Abstract
Background:
Depression poses a major public health burden and has a large treatment gap in India. The study attempts to address this treatment gap by developing a training video for Accredited Social Health Activists (ASHAs), who are community health workers, on brief psychological intervention for depression.
Methods:
The systematic steps utilized in the design and development of the training video on depression were: 1) Content development of the video script and training booklet for ASHAs based on the review of research literature and two Focus Group Discussions, 2) Mental Health Professionals’ evaluation of the video script and training booklet for ASHAs, 3) Translation from English to Kannada, 4) ASHAs’ evaluation of the video script and training booklet for ASHAs, 5) Conversion of the video script into a ‘shooting script’, 6) Video production, 7) Evaluation of the training video, 8) Post-production of the training video, and 9) Development of the training guide.
Results:
The training video titled “Light of Hope: A Training Video on Depression” was developed along with two training booklets, which are complementary resource materials, for ASHAs and the training Facilitators. The brief psychological intervention for depression elucidated in the training video incorporates the evidence-based strategies of Psychoeducation, Activity Scheduling, Problem-Solving Skills Training, and Diaphragmatic/Abdominal Breathing Skills Training.
Conclusion:
The study demonstrates the systematic approach that can be employed for the design and development of a mental health training video, which has evidence-based content, incorporates stakeholders’ evaluative perspectives, and is culturally contextualized.
Keywords: Accredited social health activist, brief psychological intervention for depression, community health workers, depression, task sharing, training video
Introduction
Depression is a common mental disorder that poses a major public health burden in India, with one in 20 persons suffering from this disorder, as reported by the National Mental Health Survey of India 2015--16.[1] The WHO has ranked depression as being globally “the single largest contributor to non-fatal health loss, accounting for 7.5% of all Years Lived with Disability (YLDs)” (p. 13).[2]
Common mental disorders have not been targeted earlier in the planning and delivery of healthcare programmes in India.[1] The treatment gap for common mental disorders in general and major depressive disorders specifically is 85% and 85.2% respectively.[3] Some of the key barriers to help-seeking for mental health problems are stigma, and certain factors related to mental health services viz. availability, cost, and distance.[3] Specialist mental health human resources in India are limited even in urban areas, thus posing a hurdle to essential mental health care for all.[1]
Task sharing between mental health specialists and non-specialist health workers has been recommended as a means to improve mental health care delivery and reduce the treatment gap in rural communities.[4,5] Research has indicated that psychological intervention by trained lay health workers can contribute to the amelioration of symptoms of depression and anxiety disorders.[6,7,8,9]
Accredited Social Health Activists (ASHAs) are female community health workers, who are usually the first point of contact for health services in rural communities of India.[10] The ‘ASHA ViDe Study’ sought to address the mental health treatment gap with respect to depression by training them through the medium of a training video in providing brief psychological intervention for depression. This article is a part of a series of articles related to the ‘ASHA ViDe Study’ on the development and evaluation of that training video. While the first article[11] deals with the perceptions of ASHAs on depression, the present article focuses on the systematic approach employed for the design and development of the training video.
Methods
The training video was developed as part of the ‘ASHA ViDe Study’ on the development and evaluation of a training video for ASHAs on brief psychological intervention for depression. The study was approved by the Institute Ethics Committee (No. NIMHANS/DO/99th IEC/2015; Date 23/09/2015). Figure 1 illustrates the systematic approach that was utilized in the design and development of the training video and the two training booklets, which are complementary resource materials with the training video, for ASHAs and the training Facilitators. This step-wise process of design and development was conducted from October 2015 to August 2017.
Figure 1.
Systematic Steps for the design and development of the training video on depression and the two training booklets
Content development of the video script and training booklet for ASHA
The first author reviewed the research literature to examine what basic psychological techniques could be effectively utilized by ASHAs to provide brief psychological intervention for depression. Two Focus Group Discussions (FGD) were held with ASHAs to examine their knowledge of depression, mental healthcare practices, and capacity-building needs related to depression.[11] Based on the review of literature and findings from the two FGDs, the interventional content was developed in English by the first author into a video script and a training booklet for ASHA.
