Digital Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression

Study Overview
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Brief Summary
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The purpose of this 3-arm randomized controlled trial is to compare two forms of digital training (i.e., low-intensity and high-intensity) with traditional face-to-face training of non-specialist health workers to deliver an evidence-based brief psychological treatment for depression called the Healthy Activity Program (HAP) in primary care settings in India. This study will evaluate a low-intensity digital training program (DGT) compared with traditional face-to-face training (F2F) on change in competence outcomes and cost-effectiveness. This study will also evaluate a high-intensity digital training program with the addition of individualized coaching support (DGT+) compared with traditional F2F on change in competence outcomes and cost-effectiveness.

Detailed Description
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Few individuals living with depression in India have access to adequate treatment in primary care settings. Task-sharing, which involves building capacity of frontline non-specialist health workers to deliver evidence-based treatment for common mental disorders such as depression, is an effective approach for bridging these gaps in available care. This emphasizes the need for novel approaches to scale up training efforts and to support the development of a skilled and competent workforce capable of delivering high quality treatment for depression in primary care settings. Therefore, the purpose of this study is to compare two forms of digital training (i.e., low-intensity and high-intensity) with traditional face-to-face training of non-specialist health workers to deliver an evidence-based brief psychological treatment for depression called the Healthy Activity Program (HAP) in primary care settings in India. This trial uses a 3-arm randomized controlled design. This study will evaluate a low-intensity digital training (DGT) compared with traditional face-to-face training (F2F) on change in competence outcomes and cost-effectiveness; and evaluate a high-intensity digital training with the addition of individualized coaching support (DGT+) compared with traditional F2F on change in competence outcomes and cost-effectiveness. In this trial, a total of 336 non-specialist health workers will be recruited from community health centers in Sehore District of Madhya Pradesh, a large and predominantly rural state situated in central India. This trial will generate knowledge on the most effective and cost-effective approaches to address the critical knowledge gap regarding the training of non-specialist health workers to deliver an evidence-based brief psychological treatment for depression in a low-resource setting. The findings from this trial will inform broader efforts to develop a mental health workforce necessary for scaling up brief psychological therapies for common mental disorders.

Official Title
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Digital Compared to Conventional Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression in Primary Care in India: A Three-Arm Randomized Controlled Trial

Conditions
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Depression, Mental Disorder, Psychological

Intervention / Treatment
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* Other: Face-to-Face Training
* Other: Digital Training
* Other: Coaching Support


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult (age ≥18 years) Non-specialist health worker Minimum education level 8th Standard Willingness to complete training to deliver HAP Willingness to stay in the study area during the trial period Exclusion Criteria: Significant speech, sight, or hearing impairment Illiterate/ who cannot read and write Prior participation in the formative research and pilot testing (during the development of the training programs)

