Technology Assisted Task-sharing to Bridge the Treatment Gap for Childhood Developmental Disorders in Rural Pakistan: an Implementation Science Case Study

Abstract Background: As in many low-income countries, the treatment gap for developmental disorders in Pakistan is near 100%. The World Health Organization (WHO) has developed the mental Health Gap Intervention guide (mhGAP-IG) to train non-specialists in the delivery of evidence-based mental health interventions in low resource settings. However, a key challenge to scale-up of non-specialist-delivered interventions is designing training programs that promote fidelity at-scale in low resource settings. In this case study, we report the experience of using a tablet device-based application to train non-specialist, family volunteers in leading a group parent skills training program, culturally adapted from the mhGAP-IG, with fidelity at-scale in rural community settings of Pakistan. Methods: The implementation evaluation was conducted as a part of the mhGAP-IG implementation in the pilot sub-district of Gujar Khan. Family volunteers used a technology-assisted approach to deliver the parent skills training in 15 rural Union Councils (UCs). We used the Proctor and RE-AIM frameworks in a mixed-methods design to evaluate the volunteers’ competency and fidelity to the intervention. Outcome was measured with the ENhancing Assessment of Common Therapeutic factors (ENACT), during training and program implementation. Data on other implementation outcomes including intervention dosage, acceptability, feasibility, appropriateness and reach was collected from program trainers, family volunteers and caregivers of children 6-months post-program implementation. Qualitative and quantitative data were analyzed using framework and descriptive analysis, respectively. Results: We trained 36 volunteers in delivering the program using technology. All volunteers were female with the mean age of 39 (±4.38) years. The volunteers delivered the program to 270 caregivers in group sessions with good fidelity (scored 2.5 out of 4 on each domain of the fidelity measure). More than 85% of the caregivers attended 6 or more of 9 sessions. Quantitative analysis showed high levels of acceptability, feasibility, appropriateness and reach of the program. Qualitative results indicated that the use of tablet device-based application, and the cultural appropriateness of the adapted intervention content, contributed to the successful implementation of the program. Conclusions: Technology can be used to train non-specialist family volunteers in delivering evidence-based intervention at-scale with fidelity in low resource settings of Pakistan.