Mental Health Professionals’ evaluation of the video script and training booklet for ASHA
The content evaluation of the video script and training booklet were done in three stages by key stakeholders. In each stage, feedback was obtained. The script and the booklet were then edited by the first author based on the comments of the Content Evaluators. The Content Evaluators in the first and second stages were Mental Health Professionals from the major mental health disciplines of Psychiatry, Clinical Psychology, Psychiatric Social Work and Psychiatric Nursing, while in the third stage they were ASHAs---the target group of this training video. In the first stage, internal expert evaluation was done by the four co-authors of this paper. In the second stage, external expert evaluation was done by five Mental Health Professionals with each of them having more than 10 years’ experience. Written informed consent was obtained from the Content Evaluators of the second and third stage. The Content Evaluators were not provided any predetermined criteria on which to evaluate, with the assumption that it would give them the freedom to utilize their expertise and experience to provide holistic feedback.
Translation from English to Kannada
As the study sample was ASHAs from the Indian state of Karnataka, the language of the video and training booklet was in Kannada. Translation of the video script and training booklet into Kannada was done using the standard procedure for translation by a person proficient in both languages. They were then back translated into English by a person proficient in both languages. The equivalence of the two versions was then established by the authors.
ASHAs’ evaluation of the video script and training booklet for ASHAs
The Content Evaluators in the third stage were three ASHAs. Written informed consent was obtained from them. The Kannada translated version of the video script and training booklet was used to obtain their feedback. As with the Mental Health Professional Evaluators, the ASHAs were not provided any predetermined criteria on which to evaluate. Again, the video script and the training booklet were edited by the first author based on the feedback of the ASHAs.
Conversion of the video script into a ‘shooting script’
The video script was then transformed into a shooting script in collaboration with the Video Production team that comprised two Cinematographers. The shooting script included some aspects of filming such as camera angles and cut or fade instructions.
Video production
The actors for the video and the locations for the shoots were identified. Written informed consent was obtained from the actors for being a part of the video. Permission was obtained for shooting at various locations of the Institute. The first and second author directed the shooting of the video. The video was shot in the Kannada language.
Evaluation of the training video
As the video shooting was in progress, feedback was obtained from the Content Evaluators regarding the video to enable relevant suggestions to be incorporated.
Post-production of the training video
This involved insertions of captions (text) in the video where required, additional sound recording, and audio and visual editing. A background instrumental music score was added to some segments of the video after obtaining permission from its Music Composer. A 2-minute trailer of the video was also developed with English subtitles to spread awareness about this training video through various platforms.
Development of the training guide
A training guide was developed for use by the Mental Health Professionals who would facilitate the group training of ASHAs utilizing this video.
Results
On the basis of the review of research literature and the results from the two FGDs, it was found that the basic psychological intervention strategies of Psychoeducation, Activity Scheduling, Problem-Solving Skills Training, and Diaphragmatic/Abdominal Breathing Skills Training could be utilized effectively by lay health workers such as ASHAs to provide brief psychological intervention for persons with depression.[7,8,9,11,12,13] Cultural considerations were incorporated into the training video and training booklet in terms of the signs and symptoms, explanatory models of depression, and the cultural adaptation of the psychological intervention.[13,14,15] The content thus developed for the training video and training booklet for ASHA has been summarized in Table 1.
Table 1.
Content Summary of training video and training booklet for ASHA
| Content Summary |
|---|
| Signs and symptoms to identify a person with depression. |
| Referral Letter format for referral of person with depression to a Mental Health Professional (if available) or Medical Officer, for further assessment, diagnosis, decision regarding the treatment plan, and treatment. |
| Need to initiate brief psychological intervention only after a referral by the Mental Health Professional/Medical Officer. |
| The basic counselling skills and the ethics to be followed while providing the brief psychological intervention. |
| Brief psychological intervention for depression with a flexible 4-session format that incorporates the strategies of Psychoeducation, Activity Scheduling and recording of mood, Problem-Solving Skills Training, Diaphragmatic/Abdominal Breathing Skills Training. Topics such as cultural considerations, goals of each session, assignment of ‘homework’ to practise the new skills, and termination of sessions are elaborated. |
| Activity Schedule chart with tips while preparing an Activity Schedule and strategies to ensure adherence. It has been indicated that if the person with depression cannot read/write, an attempt to use symbols for the activity could be made. |
| Need for ongoing supervision of brief psychological intervention sessions |
| Need to create awareness regarding depression in the community. |
On evaluation of the video script and the training booklet, the Content Evaluators---the Mental Health Professionals and ASHAs---provided feedback in the focus areas as given in Table 2.
