Innovation summary

Pakistan’s healthcare system faces existing challenges including low financing, lack of specialized services, inequitable distribution of available resources and fragmented service delivery. Rapidly rising Covid-19 cases increased the burden on healthcare providers to treat patients and provide updated information. The Covid-19 crisis has also been accompanied by an ‘infodemic’ of misinformation and increased mental distress in the general population and healthcare providers.

Pursukoon Zindagi (“Peaceful Life”), IRD’s Mental Health Program has adopted a three pronged approach to provide integrated Covid-19 and mental health counselling through:

  1. Proactive calls to patients tested for Covid-19
  2. Support Groups for frontline workers
  3. A crisis helpline for general population suffering from anxiety and depression

The goal of the innovation is to reduce burden on emergency care units and mental health specialists. It also aims to respond to the increased need for remote mental health services.

The program uses a stepped care approach and trains lay counsellors to remotely provide integrated physical and mental health patient consultations through proactive calls, a mental health reactive helpline, one-on-one counselling (phone or video based) and peer WhatsApp-based support groups.

Impact summary

  • Provided support to 20,000 clients through proactive calls, helpline, support groups and mental health awareness campaign
  • Improved capacity of at least 25 health workers to remotely provide integrated physical and mental healthcare
  • Development of a robust digital system for integrated COVID-19 management to improve efficiency of case management

Calling clients to provide updated information about Covid-19 and counselling has given me a sense of purpose in the pandemic. I feel like I have some control amidst all the uncertainty.”


- Lay Counsellor, female, 26

Innovation details

Much like other LMICS, Pakistan has also been hit by a large and rapidly rising caseload of Covid-19 cases, overwhelming the country’s already fragile health system. Provincial governments adopted a lockdown lasting two months starting March during which outpatient departments in hospitals and private practitioner clinics remained closed. The pandemic has also been accompanied by an economic downturn and rise in financial shocks, particularly for households relying on daily wages. Moreover, Pakistan already has a high burden of mental illness. According to the most recent data provided by WHO, approximately 24 million (12 percent) of the population of Pakistan has mental health conditions and there is a large treatment gap with only 0.19 psychiatrists available per 100,000 people.

The overarching goal of the intervention is to improve pandemic preparedness and response by providing integrated Covid-19 and mental healthcare through three main approaches:

  • Proactive calls: This is aimed towards patients who have been tested for Covid-19 at a large tertiary care hospital and primary care providers. Lay counsellors call patients who tested negative or positive. They also provide updated Covid-19 information, advise on isolation discontinuation, contact tracing services and mental health screening and counselling. In case of worsened Covid-19 symptoms, they refer patients to the nearest healthcare facility. Patients exhibiting symptoms of mild to moderate anxiety and/or depression are referred for further assessment and one-on-one counselling with a trained lay counsellor.
  • Mental health helpline: People experiencing anxiety can call in on a toll-free number and immediately reach a trained mental health counsellor for free-of-cost crisis counselling. The counsellor listens attentively to the caller’s concerns, and offers screening for depression and anxiety followed by enrolment in one on one counselling or consultation with a clinical psychologist for severe cases of mental illness. Counsellors are trained to provide updated information and safety recommendations related to COVID-19.
  • Mental Health Support for Frontline Practitioners: This is aimed towards all healthcare practitioners working on the frontlines. The component offers interactive webinars designed to provide a safe space to share their experiences, talk about fears and concerns in an open and informal manner as well as provide information about mental health, coping strategies and additional resources. It also offers tailored mental health support to anyone who requires it; current services include support groups, one on one counselling sessions and mental health check-ins (brief one on one sessions with Psychologists).

Key drivers

The programme is driven by three main components:

  • Training of health-workers on basic counselling, Covid-19 basic management and referral systems
  • Phone-based consultations for a) symptom tracking, b) contact tracing, c) psychosocial support and d) referral to facility
  • Robust data capturing and monitoring system for reporting and scheduling referrals and/or follow-ups

Challenges

Building trust and rapport over digital mediums

Counsellors have been trained in basic counselling skills. An important strategy for building trust and rapport with clients is to communicate openness through body language (such as maintaining eye contact etc.), ensure privacy etc. Remote and phone-based counselling made it difficult to rely on these established strategies. Counsellors relayed hesitation of clients to openly discuss mental health issues. It was also difficult to ensure the client has privacy at home and over the phone.

To mitigate this, counsellors are continuously provided refresher training to address mental health issues remotely. They are encouraged to use verbal cues to encourage clients to talk openly.

Updated information about Covid-19

Much is still unknown about Covid-19, given that it is a relatively new virus. Information and Standard Operating Procedures are continuously evolving, and counsellors need to be updated in order to provide accurate information.

To mitigate this, program managers are continuously in touch with relevant departments of the government and partner hospital. Regular training sessions are held to reinforce counsellors’ knowledge of updated protocols. Counsellors are immediately notified if there are any changes in existing protocols.

Addressing underlying causes of anxiety

Meeting the demand of the callers is a challenge for most helplines that are accessible to the entire population. Managing callers’ expectations about what the helpline is able to offer within its resources is an issue as people call-in with a wide array of support requests, including food and income support, requests for Covid-19 testing etc.

To mitigate this, the helpline is continuously evolving to build referral systems to relevant programs for food and healthcare support to address underlying sources of stress and anxiety amongst the population.

Continuation

The innovation is being scaled through partnerships by targeting specific populations in need of these services. This is being done via partnerships with civil society groups, corporations and other healthcare providing institutions.

Partners

Funders

Evaluation methods

There are a number of activities in place to monitor and evaluate the program. These include:

Monitoring of key outcomes

Key Performance Indicators and benchmarks are set at the onset of the program for each team member and program output. Patients are screened using Patient Health Questionnaire (PHQ-4), which is brief screening screening tool used in high burden primary care settings to assess depression and anxiety (Kroenke et al, 2009). The tool consists of two questions from PHQ-9 and GAD-7.  Patients with scores above 6 are offered one-on-one counselling with a trained lay counsellor for further assessment using PHQ-9 and Generalized Anxiety Disorder (GAD-7). Main outcomes are reduction in anxiety as measured on GAD-7 and PHQ-9 and client satisfaction as measured by feedback calls to a representative subset of clients.

Live monitoring

All counsellors are monitored by a supervisor who ensures operational effectiveness (including maintenance of attendance logs, coordinating logistics, maintaining contact with M&E associates) of the program on a daily basis. The M&E team live monitors incoming data to ensure quality control.

Cost of implementation

  • 3 USD per patient (approximate)

Impact details

9,767 patients tested for Covid-19 have been called for follow ups, out of which 6,171 (63%) have been provided integrated Covid-19 and mental health consultations. 109 callers provided mental health support through helpline and 181 frontline workers engaged for mental health support.

Preliminary findings that follow up calls by counsellors result in increased adherence to self-isolation and lower self-reported distress.

References

  1. World Health Organization (2019). Press release. http://www.emro.who.int/pak/pakistan-news/who-pakistan-celebrates-world-mental-health-day.html
  2. Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50(6), 613–621. https://doi.org/10.1176/appi.psy.50.6.613

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