Table 1.

Identifying barriers and facilitators of mental health services use based on Anderson’s Modified Behavioral Model of Health Services Use [20]

Key component from Andersen’s model	Scenario prior to the project	Intervention and processes implemented	Respondents perception about the intervention as mentioned in the process evaluation – positive (+)/ negative (−)
Environmental
Healthcare system	• PHCs were not providing any mental health care • ASHAs did not have any knowledge about CMDs • Primary care doctors lacked adequate knowledge and skills to identify and manage CMDs • Patients needed to travel to PHCs to get treated, leading to increased expenses and loss due to time spent in travel and waiting	• 21 ASHAs and 2 doctors were trained on using the mobile technology based applications • Training and supervision provided to both ASHAs and doctors to use the applications • An algorithm based EDSS implemented to facilitate screening by ASHAs • The mhGAP-IG based EDSS facilitated the doctors ability to manage CMDs • Health camps organized in villages to facilitate easier access to doctors • An algorithm based followup system developed for ASHAs to ensure treatment adherence	• Community members and village leaders felt that project was helpful (+) • Community members were able to share their mental health symptoms with ASHAs (+) • The ASHAs felt empowered by their enhanced skills acquired through training (+) • The doctors increased their knowledge and expertise to manage CMDs (+) • Additional booster training was suggested by ASHAs and doctors to supplement the current training and help them identify issues for improvement; current one time training was suggested as being g less than optimal (−) • Majority of participants appreciated the role of ASHAs and doctors (+) • The ASHAs repeatedly followed up with patients and enquired about their health which was appreciated by the community (+) • Health camps were appreciated as they reduced time and money spent in going to the PHCs (+)
Population characteristics
Predisposing characteristics	• Poor knowledge about CMD in the community • Most community members worked in the fields during the day which prevented data collection by field staff or screening by ASHAs or help seeking if needed	• A mental health awareness campaign organized using multimedia processes • Personalized and dramatized narratives of mental illness used along with traditional posters and brochures and video of a local film actor talk about the project • Both field staff and ASHAs often interviewed community members late in the evening after they returned from work • Community members had to migrate in search of jobs	• The community members mentioned that prior to the campaign they were neither aware of CMDs nor knew where to seek treatment (+) • Community members, community leaders, ASHAs, doctors and field staff confirmed that the mental health awareness program was useful (+) • However, some community people were not interested in revealing their health problems completely due to stigma (−) • Inspite of using evenings to contact community members who were in the field due to their work, at times others could not be contacted even after repeated attempts as they had migrated out of the villages (−) • A belief persisted amongst some community members that CMDs were a problem amongst lower socio-economic status (−) • Some community members had reservations about the doctors ability to provide adequate treatment (−)
Enabling resources	• No pre-existing mental health services in the village • Community were not oriented towards identifying CMDs • No treatment was sought from PHC for any psychological problems • Getting treated at PHCs was both time consuming and involved travel expenses	• Village leaders and local administration were kept informed about the project at each step • Local health staff – ASHAs and doctors used to provide care, and no additional resources were recruited for treatment purpose • Field staff trained using standard operational procedures and their activities monitored regularly • Field staff monitored ASHAs regularly and ensured the quality of data collected by them; supervisors followed up with doctors regularly to check for any problems that they might be facing with the application • Health camps in villages enabled patients with CMD to seek care from doctors closer to home • Supervisor coordinated with the doctor and ASHA about the health camps	• Village leaders appreciated the project (+) • Using ASHAs and doctors in primary care for providing the intervention were seen as a positive move by most community members including ASHAs and doctors (+) • ASHAs were found to be particularly useful because – they made repeated visits; used their knowledge about the community while explaining the case to the doctor; accompanied the patient to the doctor (+) • All respondents supported health camps (+) • Health camps were also seen as a place where patients discussed problems amongst themselves and sought peer-led advice on an informal basis (+) • The quality of training and its value for field staff, ASHAs and doctors were underlined by them (+) • Quantitative data showed that a large number of population were screened (>5000), there was significant increase in the proportion of screen positive individuals seeking treatment from doctors (+)
