Care at doorsteps for psychiatric disorders by the community volunteers (CAD-CV): Volunteers training and impact assessment

ABSTRACT

Background:

Mental illness is a leading cause of disability worldwide. As it is a chronic illness, proper follow-up and treatment is necessary to improve the quality of life of individuals. Lack of human resources in mental health services is the primary barrier to reach out to the needy. We tried to train volunteers in different fields to see the effectiveness in providing Care at Doorsteps for improving mental health.

Materials and Methods:

Volunteers were identified from various fields such as College students’ part of NSS and NCC, Student Nurses, Teachers, ASHA workers, Anganwadi workers, Rotarians and general public who were willing to attend a session regarding basic mental health and do home visits in community to screen and identify mental illness and to provide psycho education.

Results:

From April 2023 to June 2024, we trained 4755 volunteers in different streams and tried to implement CAD through them. Response rate from students was very minimal as many of them could not make any home visits. We have conducted sessions in 20 nursing colleges among which 7 colleges have reported back after continuous follow-up. 168 ASHA workers were trained and followed up in Doddabalapur, Tumkur and Chikkamagalur district. 400 Anganwadi workers from Kadur Taluk in Chikamagaluru were also trained and followed up.

Conclusion:

Care At Doorstep is a proven model for chronic psychiatric disorders involving volunteers in providing CAD in communities was a first-time attempt. Recruiting and proper follow-up for volunteers can help in reaching out to many unreached in the society.

Introduction

Mental health is a critical aspect of overall well-being, and mental illness is one of the leading causes of disability worldwide. According to the World Health Organization (WHO), in 2019, 1 in every 8 people, 970 million people around the world were living with a mental disorder.[1] In India, the overall current mental health morbidity is 10.6%, of which 10% prevalence is accounted for by Common Mental Disorders (CMDs) and substance abuse.[2] About 2.7% of the population is disabled due to mental illness.[2] National Mental Health Survey (NMHS) in 2016 reported a treatment gap of 84.5% for mental disorders in India. Despite the significant burden of psychiatric disorders, the treatment gap remains high; only two out of the ten affected with one or more mental morbidity reported receiving proper psychiatric care.[3]

There is an acute shortage of infrastructure and manpower in India, which is unable to meet the demands of an ever-growing population. One of the key reasons for the treatment gap is the shortage of mental health professionals, particularly in rural areas. As per NMHS 2016, there is about 77% of the deficit of psychiatrists in India. There are only 0.3 psychiatrists, 0.17 nurses, 0.05 psychologists, 0.03 social workers, and 2.3 beds per 1,00,000 people in India.[4]

As per the pilot study conducted by the District Mental Health Programme (DMHP) team in three different settings (Three districts–Bangalore urban, Bangalore BBMP and Ramanagaram) shows that delivering care at doorstep with the existing resources of DMHP is possible both in urban and rural setting and range of services such as administering depot injections to psychosocial interventions can be done with no compromise in quality of care. With adherence to treatment, improvement in symptoms and reduction in disability with decrease in caregiver burden is possible.[3]

Community-based interventions have been shown to be an effective way to address this issue by providing care and support to individuals with mental health issues in their own communities. The involvement of community volunteers can help to bridge the treatment gap and ensure that people with mental health issues receive appropriate care and support.

Care at doorstep (CAD) is a proven model of bringing the dropped-out client to the mainstream treatment. CAD is a cost-effective model compared to the other approaches and it requires volunteers and more trained manpower. In a study conducted to know the feasibility of CAD, challenges and needs of carers and health care workers, it was found that the major needs were awareness about illness, financial needs, social skills training, social support, reducing stigma, educating caregivers, early identification, ADL training and access to information. It also highlighted the challenges such as limited resources, attitudinal barriers of family and community and safety of the DMHP team members who conduct home visits, need for training health workers.[5]

CAD was used effectively in incorporating dropped out cases to mainstream of therapy as a pilot project. Home visits, assessments and medication administration were carried out as part of the program. It was regularly done in 2 months interval for 3 times. CAD was shown effective in bringing back patients to mainstay of treatment, thereby reducing the burden of disease on family members.[5]

The primary objective of this study was to evaluate the feasibility and effectiveness of a community-based intervention for the care of psychiatric disorders by community volunteers in rural areas of India. The intervention involved training community volunteers to provide basic mental health care and support to individuals with psychiatric disorders in their own communities. The training covered topics such as identifying symptoms of common psychiatric disorders, providing basic counselling and support, and referring individuals to higher-level care as needed. Volunteers were from different fields such as NCC/NSS volunteers, student nurses, teachers, ASHA workers and Anganwadi workers. The secondary objective was to do the follow-up of community activities done through the volunteers in terms of home visits, basic screening, psycho education, referral of identified new cases and dropped out cases.

Methodology

Study design

CAD is a proven model for chronic psychiatric illness. This was mainly implemented and studied through District Mental Health Programme (DMHP).[5] Our study is aimed at implementing CAD through community volunteers.

Settings and participants

Study participants were volunteers who were interested and willing to give consent to be part of the research. They were identified from different streams of life as well as from different parts of Karnataka. Streams were NCC/NSS Volunteers, Student Nurses, Teachers, Rotarians, ASHA and Anganwadi workers and general public. Places were Bangalore urban, Bangalore rural, Chikkamagaluru and Tumkuru. Schools and colleges were approached either through E-mail or through telephone. From Nursing Schools and colleges, we targeted students who will be going for community posting. From other colleges, NCC/NSS volunteers were approached through their authority.

