Innovation summary

Patients with mental disorders/epilepsy in rural settings across South Asia face stigma and persecution, and often undergo painful and dangerous rituals as religious “cures” due to superstitions. Remote locations, poverty, and lack of adequate transport facilities make access to the hospital difficult, and the problem is compounded by a lack of trained mental health professionals.

Project “Shifa” is the Community Mental Health project at Padhar Hospital which aims to address these problems. The team consists of a psychiatrist, a coordinator, 10 community field workers, and nursing students posted in the psychiatry department, covering a target area of 75 tribal villages.

Activities include:

  • Door-to-door screening by field workers using a specially-designed family-level screening tool
  • Weekly outreach clinics by the entire team in selected villages
  • Group Therapy sessions with a psycho-educational focus in the field
  • Awareness-building about mental health issues and epilepsy
  • Community-level research to improve service provision

Project Shifa was one of 3 finalists at the BMJ Awards South Asia 2016 in the category “Excellence in delivering primary care.”

**NEW: Download the book describing the model here.

 

Impact summary

  • 535 patients have been registered and evaluated to date
  • 70-80% of patients with severe mental disorders experienced symptom improvement, improvement in socio-occupational functioning, and community reintegration
  • The average cost of treatment for a patient on long-term follow-up is less than $5 USD (150-200 Rupees) per month

Innovation details

The project incorporates multiple components:

Weekly outreach visits and screening (PaCoMSI)

Outreach visits are performed weekly, picking one ‘cluster’ of villages a week. The 75 target villages are divided into 11 clusters, so that each cluster gets re-visited approximately once in 3 months. Home visits are available for selected patients who are too sick or too far to come to the location. We have recently attempted 'clubbing of clusters' (covering more than one cluster on a single outreach visit) to adjust for lost visits due to difficult weather conditions or other reasons.

In preparation for the visits, field workers screen selected areas using our new family-level screening tool, the Padhar Community Mental Health Screening Instrument (PaCoMSI), to detect mental illnesses and epilepsy. The tool is short, incorporates local terms and concepts, and can screen entire villages one family at a time (rather than one person at a time). Pilot data emerging on sensitivity and specificity are very encouraging.

Follow-up care

Those with positive PaCoMSI screens are evaluated by the psychiatrist, and managed as needed according to the following strategies:

  • Severe mental disorders & epilepsy: Medication provided in community setting; patient/family psycho-education through Group Therapy; home-based rehabilitation strategies
  • Common mental disorders: Mostly referred to base hospital for relevant tests and interventions; some medication on a case-by-case basis
  • Developmental Disorders: Intensive screening for treatable co-morbidities (which are treated in the community); parent/family psycho-education through Group Therapy; some referred to base hospital for more intensive interventions (if willing and able)
  • Alcohol use disorders: Mostly referred to base hospital; as of June 2016: community-based ‘detoxification camps’ using self-help groups (2 camps held so far)

Medication: Field workers follow up all patients receiving medications in the field twice a month in their homes

Group Therapy: Group Therapy sessions have a psycho-education focus and are held in one cluster each month (alongside the Outreach Clinic) for selected patients with severe mental illnesses, epilepsy and developmental disorders. These sessions focus on the nature and management of the disorders, family burden, stigma, and re-integration into the family and community. Sessions for alcohol treatment further focus on motivational counselling and triggers of alcohol use.

Community re-integration: The primary strategy for severe mental illnesses has been to encourage families to get patients back to work in the field or house (e.g., agricultural work, manual labour, household chores) as soon as their symptoms remit sufficiently. Psycho-education of family members further empowers families to take charge of treatment rather than depending on health professionals.

Education, capacity-building, and stakeholder engagement

Weekly team meetings bring together all field workers, coordinating staff, psychiatry nursing students, and the consultant psychiatrist. In addition to reviewing problems and planning strategies for the coming weeks, these are an important opportunity for learning and training.  We also regularly host visiting and prospective medical students, theology & sociology students, nursing students and others, who receive an orientation to psychiatry and the Project and on-site clinical teaching. These past months have seen students and visitors from Germany, Sweden, Singapore, Australia, Italy, and various parts of India. 

The field workers and success stories of individual patients help increase awareness of mental health issues in the community, and we raise awareness of events like World Mental Health Day by organizing talks, publicity pamphlets, radio talks, etc.

Finally, 3 tiers of reports are generated regularly: Weekly outreach census reports (circulated internally within Padhar hospital), Monthly reports (wider circulation to team members, donors, and well-wishers), and half-yearly reports (wider circulation and publicity, often including individual case stories as examples and plans for the future).

 

Key drivers

Readily available workforce

The project uses lay health workers and students as the primary work force – resources easily available even in remote settings.

Community as integral to recovery and re-integration

The project places great emphasis on families as the primary care providers for the severely ill patients, capitalising on the strong joint family systems present in rural settings in South Asia. As families themselves can take over rehabilitative training tasks if encouraged and guided, this approach reduces the cost of - and burden on - the limited health care professionals available. This home- and community-based approach, which emphasizes easily available, practical tasks, helps patients feel comfortable and re-integrate more easily when their symptoms improve.

