A qualitative study assessing acceptability and appropriateness of a technology-assisted mental health intervention by community frontline workers: mPareshan implementation research in rural Pakistan

A qualitative study assessing acceptability and appropriateness of a technology-assisted mental health intervention by community frontline workers: mPareshan implementation research in rural Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A qualitative study assessing acceptability and appropriateness of a technology-assisted mental health intervention by community frontline workers: mPareshan implementation research in rural Pakistan Samina Akhtar, Fauziah Rabbani, Javeria Nafis, Amna Siddiqui, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4437031/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Jan, 2025 Read the published version in BMC Psychiatry → Version 1 posted 4 You are reading this latest preprint version Abstract Background With a shortage of mental health specialists and a significant rural population in Pakistan, leveraging community-based healthcare workers becomes crucial to address mental health needs. Equipping the healthcare workers with digital tools such as mobile applications have the potential to increase access to mental health support in low-resource areas. This study examines the acceptability, appropriateness, barriers, and facilitators to implementing a technology-assisted mental health intervention ( mPareshan ) delivered by Lady Health Workers (LHWs) in rural Pakistan. Methods This is a qualitative study embedded within a larger implementation research trial assessing the feasibility of an mHealth intervention aimed at improving anxiety and depression. 8 focus group discussions and 18 in-depth interviews were conducted. Perceptions were sought before and after intervention from stakeholders comprising of policymakers, LHWs, Lady Health Supervisors (LHSs), and community participants. Data underwent thematic analysis using the RE-AIM framework. Results Six main themes emerged from the data. All participants had realization of rising burden of mental illnesses and identified key determinants for mental ill-health. Delivery of mental health counselling by LHWs through a technology-assisted intervention was deemed acceptable and appropriate. LHWs were considered capable and trustworthy by the community to deliver a home-based mHealth intervention, given their easy accessibility as residents of the same community. The technology demonstrated potential for easy adoption as these frontline health workers were already familiar with smartphone technology. Some barriers identified during implementation roll-out included heavy workload of LHWs and difficulty in internet connectivity. Use of videos for counselling, and supportive supervision by LHSs emerged as key facilitators for implementation. Conclusion This study highlights that a technology-focused mental health intervention is feasible, acceptable, and appropriate to be implemented by community frontline workers in resource-constrained rural Pakistani settings. The mPareshan intervention can be easily adopted within the LHW-P. Further research should investigate how implementation barriers can be addressed for successful delivery. acceptability appropriateness adoption mHealth mental health Lady Health Workers Figures Figure 1 Figure 2 Background Mental disorders contribute to 14% of the global burden of disease [ 1 ]. In 2019, mental disorders ranked as the second leading cause of Years Lived with Disability, posing significant challenges to health systems, particularly in low and middle-income countries (LMICs) [ 2 – 4 ]. LMICs have a 10–14% prevalence of depressive disorders [ 5 ]. 76–85% of the people who have had any mental illness have unmet need for treatment in LMICs [ 6 ]. Barriers to accessing mental-healthcare facilities in LMICs are poor resource distribution, cost, and geographical distance to community-based facilities [ 7 , 8 ]. The social burden of mental disorders is exacerbated by ignorance, misdiagnosis, and inappropriate treatment [ 8 ]. Pakistan is an LMIC of 220 million with 38% of the population living below the poverty line [ 9 , 10 ]. Studies conducted over the last decade estimate the burden of depression and anxiety between 22–60% [ 11 ]. Poverty, political turmoil, insecurity, natural disasters, socio-economic challenges, and gender inequality are essential contributors [ 1 ]. Recently, COVID-19 has worsened the situation [ 12 ]. There are only 520 practicing psychiatrists in Pakistan, resulting in a ratio of 2 psychiatrist per 1 million people [ 13 , 14 ]. Unfortunately, available mental health services are either privately-run clinics or psychiatry units in tertiary care hospitals [ 15 ]. Compounding the issue, around 60% of the population resides in rural and peri-urban areas, while most psychiatrists practice in urban regions [ 16 , 17 ]. This uneven distribution further exacerbates the limited access to mental health services across the country. Recently, digital/mobile health (mHealth) innovations such as web-based and mobile phone programmes have repeatedly been seen as a promising means of enhancing evidence-based treatments [ 18 ]. The latest Lancet Commission on Global Mental Health has emphasized the importance of exploring digital tools for enhancing mental health research [ 19 ]. Meta-analyses report that mobile app-delivered interventions can be effective in decreasing anxiety and depression symptoms [ 20 – 22 ]. To improve the delivery of mental healthcare in limited resource areas, incorporating mental health programmes into regular primary health facilities has been recommended [ 1 , 23 ]. A Peruvian study incorporated a technology-based mental health assessment programme into standard primary healthcare practice and reported that using a screening app, accompanied by basic preparation, and monitoring by non-specialized Primary Health Care professionals, is a viable technique [ 24 ]. The first contact for individuals seeking healthcare in the developing world are the Frontline Health Workers (FHWs) [ 25 ]. A systematic review on the feasibility of using mHealth strategies by FHWs in developing countries indicated that irrespective of prior training or education, FHWs can effectively utilize mobile phones for the collection of data and surveillance in healthcare delivery [ 26 ]. In Pakistan, a well-structured Community Health Worker (CHW) programme already exists since 1994, called the Lady Health Worker Programme (LHW-P) [ 27 ]. It offers preventive and promotive Maternal and Child Health services at the primary care level [ 28 ]. The LHW-P covers 85% of the rural population in Pakistan through 115,000 LHWs [ 29 ]. Each LHW is supervised by a Lady Health Supervisor (LHS). LHSs are responsible to offer supportive supervision to 20–25 LHWs. LHWs have at least 8 years of education, prior work experience and live within the locality [ 30 ]. Mental health however is not a part of their service mandate currently [ 30 ]. Nevertheless, a study in Pakistan has explored the use of technology to scale-up monitoring and training of CHWs in psychosocial treatment of perinatal depression [ 31 ]. Despite its potential, the evidence supporting the feasibility of mHealth interventions is limited [ 32 ]. Few studies have documented end-user experiences, operability, usability, and interactions with mobile applications [ 33 , 34 ]. A study attributed technology failure to a disregard for user requirements and experience [ 35 ]. To bridge this gap in provision of mental health services, a customized app was developed in a feasibility trial ( mPareshan ). The app delivered psychosocial counselling through LHWs in rural Sindh [ 36 ]. This study specifically reports on the qualitative assessments conducted before and after intervention during this trial to gauge the acceptability, appropriateness, and potential of technology adoption by relevant stakeholders and additionally understand the barriers and facilitators to implementation roll-out. Methods Study Setting This qualitative study was nested within the mPareshan project, a feasibility trial to assess the effectiveness, acceptability, and development of an mHealth intervention to reduce anxiety and depression in a rural Pakistan. The mPareshan trial was conducted in District Badin, located in the southern part of Sindh, Pakistan. Badin’s total population is 1.8 million and the literacy rate is 33.7% [37]. The district’s 1100 LHWs are working under the supervision of 36 LHSs [30, 38]. After a baseline survey using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), which are two standard psychometric instruments, 98 participants having mild and moderate anxiety and/or depression symptoms (screen positive, SPs) were eligible for the app-based mPareshan intervention delivered by LHWs during their routine household visits in their assigned catchment areas. The aim of the nested qualitative study was to understand the acceptability and appropriateness of delivering the mPareshan intervention from both the end-user and delivery perspective, as well as assessing barriers and facilitators to implementation. Participants Study participants for qualitative assessment included provincial policy makers, district health managers of the LHW-P, LHSs, LHWs from the delivery perspective and community participants (CPs) from the