Table 2.
Content Evaluators’ Feedback Focus Areas
| Feedback Focus Areas | Mental Health Professionals | ASHAs |
|---|---|---|
| Cultural Appropriateness and Acceptability: Setting, Costume, Characters, Language | ✓ | ✓ |
| Language Comprehensibility | ✓ | ✓ |
| Technical Content related to depression and brief psychological intervention for depression | ✓ | |
| Cultural Considerations related to depression and brief psychological intervention for depression | ✓ |
The suggestions obtained from the Content Evaluators were incorporated and as per the systematic steps outlined in Fig. 1, the ‘ASHA ViDe Training Program’ was designed and developed. This training program is centered on the utilization of the training video with the two booklets as complementary resource materials for ASHAs and training Facilitators. This training program involves training in groups with the group work of summarizing, reviewing, reflecting, and role-playing, being interposed inbetween the screenings of video segments.
“Light of hope: A training video on depression”
The training video titled “Light of Hope: A Training Video on Depression” is approximately 1 hour in duration and is divided into three segments (Part I, II, III).
The video has a story-like format and involves five characters---two ASHAs (‘Main’ character and an ‘Extra’ character), a Medical Officer, a woman having depression and her husband. The Part I of the video has the ‘Main’ character of the ASHAs visit the house of the woman with depression. As she is unable to understand the woman’s illness she discusses her symptoms and history with the Medical Officer at the Primary Health Centre. A discussion on depression then ensues, with the Medical Officer explaining to the ASHAs about the signs and symptoms of depression in children and adults, their causative factors, treatment options, impact of depression, and cultural considerations related to depression. In Part II of the video, the Medical Officer provides training to the ASHAs on brief psychological intervention for depression. The Medical Officer informs that he himself has been trained in the basic psychological management of depression, thereby enabling him to train the ASHAs. In Part III of the video, the ‘Main’ character of the ASHAs demonstrates the steps involved in the identification of signs and symptoms of depression and application of the strategies of brief psychological intervention through sessions with the woman having depression. The trailer of the training video can be accessed at: http://mentalhealtheducationnimhans.org/resource-hub/videos/light-of-hope-a-training-video-on-Depression
Training booklet for ASHAs[16]
This training booklet is a complementary resource material for the participants of the ‘ASHA ViDe Training Program’. Its contents are summarized in Table 1.
Training guide for facilitators[17]
This training guide of the ‘ASHA ViDe Training Program’ is for use by Mental Health Professionals who will be the ‘Facilitators’ of the training. The training guide contains a detailed information on the training procedure in terms of the materials required, Facilitators’ instructions, focus areas for group discussion, and case vignette with focus areas for the role-play of the psychological interventional skills that are detailed in the training video.
Discussion
The present study aimed at designing and developing a training video on brief psychological intervention for depression for ASHAs.
The study highlights the systematic approach [Figure 1] that can be employed for the design and development of a training video. The brief psychological intervention strategies utilized in the video are evidence-based, and cultural considerations have been incorporated [Figure 1 and Table 1]. The development of the training video and the training booklet was an iterative process with evaluation and feedback from the Content Evaluators being utilized [Figure 1 and Table 2]. The nuances of the psychological intervention strategies and the collaborative nature of the intervention process have been highlighted in this training video by the Cinematographers through the variegated-perceptive composition of camera shots, angles, and movements. Creative scene construction and framing by the Cinematographers has contributed to the aesthetic value of the video. Sound ambience authenticity has been lent to the training video through Sync Sound Recording, meaning sound recorded at the time of video shooting instead of being dubbed at post-production. Captions (text insertions) have been used in the training video to emphasize key points. A background instrumental music score was added in some segments of the video for content accentuation.
