increased risk of mental ill health and acts as a barrier to successful recovery. Community-based mental health care in the Indian context is currently mostly focussed on medical treatment, however, several non-medical lay worker programs tested internationally involving brief psychological therapies have been shown to be effective in this context.^1-2 Very few programs have addressed the social-economic factors and often mental health is not an indicator in programs and studies that address poverty.^3-4

In this context, NALAM offers a multi-interventional framework of services delivered by lay workers that combine social care with mental health care. The project aims to address socio-economic realities that are concomitant to mental health to reduce mental ill-health and promote well-being.

Services delivered by lay workers include:

Impact summary

577 users received mental health and social care services, 425 preadolescents completed a five-session mental health promotion intervention on ‘Understanding Self’
In 60% of users, there was a significant decrease in symptoms and increase in psychological well-being observed over 6 months; changes were sustained at 12 months
$141,844.47 USD (9,651,654 INR) spent over 24 months to train and supervise 27 lay workers, implement project in 20 village councils and for dissemination efforts

“I have learnt about mental health…. made 26 friends, we mutually learn a lot, I feel resourceful whenever I meet them. NALAM introduced me to larger society….. My husband who used to abuse me constantly is now proud of who I am and my work.”

- S, NALAM mobilizer, describing her experience with the initiative

This innovation was funded by Grand Challenges Canada.

Innovation details

The NALAM project is built upon a wellness-oriented, multi-interventional approach to mental health, which moves beyond the traditional case-identification, treatment of symptoms approach to mental health problems, and instead tries to holistically address the social determinants which are related to these issues. The approach consists of a combination of social care with clinical care which includes:

Social care services

Rights and welfare entitlement facilitation e.g. disability allowances, citizenship documents, land rights, pensions, loans
Links to wider community resources e.g. leisure, recreation, social groups, health services and education
Livelihood facilitation e.g.employment placements, referrals to training and skills development programs, interest-free loans for self-employment, livelihood aids such as tailoring machines, livestock, etc

Clinical care

Screening and referral to services
Supportive counseling (focusing on strengthening therapeutic alliance, building rapport, and peer support)
Home based follow up and after care
Brief group based mental health promotion interventions.

The project recruits, trains and incentives community level social mobilizes, referred to as NALAM mobilizers, who not only build relationships with community members who may have a mental illness, but also work with a larger group of the most marginalized in their communities to promote well-being.

Key drivers

Lay worker delivery supported by responsive service systems and supervision

A key driver for the success of lay worker delivered interventions is a responsive service system that is unique to the socio-cultural and geographical features of the context that offers high intensity and quality supervision to the lay workers.

Challenges

Multiple distresses among clients and NALAM mobilizers

Persistent and complex issues among clients and mobilisers’ own personal struggles were sometimes overwhelming when faced with a dearth of solutions. Vignettes from the field illustrate multiple distresses that are persistent among clients:

Presence of multiple people with disabilities within the same family that are living in poor housing conditions and further socially ostracized
An elderly father with depression and hearing disability, living in a thatched hut with poor roofing, no electricity, no entitlements, left to fend for his 7 year old growing son
A young girl who doesn't see any future for herself after witnessing her father’s suicide and her mother’s road accident
A family left without food for days after the suicide of their sole breadwinner

The NALAM mobilizers also faced several critical incidents, in addition to ongoing issues such as poverty and alcohol use among spouses, which included loss of foot in a road accident, husband left unemployed after a serious accident, hospitalization of children including one instance of a stay in the Intensive Care Unit and another of heart surgery, suicides of kin, an episode of acute psychosis, depression following discovery of husband’s extra marital affair and so on. These incidents reinforced the importance of introducing sustainable and focused interventions that address multi-dimensional poverty.

Delivery of intervention affected by social welfare dynamics

Following reviews with NALAM mobilizers on promotion of effective access to social welfare, three significant challenges emerged:

Inaccessibility of several schemes owing to their exclusion criteria and interpretations of the same by government functionaries. This was stark for mental illness, which despite being listed as a seventh disability in the Persons with Disabilities Act of 1995, is left out of most disability benefits at the local administrative level.
Political leanings, caste dynamics and favoritism of local government parties involved in welfare implementation which influences access to welfare. In the same vein, lack of adequate political representation of the opposition party was cited as being detrimental to advocacy and civic engagement processes in securing welfare.
Corruption and consequently, the inability of those who are the poorest to voice their opinions in this process

Continuation

Multi-site implementation and further study of NALAM as a multi-component package of services, including the systems in health (clinics with rational drug therapy, supervisions and so on) and social care as components of delivery (public and private social care including livelihoods), is essential to both developing the approach as well as generating associated evidence through appropriate design for complex interventions, in particular for understanding specific social care pathways to better mental health.