end-user perspective. Permanently employed LHWs and LHSs who regularly performed household visits and reported to their programme supervisors were randomly selected for the interviews. CPs were influential people of the community (religious scholars and teachers) capable of providing their viewpoint. Policy makers included key decision-makers at the Provincial Department of Health and the Provincial Program Implementation Unit of LHW-P, Badin. Their views helped to co-design the app-based intervention and assess acceptability, appropriateness, and potential of technology adoption. After intervention, qualitative assessments were repeated to ascertain the feasibility of intervention uptake and understand facilitators and barriers in implementation roll out. Key stakeholders included those randomly selected LHSs and LHWs who took part in the delivery of the intervention. Moreover, community participants in the post-intervention qualitative phase also included those individuals who received the digital counselling intervention (the SPs). The mPareshan App-based Intervention The intervention was delivered over the course of 6 months with SPs receiving one home-based counselling session per month by the LHWs. The mPareshan app was designed based on feedback received from stakeholders in the formative qualitative phase. It consisted of 3 segments: tracking, counselling, and referral. The tracking segment recorded information on participant recruitment, retention, and consent. The referral segment identified danger signs related to suicidal ideation, self-harm and harm to others and then guided appropriate referrals to the nearest mental health facility. In the absence of danger signs, the LHW facilitated psychoeducation for SPs through audio and video features using the counselling segment. Each session lasted 20-25 minutes. The SPs were involved in breathing exercises and pleasant activities to help them cope with anxiety and depression symptoms. The app could be downloaded on an android tablet and accessed without internet (Figure 1). The detailed protocol of the mPareshan intervention trial is available elsewhere [36]. Figure 1 : mPareshan intervention workflow Data Collection A semi-structured guide was developed by the study team for this nested qualitative study that helped to carry out the Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs) with relevant stakeholders. The guide had a pre-set list of open-ended questions, organized in a logical pattern with relevant probes (Table 1). The questions were designed to assess acceptability and appropriateness, and potential of technology adoption before intervention and barriers and facilitators to implementation roll out after intervention. This ensured that key topics were considered but that new themes of concern to participants could also emerge. The main themes in the guide covered: Burden and determinants of mental health Acceptability and appropriateness of delivering a mental health intervention Adoption and task-technology shift of mHealth intervention delivered by LHWs Uptake of intervention Barriers and facilitators to implementation roll-out and sustainability Table 1: Probes in Focus Group Discussions and In-depth Interview guides Sections Themes Main probes 1 Burden and determinants of mental health Perceptions of participants about mental health burden and its determinants. Availability of mental health services in the community. 2 Acceptability and appropriateness of delivering a mental health intervention Rapport of LHWs as front-line health care providers in rural areas LHW-P capacity to address mental health. Capacity of LHWs to deliver mental health intervention Acceptability of intervention among policy makers, LHWs and community 3 Adoption and task-technology shift of mHealth intervention delivered by LHWs LHSs awareness regarding android phone technology for provision of mHealth services. Willingness of LHWs to provide mental health services utilizing technology-assisted app. 4 Uptake of intervention Experience of LHWs, LHSs and community participants Views regarding app features, usage, and content Views on the benefits of intervention. 5 Barriers to implementation roll-out and sustainability Barriers experienced by stakeholders during intervention roll out. Suggestions for improvement and sustainability. 6 Facilitators in implementation roll-out Factors that facilitated implementation roll-out Importance of LHSs as supervisors of LHWs Following ethical clearance, 8 FGDs and 18 IDIs were conducted before and after intervention. Details on the modes of inquiry are presented in Figure 2. Qualitative interviews lasted about 30-45 minutes, or until the point of saturation. All participants provided written consent before starting the interview. The interviews were conducted by core research team members (SA and JN), experienced in conducting qualitative research. A relationship of trust was established with participants prior to the commencement of qualitative inquiry through community liaising, informal talks, and by introducing the study objective. Pre-intervention qualitative assessments took place from January to February 2022 and the post-intervention assessments were conducted from October to December 2022. FGDs with health workers and IDIs with SPs were held at the District LHW-P office in Badin. Policy makers were interviewed in their working spaces. Some of the post-intervention assessments were also conducted online due to COVID restrictions. All FGDs and IDIs were audio recorded, transcribed verbatim, and translated into English. Field notes were also made during the interviews. Identifiable information was removed from the interview transcripts to maintain anonymity. Figure 2 : Summary of data collection phases and methods Data Analysis An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” and works through the lens of RE-AIM framework [39, 40] to report on acceptability, adoption, and appropriateness of the proposed intervention prior to implementation [41]. Additionally, it also reports on the challenges and facilitating factors for successful implementation roll-out. After transcription, the data were analysed by using manual thematic analysis and QSR NVivo version 10 for thematic content analysis. All transcripts were first read by SA and JN for data familiarization and then independently coded. The research team met regularly during the analysis stage to compare codes and establish consensus. Data relevant to each code was organized into potential themes that reflected the RE-AIM framework outcomes. The analysis was reviewed and revised for the final write-up by FR and AS. FR had extensive knowledge about the intervention and was involved in the implementation roll out, while having prior expertise in using LHW-P platform for similar digital interventions. Other authors were involved in the manuscript write-up and took part in the initial conceptualization of the study. Results All participants who took part in the qualitative assessment before (N=44) and after (N=30) intervention consented for the interviews. Demographic data regarding stakeholders is displayed in Table 2. Table 2: Sociodemographic characteristics of participants* Pre-Intervention Post-Intervention FGDs (n=4) IDIs (n=12) FGDs (n=4) IDIs (n=6) LHWs N (%) LHSs N (%) PM N (%) CP N (%) LHWs N (%) LHSs N (%) CP N (%) Gender Female Male 16 (100) 0 16 (100) 0 0 4 (100) 3 (37.5) 5 (62.5) 12 (100) 0 12 (100) 0 2 (33.3) 4 (66.7) Age, years – Median Range (Min-Max) 33 22-55 37 29-45 30-50 35-45 33 22-55 37 29-45 35-45 Highest level of education† Matric Matric/ Intermediate Post-graduate training Matric/ University degree Matric Matric/ Intermediate No formal qualification Occupation Health workers Health workers Govt. of Sindh, Dept. of Health officials: Directorate General of Health Services, Deputy, Assistant & Additional Directors (Reproductive, Maternal, Newborn, & Child Health/LHW-P) Teachers, social activists, politically active individuals Health workers Health workers Farmers/ agricultural workers, daily wage labourers Experience in current role (median years) 12 5-15 (min, max) Experience with using digital apps before Yes Yes Yes No *Data was not always collected individually. Values presented where available. †Matric is GCSE equivalent, Intermediate is A levels equivalent. The thematic analysis resulted in six main themes; 1) The burden of mental health and its determinants , 2) Acceptability and appropriateness of delivering and receiving a mental health intervention , 3) Adoption and task-technology shift of an mHealth mental health intervention , 4) Experiences regarding uptake of intervention , 5) Barriers to implementation roll out and sustainability and 6) Factors facilitating implementation roll out , which are presented below. The burden of mental health & its determinants As an initial step, stakeholder perceptions about mental health were explored. “About 70-80% of the people are mentally ill in Badin. We don't even have a government hospital at the district. Private doctors visit on Sundays, but their fees are unaffordable.” (Community Participant, IDI, Pre-intervention) An LHW commented on the impact of mental illnesses on her community. “In some cases, people reach a point of extreme desperation, and this may result in suicidal actions. I believe that depression can lead to changes in behaviour towards family and