Training session/Intervention

Volunteers were trained regarding basic mental health, causes, signs and symptoms, how to identify mental illness using screening tools, how to refer and follow up. Further, information on Tele MANAS (Tele Mental health Assistance and Networking Across States) services such as the toll-free number 14416, available help and how to use Tele MANAS by the volunteers and the Person with Mental Illness were shared. Each training sessions lasted for about 2 hours. Instructions were given to the volunteers to implement their learning in their community and the community they visit. The screening tool provided for the volunteers to use in community was Mental Health Screening and Counselling tool (MERIT), a validated tool prepared from NIMHANS for assisting RHOs and CHOs to screen individuals in community for mental health conditions. It has 11 simple questions which can help the CHOs to screen for common mental health disorders, severe mental health disorders and substance use disorders.[6]

Impact assessment/follow-up

From student nurses, one time follow-up was taken soon after their community postings (roughly after 6 weeks). ASHA and Anganwadi workers were followed up for 2 months to know the effectiveness of training. Telephonic/WhatsApp follow-up was done for ASHA and Anganwadi workers for 2 months continuously. Student nurses were provided with an excel sheet to enter the details of their community visit.

Results

Categories of volunteers are presented through the pie chart. Majority of volunteers were student nurses (55%) followed by other students (11%) [Figure 1].

Figure 1.

Category of volunteers

The follow-up data were obtained through telephonic conversation, WhatsApp communication and through excel forms. Response rate from ASHA workers was 83.92%, followed by student nurses 30.67%, and the Anganwadi workers response rate was 30.25% [Figure 2].

Figure 2.

Response rate of volunteers

The follow-up with student nurses, ASHA workers and Anganwadi workers to know the effectiveness of training and how they have implemented CAD is depicted in Table 1. The follow up questions are 1. Number of houses visited, 2. number of basic screening and psycho educations 4. Number of cases identified 4. Number of cases referred. ASHA workers had the highest number of home visits followed by Anganwadi workers. Basic screening and psycho education were provided by all categories of volunteers, the highest number being provided by ASHA workers. The highest number of cases identified and referred by the ASHA.

Table 1.

Implementation of CAD through volunteers/impact assessment of training

Category of volunteers	Home visits	Basic screening and psycho education	Number of cases identified and referred
ASHA workers	25,277	4,046	42
Student Nurses	2,608	523	5
Anganwadi workers	4002	2714	12
Total	31,887	7283	59

Discussion

The present study aimed at implementing CAD, a proven model for mental health issues in the community through community volunteers. The previous researches in this field have focused on implementing CAD through DMHP team.[3,5] This research is the first of its kind in the country. Implementation of CAD through DMHP team was very effective in terms of drop out cases which was conducted in three areas of Bangalore, two in urban and one in rural. Here, the drop out cases were identified and psychiatric social worker and psychiatric nurse as a team made three visits to assess the condition of the patient and to know the reasons for follow-up. Many patients who were irregular on follow-up were able to return to treatment with phone call.[5] In the present study, we did not target the drop out cases alone. Our aim was to offer help to the people in community struggling with any sort of mental health issues through trained volunteers. The help can be basic screening, psychoeducation regarding mental health concerns, whom to approach, when to approach, what to watch for in people struggling with mental health concerns and to reach out to National helpline 14416 in case of emergency and when unable to visit psychiatric treatment facility.

The previous researches done regarding CAD focused on the patients, but in the present study, the focus was more on sensitization and awareness to the volunteers and through them to provide care not only to the sick but also in the preventive aspects.

There are few studies done abroad using the volunteers in providing care for the mentally ill, and it was proven effective in case of adolescent with depressive symptoms to have better positivity and social connectedness. It is also a promising and cost-effective part of treatment.[6] A systematic review conducted regarding volunteering in the care of people with severe mental illness by Halett et al.[7] with 14 papers involving 540 volunteers from a heterogenous group concluded that the evidence base for volunteers in care of people with SMI is small and inconsistent, but there are potential implications for both current and future volunteering programmes from the data. As the data suggest that there is no ‘typical’ volunteer, volunteering programmes should recruit individuals from a variety of backgrounds. The act of volunteering can not only benefit people with SMI but also the volunteers. Further research may specify methods of recruiting, training, supervising and using volunteers to maximise the benefit for all involved. The present study can also act as a pioneer to form more structured volunteer training programs and using them in mental health awareness and basic screening as there is huge shortage of mental health professionals in India and we have increasing burden of mental health concerns.[4,8,9]

Conclusion

This research focused on how volunteers can be used to provide mental health services in the community. Structured recruitment and training of volunteers can help in providing basic screening, psychoeducation and identifying new cases, drop out cases, appropriate referrals and making follow-up in the community. Identifying and recruiting volunteers is crucial in this part of CAD for psychiatric disorders by community volunteers.

Future directions and recommendations

Identifying the volunteers from educational institutions and other areas can be done in a systematic way, and training can be conducted in designated centers. This can be considered as a subteam of DMHP, and planning and interventions can be more structured. Incorporating the volunteers training in policy making will have a great impact as we are lacking personnels to work in the field of mental health. Volunteers can be trained in basic mental health and screening tools for mental health issues, which they can use in the community.

Ethical approval

No. NIMHANS/EC (BEH.SC.DIV.) MEETNG/2024/Dated 23/03/2024.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Financial support for this project was from National Health Mission (NHM), Government of Karnataka.