In addition, over the next five years, existing NALAM components will be expanded to include more diverse livelihood interventions and academic enrichment programs. Therapeutic approaches that are disorder specific are proposed to be introduced for depression and alcohol use. In addition, preventive and promotion group therapies aimed at egalitarian gender norms and for carers of people with mental health issues, have been proposed. Partners with competencies in these services have been identified and discussions have been initiated.

Partners

Funder

Grand Challenges Canada (Canada)

Evaluation methods

Mixed methods were used to evaluate this project between September 2014 to September 2015. Client level outcomes - symptoms (PHQ-9), psychological well-being (Flourishing Scale) and subjective wellbeing (Cantril’s ladder) - were measured every six months. There was not a comparison group for client level outcomes and changes were observed as a single group. Outcomes at the NALAM mobilizer level and community level (mainly Knowledge, Attitudes, and Practice (KAP)) were measured at baseline and endline over the 12 month period. To understand KAP of those participating at the community level, outcomes were compared with usual-care clusters.

Cost of implementation

A total of $141,844 USD (9,651,654 INR) was spent over 24 months for training and supervision of 27 lay workers, implementation of the project in 20 panchayats by a multidisciplinary team of psychiatrists, social workers and psychologists and for implementation of the evaluation (assessment at three points in time). Cost effectiveness was not evaluated.

Impact details

Mental health services

577 users received mental health and social care services as part of the NALAM project.

133 out of 186 clients with mental health issues, referred by NALAM mobilizers, registered at a clinic. A total of 199 active clients were part of NALAM clusters, out of which 165 received follow-up home visits.

Social care services

Social care was much more variegated. The key service offered by the NALAM mobilizers was welfare facilitation, specifically the facilitation of the disability card for 102 people, disability aids for 39 people, and monetary benefits from welfare schemes (disability, elderly, widowed) for 126 people.

130 people received support to access private and government loans and 89 people received support with their to citizenship documents.

The team facilitated employment for 62 people, self-employment aid for 7 people, and skills development training for 35 people.

78 people registered for the government’s national employment guarantee scheme and 62 people enrolled into the government’s health insurance scheme through NALAM mobilizer efforts.

Client outcomes

425 preadolescents completed a five-session mental health promotion intervention on ‘Understanding Self’. A significant increase in self-esteem scores was observed when comparing pre- and post-intervention data (Pre-intervention: M=23.56, SD=3.64; post-intervention: M=24.89, SD=4.32).

512 users were evaluated over a 6-month period (baseline to midline). There was a significant difference in mean PHQ-9 scores which decreased from T1 (M=10.15, SD=8) to T2 (M=6.6, SD=7.3); and a significant increase in mean scores on Flourishing Scale from T1 (M=38.95, SD=12.27) to T2 (M=42.44, SD=11.5).

232 people enrolled at baseline completed the endline aseessment (T3). Preliminary analysis using a repeated measures ANOVA test determined that mean scores on PHQ-9 and the FS were statistically significantly between time points. This indicates that changes in user level outcomes were sustained over the 12 month period.

Community outcomes

There was a larger increase in KAP in the NALAM clusters compared to the control group. Mean KAP scores in NALAM intervention improved from 83.86 (SD=9.12) at baseline to 89.36 (SD=10.07) at endline, whereas in as usual care it improved from 85.25 (SD=8.56) at baseline to 88.76 (SD=7.99) at endline.

References

Patel V et al (2010) Effectiveness of an intervention led by lay health counselors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomized controlled trial. The Lancet, 376 (9758): 2086-2095.
Chibanda D et al (2015) The Friendship Bench program: a cluster randomized controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe. International Journal of Mental Health Systems, 9.
Van Ginneken N et al (2011) Non-specialist health worker interventions for mental health care in low- and middle- income countries. The Cochrane Database of Systematic Reviews, 5.
Mutamba BB et al (2013) Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review. BMC Health Services Research, 13.

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Country

India

Affiliated organizations

The Banyan