friends.” (LHW, FGD, Pre-intervention) Participants highlighted some of the possible stressors that contribute to mental ill-health and reasons for not accessing mental health services. “If the person supporting the family is struggling with money and there are kids to take care of, it can make the whole family feel uneasy.” (LHW, FGD, Pre-intervention) "Due to poverty and large families with 10-12 members, individuals suffer from mental illness.” (Community Participant, IDI, Pre-intervention) Fear of being stigmatized also prevented people from accessing mental health services. “People with mental illnesses tend to suppress their feelings and fear being labelled as 'dewana/pagal' (mad/insane)” (LHS, FGD, Pre-intervention) Acceptability and appropriateness of delivering and receiving a mental health intervention For assessing the acceptability and appropriateness of LHWs as providers of mental health services, it was important to first judge the rapport of LHWs as frontline CHWs. Community participants commented. “We are absolutely satisfied with the LHWs. They visit every household in our village, and it feels like they are a part of our family.” (Community Participant, IDI, Pre-intervention) “LHSs and LHWs are highly regarded in the community, considered almost like doctors.” (Community Participant, IDI, Pre-intervention) Policy makers also displayed strong confidence in LHWs’ capabilities and role in social mobilization. “Our LHWs are akin to our army; they work tirelessly and consistently.” (Policy maker, IDI, Pre-intervention) “LHWs can make a big difference by mobilizing the community and creating awareness. They act as a bridge between us and the community.” (Policy maker, IDI, Pre-intervention) Health workers also expressed their ease and satisfaction with their work. “(Families) listen and understand what we suggest. If our way of counselling is effective, the people will surely stand by us.” (LHWs, FGD, Pre-intervention) Researchers further probed about the appropriateness of LHWs delivering a mental health intervention. “If (LHWs) are assigned to care for a mentally ill person, they would excel at it because they are already familiar with our community.” (Community Participant, IDI, Pre-intervention) Policy makers acknowledged LHWs as a valuable resource for addressing mental health concerns. “LHWs are an essential resource. They can go door-to-door to identify cases and educate people about mental health." (Policy maker, IDI, Pre-intervention) Stakeholders also highlighted some areas of concern. “I doubt that LHWs cover 100% of the area. Coastal regions are quite distant from the city.” (LHW, FGD, Pre-intervention) “The primary concern here is that LHWs have a heavy workload. They are engaged in tasks related to polio, family planning, measles, and now COVID. However, if we want to involve them in mental health service provision, we need to find a feasible strategy (easy to understand and user-friendly)”. (Policy Maker, FGD, Pre-intervention) Adoption and task-technology shift of an mHealth mental health intervention Health workers’ views regarding the task-technology shift of adopting the mHealth intervention were explored. “If LHWs use mobile devices, it should work smoothly. We've already established WhatsApp groups, and since they (LHWs) are using touchscreen phones, they can easily perform tasks. They also use their phones to share videos.” (LHS, FGD, Pre-intervention) "We will visit them repeatedly and show content in app, so why wouldn't this have a positive impact? It's quite likely to be beneficial, without doubt." (LHWs, FGD, Pre-intervention) “We can understand English and operate mobiles since its the era of mobile technology. Main video content should be in Sindhi (local language) for the sake of clarity.” (LHWs, FGD, Pre-intervention) “Our role involves presenting the counselling video and explaining its contents. If they (SP) make an effort, they will experience improvement.” (LHWs, FGD, Pre-intervention) Some emphasis on proper training was noted to execute the intervention successfully. “No task is ever easy, especially before proper training.” (LHW, FGD, Pre-intervention) Experiences regarding uptake of intervention Stakeholders were inquired regarding their experiences during the intervention roll-out. “We are completely satisfied with the app. It has effectively addressed our mental health concerns.” (LHWs, FGD, Post-intervention) “Previously, she (SP) used to spend her time alone and displayed no interest in anything. However, after receiving intervention, she took up sewing and embroidery.” (LHWs, FGD, Post-intervention) “As I gradually committed myself, I realized its inherent benefits. The initial difficulties faded as I recognized the value it brought to me." (SP, IDI, Post-intervention) Some LHWs noted a gender disparity in the uptake of intervention. “Feedback from women was notably more positive than that from men. Some men expressed concerns about time constraints.” (LHWs, FGD, Post-intervention) Barriers in implementation roll-out and sustainability Health workers underlined some technological barriers during the implementation roll-out. “In the first session, submitting feedback (through the designated app portal) was a bit challenging.” (LHW, FGD, Post-intervention) “Prolonged power outages render our mobiles powerless and disrupt internet connectivity.” (LHW, FGD, Post-intervention) Existing workloads and lack of dedicated time to conduct counselling sessions emerged as constraints in successful intervention delivery. “Having a 20-minute session was suitable for SPs, but for us, it wasn't just 20 minutes. Our journey took time. After reaching, we had to wait for ½ hour if the SP was occupied. Some time went into building trust and allaying any concerns” (LHS, FGD, Post-intervention) “She (the LHW) is extremely occupied. She's been engaged non-stop since the start of the pandemic.” (LHS, FGD, Post-intervention) Health workers shared their opinion on the intervention’s prospects for sustainability in the future. “Young generation faces considerable anxiety. If a portion of college/high school teachers could be trained (in mPareshan app), it might be beneficial in the future.” (LHS, FGD, Post-intervention) “Breathing exercises were explained through audios. Incorporating more videos/visual aids would have enhanced clarity, especially for less literate (SPs).” (LHW, FGD, Post-intervention) Factors facilitating implementation roll-out Supportive supervision by LHSs during implementation was considered positively. “Working as a team with our LHSs was more effective than us going alone. Presence of LHSs helped in answering participant queries and motivating (SPs) to take part in intervention.” (LHW, FGD, Post-intervention) “When Baji (LHS) is with us, our responsibilities diminish. Baji takes care of the technical aspects, and we know we can rely on her for guidance.” (LHW, FGD, Post-intervention) “Due to our presence, LHWs did well and got a positive response from SPs, reinforcing our role as supervisors.” (LHSs, FGD, Post-intervention) It was highlighted that LHWs felt supported in the presence of LHSs, especially when counselling male SPs. “Since my LHW deals with all male SPs, having a supervisor (like me) present during her sessions provides her courage and a sense of ease.” (LHS, IDI, Post-intervention) One SP conveyed his perspective regarding the feasibility of the counselling session. “Duration of counselling is appropriate. It didn't interfere with our daily work; in fact, it was quite effective.” (SP, FGD, Post-intervention) Participants undergoing intervention showcased their optimistic response regarding the improvement of their mental well-being. “Video counselling was particularly helpful, guiding us to alleviate anxiety. We diligently followed the advice presented in the videos, which were further reinforced by visits from the LHS and LHW.” (SP, IDI, Post-intervention) Discussion This study is among the first of its kind to explore perceptions about acceptability and appropriateness of a digital mental health intervention prior to implementation and identify barriers and facilitating factors for smooth implementation roll-out. All stakeholders displayed a comprehensive understanding of mental health, emphasizing its importance. They agreed that it significantly contributes to the disease burden and expressed concerns that mental health issues are rising. Various determinants of mental illnesses were identified including poverty, stigmatization in seeking care and large family sizes etc. These findings align with literature from other LMICs like Indonesia, Iran, and Nepal where similar determinants have been noted [ 42 – 45 ]. In the current study, both policy makers and community participants considered LHWs as a trusted human resource to deliver mental health services. A previous study in India and Pakistan showed that community participants favoured frontline workers who were residents of the same area [ 46 ]. In the absence of specialized workers, similar findings reported in Pakistan and Africa show that these frontline workers are trusted as peers and empower their communities [ 47 , 48 ]. LHWs demonstrated a willingness to deliver the services while the community indicated their acceptability to receive it. The intervention was timely and appropriate given the rural context where mental health services are neither