Need	• Perceived need to seek care for CMD was negligible as awareness about CMD was absent • Health workers including PHC doctors were not trained to identify or manage CMDs • No mechanism to increase the perceived need of those with CMD	• Mental health awareness activities and screening of the whole population by ASHAs led to increase in help seeking • The ability of primary health workers including doctors to identify and manage CMD was enhanced by using evidence-based algorithm driven EDSS • 1243 IVRS calls were attempted to remind screen positive individuals about treatment adherence and ASHAS and doctors about regular followups	• With increased perceived and evaluative need, identification of CMD and uptake of services was increased (+) • The treatment provided by doctors and provision of such through health camps also helped to increase ability of the community to seek care (+) • ASHAs provided brief suggestions to cope with stressful situations (+) • The EDSS was found to be acceptable and easy to use by ASHAs and doctors (+) • The mhGAP-IG based doctors app was found a bit time consuming by doctors at least initially (−) • IVRS was opined as a positive move to enhance care (+) • Only 65% of attempted IVRS calls were successful due to various reasons:  i. Some community members failed to receive calls as they were either apprehensive about the source of the call or assumed that it will cost them in form of loss of talk time (−)  ii. Mobile phones were at times not with the screen positive person as someone else had them, as only one phone was shared in the household (−)  iii. Network connectivity was patchy across the villages leading to call drop (−)
Health Behaviour
Personal health practises	• Stigma related to mental health and help seeking • Poor knowledge about CMDs amongst community members and health workers	• A campaign to increase mental health awareness and reduce stigma organized • Enquiring about suicide was a sensitive issue during the intervention	• Overall the campaign was beneficial (+) • Everyone opined that the project led to increased awareness about CMDs and the need to seek care, and led to more people visiting doctors (+) • Some community members did not seek treatment because they continued to be apprehensive about the kind of treatment they would receive (−), or stigma associated with help-seeking (−) • Many community members found the suicide question to be negative and did not like to respond (−)
Use of health services	• No treatment for CMDs in PHCs	• The intervention had a focus on increasing mental health services use for CMDs • Task shifting was used to enable mental health care for the rural population • Technology driven platforms were used to facilitate provision of mental health services • A system developed to ensure followup by ASHAs and doctors • Only 3 camps could be organized in the short time period	• Overall the interventions were thought to be useful by all (+) • Reluctance to seek care to avoid being marked as a family with mental disorders thus jeopardizing the ability to get their children married off (−) • ASHAs and doctors worked collaboratively to provide care (+) • ASHAs were deemed as instrumental to the intervention by everyone (+) • The EDSS and IVRS were seen as facilitating the intervention (+) • Medical camps facilitated increased service use (+)
Outcomes
Perceived health status	• Community members were unaware about CMDs	• A comprehensive mental health intervention implemented	• Most respondent felt that the intervention led to greater perception about CMDs in the community (+) • Some community members were not convinced about seeking care or being screened even after the mental health awareness campaign (−)
Evaluated health status	• No screening or treatment provided at primary care level for CMDs	• All components of the intervention had a primary care level focus	• Mental health services use was increased significantly; depression and anxiety scores reduced significantly (+)
Consumer satisfaction	• No measure of consumer satisfaction in the community	• A pre-post evaluation of the project provided objective assessment of the outcomes	• Most respondents felt that the intervention was beneficial in not only providing increased awareness about CMDs but also the need for seeking care (+) • Some community members highlighted that the project helped then to discuss and share their problems with others which in turn helped those individuals (+) • The role played by ASHAs and doctors were seen positively (+) • Repeated followup by ASHAs was appreciated by the community as a process that motivated the community to access care (+) • Organizing medical camps in villages was appreciated (+)