Evaluation of a training program of hypertension for accredited social health activists (ASHA) in rural India.

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).

Learnings From Implementation of Technology-Enabled Mental Health Interventions in India: Implementation Report.

BACKGROUND: Recent years have witnessed an increase in the use of technology-enabled interventions for delivering mental health care in different settings. Technological solutions have been advocated to increase access to care, especially in primary health care settings in low- and middle-income countries, to facilitate task-sharing given the lack of trained mental health professionals. OBJECTIVE: This report describes the experiences and challenges faced during the development and implementation of technology-enabled interventions for mental health among adults and adolescents in rural and urban settings of India. METHODS: A detailed overview of the technological frameworks used in various studies, including the Systematic Medical Appraisal and Referral Treatment (SMART) Mental Health pilot study, SMART Mental Health cluster randomized controlled trial, and Adolescents' Resilience and Treatment Needs for Mental Health in Indian Slums (ARTEMIS) study, is provided. This includes the mobile apps that were used to collect data and the use of the database to store the data that were collected. Based on the experiences faced, the technological enhancements and adaptations made at the mobile app and database levels are described in detail. IMPLEMENTATION (RESULTS): Development of descriptive analytics at the database level; enabling offline and online data storage modalities; customizing the Open Medical Record System platform to suit the study requirements; modifying the encryption settings, thereby making the system more secure; and merging different apps for simultaneous data collection were some of the enhancements made across different projects. CONCLUSIONS: Technology-enabled interventions prove to be a useful solution to cater to large populations in low-resource settings. The development of mobile apps is subject to the context and the area where they would be implemented. This paper outlines the need for careful testing using an iterative process that may support future research using similar technology. TRIAL REGISTRATION: SMART Mental Health trial: Clinical Trial Registry India CTRI/2018/08/015355; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MjMyNTQ=&Enc=&userName=CTRI/2018/08/015355. ARTEMIS trial: Clinical Trial Registry India CTRI/2022/02/040307; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDcxMTE=&Enc=&userName=CTRI/2022/02/040307.

Protocol for process evaluation of ARTEMIS cluster randomised controlled trial: an intervention for management of depression and suicide among adolescents living in slums in India.

INTRODUCTION: There are around 250 million adolescents (10-19 years) in India. The prevalence of mental health-related morbidity among adolescents in India is approximately 7.3%. Vulnerable subpopulations among adolescents such as those living in slum communities are particularly at risk due to poor living conditions, financial difficulty and limited access to support services. Adolescents' Resilience and Treatment nEeds for Mental Health in Indian Slums (ARTEMIS) is a cluster randomised controlled trial of an intervention that intends to improve the mental health of adolescents living in slum communities in India. The aim of this paper is to describe the process evaluation protocol for ARTEMIS trial. The process evaluation will help to explain the intervention outcomes and understand how and why the intervention worked or did not work. It will identify contextual factors, intervention barriers and facilitators and the adaptations required for optimising implementation. METHODS: Case study method will be used and the data will include a mix of quantitative metrics and qualitative data. The UK Medical Research Council's guidance on evaluating complex interventions, the Reach, Efficacy, Adoption, Implementation and Maintenance Framework and the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Safety/Side Effects and, Equity criteria will be used to develop a conceptual framework and a priori codes for qualitative data analysis. Quantitative data will be analysed using descriptive statistics. Implementation fidelity will also be measured. DISCUSSION: The process evaluation will provide an understanding of outcomes and causal mechanisms that influenced any change in trial outcomes. ETHICS AND DISSEMINATION: Ethics Committee of the George Institute for Global Health India (project number 17/2020) and the Research Governance and Integrity Team, Imperial College, London (ICREC reference number: 22IC7718) have provided ethics approval. The Health Ministry's Screening Committee has approved to the study (ID 2020-9770). TRIAL REGISTRATION NUMBER: CTRI/2022/02/040307.

Family-led rehabilitation after stroke in India: the ATTEND trial, study protocol for a randomized controlled trial.

BACKGROUND: Globally, most strokes occur in low- and middle-income countries, such as India, with many affected people having no or limited access to rehabilitation services. Western models of stroke rehabilitation are often unaffordable in many populations but evidence from systematic reviews of stroke unit care and early supported discharge rehabilitation trials suggest that some components might form the basis of affordable interventions in low-resource settings. We describe the background, history and design of the ATTEND trial, a complex intervention centred on family-led stroke rehabilitation in India. METHODS/DESIGN: The ATTEND trial aims to test the hypothesis that a family-led caregiver-delivered home-based rehabilitation intervention, designed for the Indian context, will reduce the composite poor outcome of death or dependency at 6 months after stroke, in a multicentre, individually randomized controlled trial with blinded outcome assessment, involving 1200 patients across 14 hospital sites in India. DISCUSSION: The ATTEND trial is testing the effectiveness of a low-cost rehabilitation intervention that could be widely generalizable to other low- and middle-income countries. TRIAL REGISTRATION: Clinical Trials Registry-India CTRI/2013/04/003557 . Australian New Zealand Clinical Trials Registry ACTRN12613000078752 . Universal Trial Number U1111-1138-6707.