available nor easily accessible. Evidence from the Eastern Mediterranean Region shows that rural areas remain limited in terms of mental healthcare access [ 49 ]. A previous narrative review from LMICs has supported the role of frontline non-specialist workers to bridge this mental health treatment gap by delivering low-intensity psychosocial interventions [ 50 ]. The task-technology shift of delivering digital mental health services through LHWs was found to be relatively feasible. The technology was easy to adopt since LHWs are already using smartphones for maternal and child healthcare and are familiar with digital data entry systems [ 51 ]. Earlier studies in rural Sindh have demonstrated successful implementation of mHealth applications by LHWs for home-based pregnancy care and tackling childhood diarrhoea [ 52 , 53 ]. Similarly, a pilot study in rural Tanzania showed that health workers effectively used a tablet-based platform for preventing mother-to-child transmission of HIV services [ 54 ]. However, these results should be interpreted with caution. Concerns about the heavy workloads of LHWs were voiced by the stakeholders. There were also some issues with sub-optimal coverage and accessibility of health workers in remote areas. Similar challenges have been highlighted before in studies in Pakistan and Myanmar, where conflicting pressures often lead them to become agents of the state, burdened with directives and programmes without adequate training and equipment [ 55 , 56 ]. Another study in Niger also showed the geographical coverage of CHWs being less than optimal despite efforts to upscale [ 57 ]. To counter these challenges, deployment strategies need to be revisited by the government to streamline the integration of additional responsibilities with LHW’s routine work. Some issues with internet connectivity were noted which were resolved with prior downloading of content and uploading of data when connectivity resumed. Previous studies from Pakistan and Africa have highlighted similar concerns [ 52 , 58 ]. Following insights from stakeholders prior to intervention, the app content was designed in Sindhi language. Hence, language did not appear as a barrier during intervention roll-out. However, it was suggested that for future, the video content should replace some of the audio sessions. This is understandable given the greater penetration and impact of the latter, especially amongst low-literacy populations. Supportive supervision provided by the LHSs to LHWs was perceived as an important facilitating factor to implementation, particularly while dealing with male SPs. Such supportive supervision by LHSs has shown to work well previously in rural Pakistan [ 29 , 48 , 53 ]. One of the limitations of the study was the inability to conduct IDIs with policy makers post-intervention, due to their involvement in disaster management of floods in the district. The mPareshan trial used mixed methods of data collection. This paper only reports on the qualitative inquiry. Hence, the effectiveness of the intervention can only be judged once the complete study results are published, and findings are triangulated. Conclusion Using the RE-AIM implementation outcomes, the formative (pilot) assessment in the pre-intervention phase of this qualitative inquiry helped to co-design the mHealth intervention with input from relevant stakeholders. Meanwhile, the post-intervention assessments assisted in understanding the barriers and facilitators to implementation roll-out in the real-life setting. Given the lack of resources, we believe that the task-technology shift (as demonstrated by mPareshan project) of utilising LHWs in delivering mental health screening and counselling services at community doorsteps is quite feasible, acceptable, and appropriate. It can be easily adopted within the context of LHW-P. Implemented at scale, this intervention has the potential to improve mental health at the primary care level. Abbreviations CHWs: Community Health Workers; CPs: Community Participants; FGDs: Focus Group Discussions; FHWs: Frontline Health Workers; IDIs: In-Depth Interviews; LHSs: Lady Health Supervisors; LHW-P: Lady Health Worker Programme; LHWs: Lady Health Workers; LMICs: Lower middle-income countries; PMs: Policy Makers; RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance; SPs: Screen Positives. Declarations Ethics approval and consent to participate The study was approved by the Ethical Review Committee of Aga Khan University (ERC# 2021-6570-20015). All participants provided written informed consent before starting interviews. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests None declared. Funding This study was supported by a grant from the Brain & Mind Institute (BMI), Aga Khan University (Grant Brain & Mind-FR-11E-mPareshan App 83000). Author contributions All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas. Acknowledgements This qualitative inquiry is nested within the larger mPareshan trial. The authors would like to thank the overall members involved in the implementation of this trial. 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World Bank. Rural Population Pakistan (% of total population). World Development Indicators. 2023. Rural population (% of total population) - Pakistan | Data (worldbank.org). Accessed 1 Aug 2023. Rabbani F, Akhtar S, Nafis J, Khan S, Siddiqi S, Merali Z. Addition of mental health to the lady health worker curriculum in Pakistan: now or never. Hum Resour Health. 2023;21:29. World Health Organization. mHealth - New horizons for health through mobile technologies. 2011. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018;392:1553–98. Firth J, Torous J, Nicholas J, Carney R, Pratap A, Rosenbaum S et al. The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials. World Psychiatry. 2017;16. Firth J, Torous J, Nicholas J, Carney R, Rosenbaum S, Sarris J. Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials. J Affect Disord. 2017;218:15–22. Kim J, Aryee LMD, Bang H, Prajogo S, Choi YK, Hoch JS, et al. Effectiveness of Digital Mental Health Tools to Reduce Depressive and Anxiety Symptoms in Low- and Middle-Income Countries: Systematic Review and Meta-analysis. JMIR Ment Health. 2023;10:e43066. Irfan M. Integration of mental health in primary care in Pakistan. J Postgrad Med Inst. 2013;27. Diez-Canseco F, Toyama M, Ipince A, Perez-Leon S, Cavero V, Araya R et al. Integration of a technology-based mental health screening program into routine practices of primary health care services in Peru (The Allillanchu Project): Development and implementation. J Med Internet Res. 2018;20. Walker R. Walking beyond our borders with frontline health workers in guatemala. Nurs Womens Health. 2013;17. Agarwal S, Perry HB, Long LA, Labrique AB. 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Rahman A, Akhtar P, Hamdani SU, Atif N, Nazir H, Uddin I et al. Using technology to scale-up training and supervision of community health workers in the psychosocial management of perinatal depression: a non-inferiority, randomized controlled trial. Global Mental Health. 2019;6. Martínez-Pérez B, de la Torre-Díez I, López-Coronado M. Mobile Health Applications for the Most Prevalent Conditions by the World Health Organization: Review and Analysis. J Med Internet Res. 2013;15:e120. Braun R, Catalani C, Wimbush J, Israelski D. Community Health Workers and Mobile Technology: A Systematic Review of the Literature. PLoS ONE. 2013;8:e65772. Källander K, Tibenderana JK, Akpogheneta OJ, Strachan DL, Hill Z, ten Asbroek AHA, et al. Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low- and Middle-Income Countries: A Review. J Med Internet Res. 2013;15:e17. Schnall R, Rojas M, Bakken S, Brown W, Carballo-Dieguez A, Carry M, et al. A user-centered model for designing consumer mobile health (mHealth) applications (apps). J Biomed Inf. 2016;60:243–51. Rabbani F, Nafis J, Akhtar S, Khan MS, Sayani S, Siddiqui A, et al. Technology-assisted mental health intervention delivered by frontline workers at community doorsteps for reducing anxiety and depression in rural Pakistan: Protocol for mPareshan mixed methods implementation trial (Preprint). JMIR Res Protoc. 2024. https://doi.org/10.2196/54272 . Pakistan Bureau of Statistics. Census 2017 District Wise Sindh (Badin). 2017. Rabbani F, Perveen S, Aftab W, Zahidie A, Sangrasi K, Qazi SA. Health workers’ perspectives, knowledge and skills regarding community case management of childhood diarrhoea and pneumonia: a qualitative inquiry for an implementation research project Nigraan in District Badin, Sindh, Pakistan. BMC Health Serv Res. 2016;16:462. Holtrop JS, Estabrooks PA, Gaglio B, Harden SM, Kessler RS, King DK, et al. Understanding and applying the RE-AIM framework: Clarifications and resources. J Clin Transl Sci. 2021;5:e126. Harden SM, Smith ML, Ory MG, Smith-Ray RL, Estabrooks PA, Glasgow RE. RE-AIM in Clinical, Community, and Corporate Settings: Perspectives, Strategies, and Recommendations to Enhance Public Health Impact. Front Public Health. 2018;6. Proctor EK, Bunger AC, Lengnick-Hall R, Gerke DR, Martin JK, Phillips RJ, et al. Ten years of implementation outcomes research: a scoping review. Implement Sci. 2023;18:31. Alegría M, NeMoyer A, Falgàs Bagué I, Wang Y, Alvarez K. Social determinants of mental health: where we are and where we need to go. Curr Psychiatry Rep. 2018;20:1–13. Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med. 2010;71:517–28. Lund C. Poverty and mental health: Towards a research agenda for low and middle-income countries. Commentary Tampubolon Hanandita (2014) Soc Sci Med. 2014;111:134–6. Siddiqui F. Barriers and challenges to mental health care in Pakistan. Pakistan J Neurol Sci (PJNS). 2021;16:1–2. Singla D, Lazarus A, Atif N, Sikander S, Bhatia U, Ahmad I, et al. Someone like us: Delivering maternal mental health through peers in two South Asian contexts. J Affect Disord. 2014;168:452–8. Rachlis B, Naanyu V, Wachira J, Genberg B, Koech B, Kamene R et al. Community perceptions of community health workers (CHWS) and their roles in management for HIV, tuberculosis and hypertension in Western Kenya. PLoS ONE. 2016;11. Atif N, Lovell K, Husain N, Sikander S, Patel V, Rahman A. Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study. Int J Ment Health Syst. 2016;10:24. Rabbani F, Zahidie A, Siddiqui A, Shah S, Merali Z, Saeed K et al. Mental Health of Women in Fragile and Humanitarian Settings of the Eastern Mediterranean Region: A Systematic Review (manuscript submitted for publication). Raviola G, Naslund JA, Smith SL, Patel V. Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap. Curr Psychiatry Rep. 2019;21:44. Rabbani F, Zahidie A. Recent strategies to improve community case management of diarrhea among children under five in developing countries. Diarrhea Treatment. Avid Science; 2016. pp. 2–25. Kinshella M-LW, Sheikh S, Bawani S, La M, Sharma S, Vidler M et al. Now You Have Become Doctors: Lady Health Workers’ Experiences Implementing an mHealth Application in Rural Pakistan. Front Glob Womens Health. 2021;2. Aftab W, Piryani S, Rabbani F. Does supportive supervision intervention improve community health worker knowledge and practices for community management of childhood diarrhea and pneumonia? Lessons for scale-up from Nigraan and Nigraan Plus trials in Pakistan. Hum Resour Health. 2021;19:99. Thomas DS, Daly K, Nyanza EC, Ngallaba SE, Bull S. Health worker acceptability of an mHealth platform to facilitate the prevention of mother-to-child transmission of HIV in Tanzania. Digit Health. 2020;6:205520762090540. Chaudhry A. Lady Health Workers in Pakistan: Tracing personal and professional trajectories within a patriarchal context. Doctoral Thesis. Queen Margaret University, Edinburgh; 2019. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health. 2016;14:64. Oliphant NP, Ray N, Bensaid K, Ouedraogo A, Gali AY, Habi O, et al. Optimising geographical accessibility to primary health care: a geospatial analysis of community health posts and community health workers in Niger. BMJ Glob Health. 2021;6:e005238. Aranda-Jan CB, Mohutsiwa-Dibe N, Loukanova S. Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa. BMC Public Health. 2014;14:188. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Jan, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 30 May, 2024 Submission checks completed at journal 27 May, 2024 Editor assigned by journal 27 May, 2024 First submitted to journal 17 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4437031","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308463958,"identity":"02c5836b-f872-4cc3-9aef-66acb67b29b6","order_by":0,"name":"Samina Akhtar","email":"","orcid":"","institution":"Department of Community Health Sciences, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Samina","middleName":"","lastName":"Akhtar","suffix":""},{"id":308463959,"identity":"2b8a7802-8c95-4136-9c77-49c089fe648d","order_by":1,"name":"Fauziah Rabbani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBAC9gYgkcBwgMG+gYcNyJSQY+ABibPh1sJzAKrF4ABEizFxWhgQWhgSGwhqYT9j/OFBzR0Gg+Nnjz34ucMivb/njAHDh7LDuLXw5BgYJBx7xmDfk5du2HtGInfG2R4DxhnncGuxZ8gxSEhgO8xgx5BjJsHbJpHbcJ7HgJm3DY8t/G8MDiT8O8xgzP/GTPJvm0S6PEjLX3xaJHIMGxKBCgxn5JhJA21JMAA6jJkRr5ZnxQyJfYd5DG68SzeWbZMw3HjmWMHBnnPpeByWvPnjj2+H5QzO5x57+LatTl7uTPLGBz/KrHFqgWtF4R0gqH4UjIJRMApGAV4AAL+6WOIYr5kDAAAAAElFTkSuQmCC","orcid":"","institution":"Brain and Mind Institute, Aga Khan University","correspondingAuthor":true,"prefix":"","firstName":"Fauziah","middleName":"","lastName":"Rabbani","suffix":""},{"id":308463960,"identity":"807f9b47-f00b-4fcd-a723-012834fa63ed","order_by":2,"name":"Javeria Nafis","email":"","orcid":"","institution":"Department of Community Health Sciences, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Javeria","middleName":"","lastName":"Nafis","suffix":""},{"id":308463961,"identity":"6b649f09-d25c-435d-9827-6ea7f6a1fe1c","order_by":3,"name":"Amna Siddiqui","email":"","orcid":"","institution":"Brain and Mind Institute, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Amna","middleName":"","lastName":"Siddiqui","suffix":""},{"id":308463962,"identity":"fd7fddc0-d4b1-4172-abd3-6777b00a8a0e","order_by":4,"name":"Zul Merali","email":"","orcid":"","institution":"Brain and Mind Institute, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Zul","middleName":"","lastName":"Merali","suffix":""}],"badges":[],"createdAt":"2024-05-17 13:29:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4437031/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4437031/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-06459-8","type":"published","date":"2025-01-06T15:57:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58146646,"identity":"e7662cc9-bc26-47c2-aeaa-9bbdc9ec7089","added_by":"auto","created_at":"2024-06-11 18:37:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1869060,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003emPareshan \u003c/em\u003eintervention workflow\u003c/p\u003e","description":"","filename":"Fig1BMCPsych.png","url":"https://assets-eu.researchsquare.com/files/rs-4437031/v1/36cf731765f4d49afbfb6f0d.png"},{"id":58146643,"identity":"505146ce-7394-4d6d-b3e9-20cdccb06a56","added_by":"auto","created_at":"2024-06-11 18:37:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":107493,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of data collection phases and methods\u003c/p\u003e","description":"","filename":"Fig2BMCPsych.png","url":"https://assets-eu.researchsquare.com/files/rs-4437031/v1/01e32bdcc139b1b2843046ea.png"},{"id":73694717,"identity":"5e5c3e36-9f09-4ca8-a50b-3d66fe1a92b7","added_by":"auto","created_at":"2025-01-13 16:13:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3240750,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4437031/v1/4b8d8166-5e63-47dd-87b2-d808a965cbda.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A qualitative study assessing acceptability and appropriateness of a technology-assisted mental health intervention by community frontline workers: mPareshan implementation research in rural Pakistan","fulltext":[{"header":"Background","content":"\u003cp\u003eMental disorders contribute to 14% of the global burden of disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2019, mental disorders ranked as the second leading cause of Years Lived with Disability, posing significant challenges to health systems, particularly in low and middle-income countries (LMICs) [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. LMICs have a 10\u0026ndash;14% prevalence of depressive disorders [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e76\u0026ndash;85% of the people who have had any mental illness have unmet need for treatment in LMICs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Barriers to accessing mental-healthcare facilities in LMICs are poor resource distribution, cost, and geographical distance to community-based facilities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The social burden of mental disorders is exacerbated by ignorance, misdiagnosis, and inappropriate treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePakistan is an LMIC of 220\u0026nbsp;million with 38% of the population living below the poverty line [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Studies conducted over the last decade estimate the burden of depression and anxiety between 22\u0026ndash;60% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Poverty, political turmoil, insecurity, natural disasters, socio-economic challenges, and gender inequality are essential contributors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Recently, COVID-19 has worsened the situation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are only 520 practicing psychiatrists in Pakistan, resulting in a ratio of 2 psychiatrist per 1\u0026nbsp;million people [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Unfortunately, available mental health services are either privately-run clinics or psychiatry units in tertiary care hospitals [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Compounding the issue, around 60% of the population resides in rural and peri-urban areas, while most psychiatrists practice in urban regions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This uneven distribution further exacerbates the limited access to mental health services across the country.