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This study employs a 3-arm parallel randomized controlled trial design. Participants are randomly allocated to one of three training interventions: 1) low-intensity digital training (DGT); 2) high-intensity digital training with additional coaching support (DGT+); and 3) traditional face-to-face training (F2F).
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Digital Training (DGT)<br>Participants allocated to this arm receive a low-intensity digital program accessible by smart phone app for training non-specialist health workers to deliver an evidence-based brief psychological treatment for depression, called the Healthy Activity Program (HAP), in primary care settings in India. | Other: Digital Training<br>* This 4-week digital training program for non-specialist health workers is accessed through a smart phone app and offers instruction in the delivery of the Healthy Activity Program (HAP) in primary care settings. HAP is an evidence-based brief psychological treatment for depression. The digital training covers the same content as the Face-to-Face training. The course includes 16 modules with video lectures, role-play videos, graphics, slide presentations, quizzes, and assessment questions. Participants also receive low-intensity support to enhance their learning experience and sustain engagement, including: 1) access to an automated 'Help Line' that participants can call any time with questions about the program; 2) weekly automated messages sent through the mobile app to encourage participants; and 3) automated messages and phone calls to participants who show prolonged periods of inactivity in the mobile app to offer technical support and help them complete the training program.<br>|
| Experimental: Digital Training with Coaching Support (DGT+)<br>Participants allocated to this arm receive a high-intensity digital program accessible by smart phone app augmented with weekly telephone coaching support for training non-specialist health workers to deliver an evidence-based brief psychological treatment for depression, called the Healthy Activity Program (HAP), in primary care settings in India. | Other: Digital Training<br>* This 4-week digital training program for non-specialist health workers is accessed through a smart phone app and offers instruction in the delivery of the Healthy Activity Program (HAP) in primary care settings. HAP is an evidence-based brief psychological treatment for depression. The digital training covers the same content as the Face-to-Face training. The course includes 16 modules with video lectures, role-play videos, graphics, slide presentations, quizzes, and assessment questions. Participants also receive low-intensity support to enhance their learning experience and sustain engagement, including: 1) access to an automated 'Help Line' that participants can call any time with questions about the program; 2) weekly automated messages sent through the mobile app to encourage participants; and 3) automated messages and phone calls to participants who show prolonged periods of inactivity in the mobile app to offer technical support and help them complete the training program.<br>Other: Coaching Support<br>* Individualized remote coaching is a form of high-intensity support that will be used to help sustain participant engagement in the digital training program and promote success in progressing through the course. Each week, a Coach will phone participants and offer encouragement and support related to the course. The phone call will last no more than 60 minutes. The Coach will be someone who has successfully completed the course, and therefore can offer first hand knowledge of the content. During the coaching session, the coach will review the participants' progress through the course, offer praise and encouragement, discuss any challenges or questions related to the course content, and review the participants' goals and plans for the upcoming week. Each participant will receive a maximum of 4 remote coaching sessions (1 per week over the 4-week training program).<br>|
| Active Comparator: Face-to-Face Training<br>Participants allocated to this arm receive a traditional classroom-based (face-to-face) program hosted in community settings for training non-specialist health workers to deliver an evidence-based brief psychological treatment for depression, called the Healthy Activity Program (HAP), in primary care settings in India. | Other: Face-to-Face Training<br>* This intervention is a traditional classroom-based (face-to-face) training program for non-specialist health workers offering instruction for the delivery of the Healthy Activity Program (HAP) in primary care settings. HAP is an evidence-based brief psychological treatment for depression. The classroom instruction follows the HAP manuals and is facilitated by an experienced counselor with certification as a Master Trainer, meaning that they have significant experience delivering HAP to patients with depression in clinical settings and also training other health workers in the delivery HAP. The total duration of classroom instruction is 6 days.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Competency | 26-item multiple choice exam to assess the competency of the non-specialist health workers in delivering the Healthy Activity Program (HAP) after training. The measure consists of clinical vignettes followed by multiple-choice questions focused predominantly on assessing applied knowledge. Scores on the measure range from 0 to 26, with higher scores indicating higher levels of competency for delivering HAP. There are three different equivalent versions of this 26-item measure, and each participant will be assessed randomly with one of these at each of the two time points, ensuring that the same test is not used twice.To assess change in competency between two time points, this measure will be collected at baseline and at up to 8 weeks. | Change from Baseline to up to 8 weeks. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Mental Health Knowledge, Attitude, and Behavior | 13-item self-report questionnaire uses a 5-point Likert scale to ascertain non-specialist health workers' knowledge, attitudes, and behavior about different aspects of mental health. Scores range from 13 to 65, with higher scores indicating greater knowledge and better attitudes and behaviors towards persons living with a mental illness. Lower scores on this measure suggest lower levels of knowledge and greater stigma towards mental illness. This is important to measure because completion of the training program may contribute to improvements in knowledge, attitudes and behaviors about mental health. To assess change in mental health knowledge, attitudes, and behavior between two time points, this measure will be collected at baseline and at up to 8 weeks. | Change from Baseline to up to 8 weeks. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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health worker training, non-specialist health worker, community health worker, task sharing, common mental disorders, low-resource setting, primary care, global mental health, digital technology, mobile health