Box 1.

Principles guiding the Indigo-Local intervention

Service user involvement and incorporating social contact elements (e.g. sharing of ‘lived testimonies’), both within the training components and community engagement activities. Service user involvement is a key element of the Indigo-Local intervention. Service users are being trained together with community health workers (or similar cadres of workers) where possible. The intention is for direct social contact to be incorporated within all training elements.

Gaining buy-in from health system leaders and linking the awareness-raising to the existing services, for example by using existing personnel and mapping the training to specific health system infrastructures.

Involving front-line community-based health workers, such as community health workers or similar cadres of workers, who know their communities well, are trusted within the communities, and are familiar with community education and health mobilisation—in many low- and middle-income settings these will be volunteer workers, though not always. In addition to the principle that they should be well known by their communities, and are intimately familiar with community cultural perspectives, it is efficient to use existing cadres of personnel to implement health initiatives linked to novel services or scale-up efforts.

Developing key messages and materials with key community members who understand the local community beliefs and attitudes, as well as the local health service context. This is done by holding a stakeholder workshop with mental health experts, community health workers (or other delivery agents), community members and people with lived experience. The local underlying stereotypes and beliefs are documented, and counter-points to the misconceived or stigmatising ideas developed. They are then formulated in a way that will be understood by the local community.

Achieving scale-up through a stepped process of ‘Training of Trainers’, followed by training of community health workers (or similar cadres of workers). This also allows the building of relationships and key referral links for subsequent services (both through networking of participants and increasing awareness amongst participants of available resources). As an example, in the Amaudo study, the community psychiatric nurse carried out the training for the community health workers in their catchment area.

Linking the training in each site with activities mobilising key leaders and decision-makers in the community. In the Amaudo study, this was done through visits to community leaders ahead of the training to elicit their support for the project, and an opening ceremony on the first day of training.

Using media as a means of reinforcing the community engagement activities in each area. In the previous study, this comprised radio and TV reports, as well as ‘jingles’ on local radio informing communities of the existence of the clinics. These were timed to coincide with the community engagement. This was a means of rolling out the stigma reduction materials; it was not a mandated activity.

Implementing/establishing a continuous support process of providing ongoing basic supervision, continued linkage with trained community health workers and motivational strategies (e.g. biannual meetings, and awards for the most effective workers.)