\u003c/p\u003e \u003cp\u003eRecently, digital/mobile health (mHealth) innovations such as web-based and mobile phone programmes have repeatedly been seen as a promising means of enhancing evidence-based treatments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The latest Lancet Commission on Global Mental Health has emphasized the importance of exploring digital tools for enhancing mental health research [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Meta-analyses report that mobile app-delivered interventions can be effective in decreasing anxiety and depression symptoms [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo improve the delivery of mental healthcare in limited resource areas, incorporating mental health programmes into regular primary health facilities has been recommended [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A Peruvian study incorporated a technology-based mental health assessment programme into standard primary healthcare practice and reported that using a screening app, accompanied by basic preparation, and monitoring by non-specialized Primary Health Care professionals, is a viable technique [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe first contact for individuals seeking healthcare in the developing world are the Frontline Health Workers (FHWs) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A systematic review on the feasibility of using mHealth strategies by FHWs in developing countries indicated that irrespective of prior training or education, FHWs can effectively utilize mobile phones for the collection of data and surveillance in healthcare delivery [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Pakistan, a well-structured Community Health Worker (CHW) programme already exists since 1994, called the Lady Health Worker Programme (LHW-P) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It offers preventive and promotive Maternal and Child Health services at the primary care level [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The LHW-P covers 85% of the rural population in Pakistan through 115,000 LHWs [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Each LHW is supervised by a Lady Health Supervisor (LHS). LHSs are responsible to offer supportive supervision to 20\u0026ndash;25 LHWs. LHWs have at least 8 years of education, prior work experience and live within the locality [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Mental health however is not a part of their service mandate currently [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Nevertheless, a study in Pakistan has explored the use of technology to scale-up monitoring and training of CHWs in psychosocial treatment of perinatal depression [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite its potential, the evidence supporting the feasibility of mHealth interventions is limited [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Few studies have documented end-user experiences, operability, usability, and interactions with mobile applications [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A study attributed technology failure to a disregard for user requirements and experience [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo bridge this gap in provision of mental health services, a customized app was developed in a feasibility trial (\u003cem\u003emPareshan\u003c/em\u003e). The app delivered psychosocial counselling through LHWs in rural Sindh [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This study specifically reports on the qualitative assessments conducted before and after intervention during this trial to gauge the acceptability, appropriateness, and potential of technology adoption by relevant stakeholders and additionally understand the barriers and facilitators to implementation roll-out.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Setting\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study was nested within the \u003cem\u003emPareshan\u003c/em\u003e project, a feasibility trial to assess the effectiveness, acceptability, and development of an mHealth intervention to reduce anxiety and depression in a rural Pakistan. The \u003cem\u003emPareshan\u003c/em\u003e trial was conducted in District Badin, located in the southern part of Sindh, Pakistan. Badin\u0026rsquo;s total population is 1.8 million and the literacy rate is 33.7% [37]. The district\u0026rsquo;s 1100 LHWs are working under the supervision of 36 LHSs [30, 38].\u003c/p\u003e\n\u003cp\u003eAfter a baseline survey using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), which are two standard psychometric instruments, 98 participants having mild and moderate anxiety and/or depression symptoms (screen positive, SPs) were eligible for the app-based \u003cem\u003emPareshan\u003c/em\u003e intervention delivered by LHWs during their routine household visits in their assigned catchment areas. The aim of the nested qualitative study was to understand the acceptability and appropriateness of delivering the \u003cem\u003emPareshan\u003c/em\u003e intervention from both the end-user and delivery perspective, as well as assessing barriers and facilitators to implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy participants for qualitative assessment included provincial policy makers, district health managers of the LHW-P, LHSs, LHWs from the delivery perspective and community participants (CPs) from the end-user perspective. Permanently employed LHWs and LHSs who regularly performed household visits and reported to their programme supervisors were randomly selected for the interviews. CPs were influential people of the community (religious scholars and teachers) capable of providing their viewpoint. Policy makers included key decision-makers at the Provincial Department of Health and the Provincial Program Implementation Unit of LHW-P, Badin. Their views helped to co-design the app-based intervention and assess acceptability, appropriateness, and potential of technology adoption. After intervention, qualitative assessments were repeated to ascertain the feasibility of intervention uptake and understand facilitators and barriers in implementation roll out. Key stakeholders included those randomly selected LHSs and LHWs who took part in the delivery of the intervention. Moreover, community participants in the post-intervention qualitative phase also included those individuals who received the digital counselling intervention (the SPs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe mPareshan App-based Intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention was delivered over the course of 6 months with SPs receiving one home-based counselling session per month by the LHWs. The \u003cem\u003emPareshan\u003c/em\u003e app was designed based on feedback received from stakeholders in the formative qualitative phase. It consisted of 3 segments: tracking, counselling, and referral. The tracking segment recorded information on participant recruitment, retention, and consent. The referral segment identified danger signs related to suicidal ideation, self-harm and harm to others and then guided appropriate referrals to the nearest mental health facility. In the absence of danger signs, the LHW facilitated psychoeducation for SPs through audio and video features using the counselling segment. Each session lasted 20-25 minutes. The SPs were involved in breathing exercises and pleasant activities to help them cope with anxiety and depression symptoms. The app could be downloaded on an android tablet and accessed without internet (Figure 1). The detailed protocol of the \u003cem\u003emPareshan\u003c/em\u003e intervention trial is available elsewhere\u0026nbsp;[36].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e: \u003cem\u003emPareshan\u0026nbsp;\u003c/em\u003eintervention workflow\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA semi-structured guide was developed by the study team for this nested qualitative study that helped to carry out the Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs) with relevant stakeholders. The guide had a pre-set list of open-ended questions, organized in a logical pattern with relevant probes (Table 1). The questions were designed to assess acceptability and appropriateness, and potential of technology adoption before intervention and barriers and facilitators to implementation roll out after intervention. This ensured that key topics were considered but that new themes of concern to participants could also emerge. The main themes in the guide covered:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eBurden and determinants of mental health\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAcceptability and appropriateness of delivering a mental health intervention\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdoption and task-technology shift of mHealth intervention delivered by LHWs\u003c/li\u003e\n \u003cli\u003eUptake of intervention\u003c/li\u003e\n \u003cli\u003eBarriers and facilitators to implementation roll-out and sustainability\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1:\u003c/em\u003e\u003c/strong\u003e Probes in Focus Group Discussions and In-depth Interview guides\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain probes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003eBurden and determinants of mental health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cul type=\"square\"\u003e\n \u003cli\u003ePerceptions of participants about mental health burden and its determinants.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAvailability of mental health services in the community.