Cost minimization

By limiting medications to a small list of effective and inexpensive drugs, using existing hospital staff and students rather than specialists, and empowering families to provide care and rehabilitation, we have kept cost of intervention to a very basic minimum.

Team and administrative structure

Weekly team meetings are an important opportunity for learning and training, as well as feedback, encouragement, and fostering team work and spirit.  We also take care in record-keeping, including case notes for individual patients screened in the field and unique project numbers to help identify them in the field and make their visits to Padhar hospital easier.

Challenges

Manpower shortage

We have only one trained mental health professional, and no staff nurse, pharmacist, accountant or medical records staff in the project team. We therefore use available nursing students (on psychiatry rotation) for medication dispensing and records, and train field workers to help with education and monitoring in the community. Team members also share roles, helping each other in crises.

Poor accessibility

Many villages are in interior areas that lack public transport, posing a major problem during the monsoons in particular. These issues area tackled by careful planning, and ensuring that clusters of villages are clubbed appropriately to make up for any cancelled outreach visits.

Cultural beliefs

In the initial phase, strong magico-religious belief systems impacted compliance. However, regular and frequent contact with team members and psycho-education have improved compliance, and we encourage patients to continue their beliefs along with our treatments if they so desire.

Lack of funding

Despite the interest of the district collector, no government funding has thus far materialized. By using available human resources, inexpensive medicines, and families in patient care, we have restricted average costs.

 

Continuation

We are training government health workers from 120 additional villages in the use of the PaCoMSI screening tool. They have already begun screening their respective villages, and we plan to evaluate and diagnose screened patients over the coming months.

We are discussing plans with another mission hospital in North India (Harriet Benson Memorial Hospital at Lalitpur) on starting a similar community mental health program in their setting. We are also discussing with the Distance Education department of Christian Medical College, Vellore about the possibility of starting mental health courses for health workers to increase the pool of human resources across the country. 

In terms of research, we plan to write up the screening data compiled so far as a pilot evaluation study. Other ongoing research work includes a descriptive study of post-encephalitic syndromes being encountered in the field. 

 

Partners

Key funders:

  • Predominantly individual donations from interested well-wishers
  • Friends of Padhar (UK)

Evaluation methods

We have designed a simple outcome evaluation tool that can be easily filled by any member of the team using available clinical and field records. We evaluate the project every 6 months using this tool to help evaluate our progress and identify areas for improvement.

The tool generates data in four broad domains:

  • Symptom improvement (disorder-specific)
  • Compliance with treatment
  • Functional/occupational recovery
  • Community re-integration

Given the subtle differences in presentation and desired outcomes, separate outcome evaluation forms have been designed for:

  • Severe mental disorders
  • Common mental disorders
  • Epilepsy
  • Developmental disorders
  • Non-epileptic neurological disorders

Cost of implementation

The project operates on a very limited budget financed primarily by donations from well-wishers. Costs are kept to a minimum by the following means:

  • All team members are existing staff or students of Padhar Hospital who multi-task to fulfil pharmacist, nursing, and medical records roles in addition to their project roles.
  • Training and empowering family members minimizes dependence on health care workers.
  • We use a small list of inexpensive and easily available medications.
  • By focusing on a specified area within a limited distance from the hospital (20 km), transportation costs for outreach visits and follow-up are limited.
  • The team cuts expenses by recycling old material (e.g., registration cards are recycled from the hospital’s medical records department).

 

Impact details

To date, we have registered and evaluated 523 patients. 200 of these patients have received medications in the field. Currently, after excluding those whose courses are completed or who refused further treatment, 114 are on long-term follow up in the field

Severe mental disorders

A total of 98 patients have been diagnosed with severe mental disorders (66 with schizophrenia, 23 with other psychotic spectrum disorders, and 9 with bipolar disorder). 19 patients were lost to follow-up and could not be traced, while 16 dropped out voluntarily and 3 died; the majority of patients chose to continue treatment, and of these, 80% of patients show good compliance rates with medication. 70 – 80 percent of patients have displayed improvement in function and community re-integration, and this figure has remained stable over time.

Epilepsy

58 patients have been diagnosed with epilepsy, and 70% show fairly good medication compliance. Complete seizure control has been achieved in 54% of patients, and another 32% show >50% seizure reduction. More than 80% of patients show good functional/occupational recovery as well as community re-integration.

Developmental disorders

We have identified 123 patients with developmental disorders (e.g., autism spectrum disorders, developmental delays, cerebral palsy). Of the patients given medication, 60% show good compliance. Among the 83 patients followed up, 35% show at least some improvement in functional status and community re-integration.

Common mental disorders

The group of common mental disorders (168 patients:  66 with depressive disorders, 79 with anxiety disorders, 23 with substance use disorders, predominantly alcohol and nicotine) remains a challenge. The strategy has for the most part been limited to referral to Padhar hospital for further interventions, but less than 20% of those referred actually come to the hospital, and less than half of those prescribed medications are compliant. The number of patients documented to show symptom improvement remains constant at about 30%. At present, we have little more we can offer to the patients with depressive and anxiety disorders at a community-based level, but programmes for patients with alcohol use disorders show promise.

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Associates

Johann Ebenezer
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