The video has been developed in line with the cultural context and the work profile of ASHAs, which is manifested by the setting, costumes of the characters, and dialogues. For example, the psychological intervention by the ASHAs is more likely to take place at the home of a person with depression instead of a hospital setting. Hence, for the scenes in which the ASHA is providing psychological intervention, the table--chair seating of a hospital-setting has been substituted with a wicker-floor-mat seating of a home-setting. Another example of cultural contextualization is the oblique utilization of ‘rangoli,’ the traditional Indian floor artwork, as a psychoeducative tool, to explain to the person with depression the link between somatic symptoms and psychological problems by drawing it on the floor of the home with a chalk instead of using the typical writing tools like paper--pencil, blackboard--chalk. The key features of the “Light of Hope: A Training Video on Depression” that make it an immersive learning experience are outlined in Table 3.
Table 3.
Key Features of the “Light of Hope: A Training Video on Depression”
| Script has a story-like format resembling actual (real life) interactions/situations |
| Content is evidence-based and evaluated by key stakeholders |
| Aesthetic scene construction and framing |
| Variegated-perceptive composition of camera shots, angles and movements |
| Sync sound recording |
| Usage of captions |
| Background instrumental music score |
| Cultural contextualization e.g., use of rangoli as a psychoeducative tool |
The advantage of training through a video method is that it aids learning as it provides an audio-visual demonstration of psychological intervention process and techniques, which the trainee can assimilate through observational learning. Research has indicated the effectiveness of video as a pedagogical tool for transfer of knowledge and skills.[18,19] Another advantage is that, given the multiplicity of languages/dialects in India, the video provides an opportunity to have consistency in training as it can retain a standard format with dubbing of the video into local languages as required. At present, the training video which is in Kannada has a dubbed English language version.
With the current impetus on training of community health workers through digital technology, and research indicating its acceptability and feasibility,[20,21] this training video could well be incorporated into digital training programs. In a low-resource setting such as India, the training video in the digital context has the benefits of being an easy-to-disseminate and an accessible (anytime anywhere) training tool, which provides each trainee an equal training experience.
The study has limitations in terms of not including a patient and a caregiver evaluative perspective to the development of the video. Furthermore, the video has been developed in line with the culture of the Indian state of Karnataka, and hence may not be culturally generalizable to all other states of the country. Future research needs to validate the systematic approach used for the design and development of the training video and identify further ways to improve the same. Additionally, the effectiveness of the training video needs to be evaluated.
Conclusion
The study demonstrates the systematic approach that can be employed for the design and development of a mental health training video, which has evidence-based content, incorporates stakeholders’ evaluative perspectives, and is culturally contextualized. This systematic approach to training video development essentially goes through from the content development of the video script based on review of research literature and FGDs, evaluation of the video script by key stakeholders, conversion of the video script into a ‘shooting script’, video production, evaluation of the training video, and post-production of the training video. Complementary resource material in the form of booklets for training participants and Facilitators is developed in conjunction with the video.
The huge mental health treatment gap in India makes it imperative that ‘task sharing’ can be employed and community health workers such as ASHAs can be trained in providing basic mental health services. In this context, the “Light of Hope: A Training Video on Depression” could be a useful tool to provide training to ASHAs on brief psychological intervention for depression. The training video could be a beneficial pedagogical tool as it provides an audio-visual demonstration of psychological intervention strategies that would aid the transfer of knowledge and skills to ASHAs. Furthermore, the training video can be easily disseminated, is accessible, and retains a standard format to provide an equal training experience to all.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
We acknowledge the support of the Taluk Health Officer and the PHC Medical Officer from the Bangalore Urban District for conducting this study. Our gratitude to all those involved in the development of the training video viz. the Content Evaluators, the Actors, the Cinematographers (Mr. Anand Sundaresha and Mr. Madhusudan S.), Mr. Deepak Ullal for background music score, Mr. Sunil Shashidhara, Mr. Rajeev V., Mr. Vasudeva Manja, Ms. Lakshmi Mohan, and others from the Dept. of Mental Health Education, NIMHANS. We are also grateful for the permission we obtained for video shooting at NIMHANS from the Medical Superintendent and the Head of the Centre for Addiction Medicine.
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