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003eAcceptability and appropriateness of delivering a mental health intervention\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cul type=\"square\"\u003e\n \u003cli\u003eRapport of LHWs as front-line health care providers in rural areas\u003c/li\u003e\n \u003cli\u003eLHW-P capacity to address mental health.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCapacity of LHWs to deliver mental health intervention\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAcceptability of intervention among policy makers, LHWs and community\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003eAdoption and task-technology shift of mHealth intervention delivered by LHWs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cul type=\"square\"\u003e\n \u003cli\u003eLHSs awareness regarding android phone technology for provision of mHealth services.\u003c/li\u003e\n \u003cli\u003eWillingness of LHWs to provide mental health services utilizing technology-assisted app.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003eUptake of intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cul type=\"square\"\u003e\n \u003cli\u003eExperience of LHWs, LHSs and community participants\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eViews regarding app features, usage, and content\u003c/li\u003e\n \u003cli\u003eViews on the benefits of intervention.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003eBarriers to implementation roll-out and sustainability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cul type=\"square\"\u003e\n \u003cli\u003eBarriers experienced by stakeholders during intervention roll out.\u003c/li\u003e\n \u003cli\u003eSuggestions for improvement and sustainability.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.070707070707071%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.303030303030305%\" valign=\"top\"\u003e\n \u003cp\u003eFacilitators in implementation roll-out\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.62626262626262%\" valign=\"top\"\u003e\n \u003cul type=\"square\"\u003e\n \u003cli\u003eFactors that facilitated implementation roll-out\u003c/li\u003e\n \u003cli\u003eImportance of LHSs as supervisors of LHWs\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFollowing ethical clearance, 8 FGDs and 18 IDIs were conducted before and after intervention. Details on the modes of inquiry are presented in Figure 2. Qualitative interviews lasted about 30-45 minutes, or until the point of saturation. All participants provided written consent before starting the interview. The interviews were conducted by core research team members (SA and JN), experienced in conducting qualitative research. A relationship of trust was established with participants prior to the commencement of qualitative inquiry through community liaising, informal talks, and by introducing the study objective. Pre-intervention qualitative assessments took place from January to February 2022 and the post-intervention assessments were conducted from October to December 2022. FGDs with health workers and IDIs with SPs were held at the District LHW-P office in Badin. Policy makers were interviewed in their working spaces. Some of the post-intervention assessments were also conducted online due to COVID restrictions. All FGDs and IDIs were audio recorded, transcribed verbatim, and translated into English. Field notes were also made during the interviews. Identifiable information was removed from the interview transcripts to maintain anonymity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFigure 2\u003c/em\u003e\u003c/strong\u003e: Summary of data collection phases and methods\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of \u0026ldquo;implementation outcomes\u0026rdquo; and works through the lens of RE-AIM framework [39, 40] to report on acceptability, adoption, and appropriateness of the proposed intervention prior to implementation [41]. Additionally, it also reports on the challenges and facilitating factors for successful implementation roll-out.\u003c/p\u003e\n\u003cp\u003eAfter transcription, the data were analysed by using manual thematic analysis and QSR NVivo version 10 for thematic content analysis. All transcripts were first read by SA and JN for data familiarization and then independently coded. The research team met regularly during the analysis stage to compare codes and establish consensus. Data relevant to each code was organized into potential themes that reflected the RE-AIM framework outcomes. The analysis was reviewed and revised for the final write-up by FR and AS. FR had extensive knowledge about the intervention and was involved in the implementation roll out, while having prior expertise in using LHW-P platform for similar digital interventions. Other authors were involved in the manuscript write-up and took part in the initial conceptualization of the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll participants who took part in the qualitative assessment before (N=44) and after (N=30) intervention consented for the interviews. Demographic data regarding stakeholders is displayed in Table 2. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Sociodemographic characteristics of participants*\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"931\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.219119226638025%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.723952738990334%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-Intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5370569280343717%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.51987110633727%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-Intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.219119226638025%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.293233082706767%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGDs (n=4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.430719656283568%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDIs (n=12)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5370569280343717%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.67454350161117%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGDs (n=4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.8453276047261%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDIs (n=6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLHWs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLHSs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLHWs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLHSs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (100)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (100)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (100)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (100)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (33.3)\u003c/p\u003e\n \u003cp\u003e4 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, years \u0026ndash; Median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRange \u003cem\u003e(Min-Max)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003cp\u003e22-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e29-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003cp\u003e22-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e29-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35-45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education\u0026dagger;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMatric\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMatric/ Intermediate\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-graduate training\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMatric/ University degree\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMatric\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMatric/ Intermediate\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo formal qualification\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003eGovt. of Sindh, Dept. of Health officials: Directorate General of Health Services, Deputy, Assistant \u0026amp; Additional Directors (Reproductive, Maternal, Newborn, \u0026amp; Child Health/LHW-P)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003eTeachers, social activists, politically active individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eHealth workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003eFarmers/ agricultural workers, daily wage labourers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience in current role (median years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003e5-15 (min, max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.236559139784948%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience with using digital apps before\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.268817204301076%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.193548387096774%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.5376344086021505%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.473118279569892%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.043010752688172%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Data was not always collected individually. Values presented where available.\u003c/p\u003e\n\u003cp\u003e\u0026dagger;Matric is GCSE equivalent, Intermediate is A levels equivalent.\u003c/p\u003e\n\u003cp\u003eThe thematic analysis resulted in six main themes; \u003cem\u003e1) The burden of mental health and its determinants\u003c/em\u003e, 2) \u003cem\u003eAcceptability and appropriateness of delivering and receiving a mental health intervention\u003c/em\u003e, 3) \u003cem\u003eAdoption and task-technology shift of an mHealth mental health intervention\u003c/em\u003e, 4) \u003cem\u003eExperiences regarding uptake of intervention\u003c/em\u003e, 5) \u003cem\u003eBarriers to implementation roll out and sustainability\u003c/em\u003e and 6) \u003cem\u003eFactors facilitating implementation roll out\u003c/em\u003e, which are presented below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe burden of mental health \u0026amp; its determinants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs an initial step, stakeholder perceptions about mental health were explored.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;About 70-80% of the people are mentally ill in Badin. We don\u0026apos;t even have a government hospital at the district. Private doctors visit on Sundays, but their fees are unaffordable.\u0026rdquo; (Community Participant, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAn LHW commented on the impact of mental illnesses on her community.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In some cases, people reach a point of extreme desperation, and this may result in suicidal actions. I believe that depression can lead to changes in behaviour towards family and friends.\u0026rdquo; (LHW, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted some of the possible stressors that contribute to mental ill-health and reasons for not accessing mental health services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If the person supporting the family is struggling with money and there are kids to take care of, it can make the whole family feel uneasy.\u0026rdquo; (LHW, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Due to poverty and large families with 10-12 members, individuals suffer from mental illness.\u0026rdquo; (Community Participant, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFear of being stigmatized also prevented people from accessing mental health services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;People with mental illnesses tend to suppress their feelings and fear being labelled as \u0026apos;dewana/pagal\u0026apos; (mad/insane)\u0026rdquo; (LHS, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcceptability and appropriateness of delivering and receiving a mental health intervention\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor assessing the acceptability and appropriateness of LHWs as providers of mental health services, it was important to first judge the rapport of LHWs as frontline CHWs. Community participants commented.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are absolutely satisfied with the LHWs. They visit every household in our village, and it feels like they are a part of our family.\u0026rdquo; (Community Participant, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;LHSs and LHWs are highly regarded in the community, considered almost like doctors.\u0026rdquo; (Community Participant, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePolicy makers also displayed strong confidence in LHWs\u0026rsquo; capabilities and role in social mobilization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Our LHWs are akin to our army; they work tirelessly and consistently.\u0026rdquo; (Policy maker, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;LHWs can make a big difference by mobilizing the community and creating awareness. They act as a bridge between us and the community.\u0026rdquo; (Policy maker, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers\u0026nbsp;also expressed their ease and satisfaction with their work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;(Families)\u0026nbsp;listen and understand what we suggest. If our way of counselling is effective, the people will surely stand by us.\u0026rdquo; (LHWs, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eResearchers further probed about the appropriateness of LHWs delivering a mental health intervention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If (LHWs) are assigned to care for a mentally ill person, they would excel at it because they are already familiar with our community.\u0026rdquo; (Community Participant, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePolicy makers acknowledged LHWs as a valuable resource for addressing mental health concerns.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;LHWs are an essential resource. They can go door-to-door to identify cases and educate people about\u0026nbsp;mental health.\u0026quot; (Policy maker, IDI, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStakeholders also highlighted some areas of concern.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I doubt that LHWs cover 100% of the area. Coastal regions are quite distant from the city.\u0026rdquo; (LHW, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The primary concern here is that LHWs have a heavy workload. They are engaged in tasks related to polio, family planning, measles, and now COVID. However, if we want to involve them in mental health service provision, we need to find a feasible strategy (easy to understand and user-friendly)\u0026rdquo;. (Policy Maker, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdoption and task-technology shift of an mHealth mental health intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers\u0026rsquo; views regarding the task-technology shift of adopting the mHealth intervention were explored.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If LHWs use mobile devices, it should work smoothly. We\u0026apos;ve already established WhatsApp groups, and since they (LHWs) are using touchscreen phones, they can easily perform tasks. They also use their phones to share videos.\u0026rdquo; (LHS, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We will visit them repeatedly and show content in app, so why wouldn\u0026apos;t this have a positive impact? It\u0026apos;s quite likely to be beneficial, without doubt.\u0026quot; (LHWs, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We can understand English and operate mobiles since its the era of mobile technology. Main video content should be in Sindhi (local language) for the sake of clarity.\u0026rdquo; (LHWs, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Our role involves presenting the counselling video and explaining its contents. If they (SP) make an effort, they will experience improvement.\u0026rdquo; (LHWs, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome emphasis on proper training was noted to execute the intervention successfully.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;No task is ever easy, especially before proper training.\u0026rdquo; (LHW, FGD, Pre-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExperiences regarding uptake of intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStakeholders were inquired regarding their experiences during the intervention roll-out.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are completely satisfied with the app. It has effectively addressed our mental health concerns.\u0026rdquo; (LHWs, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Previously, she (SP) used to spend her time alone and displayed no interest in anything. However, after receiving intervention, she took up sewing and embroidery.\u0026rdquo; (LHWs, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;As I gradually committed myself, I realized its inherent benefits. The initial difficulties faded as I recognized the value it brought to me.\u0026quot; (SP, IDI, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome LHWs noted a gender disparity in the uptake of intervention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Feedback from women was notably more positive than that from men. Some men expressed concerns about time constraints.\u0026rdquo; (LHWs, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBarriers in implementation roll-out and sustainability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers underlined some technological barriers during the implementation roll-out.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the first session, submitting feedback (through the designated app portal) was a bit challenging.\u0026rdquo; (LHW, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Prolonged power outages render our mobiles powerless and disrupt internet connectivity.\u0026rdquo; (LHW, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eExisting workloads and lack of dedicated time to conduct counselling sessions emerged as constraints in successful intervention delivery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Having a 20-minute session was suitable for SPs, but for us, it wasn\u0026apos;t just 20 minutes. Our journey took time. After reaching, we had to wait for \u0026frac12; hour if the SP was occupied. Some time went into building trust and allaying any concerns\u0026rdquo; (LHS, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;She (the LHW) is extremely occupied. She\u0026apos;s been engaged non-stop since the start of the pandemic.\u0026rdquo; (LHS, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers shared their opinion on the intervention\u0026rsquo;s prospects for sustainability in the future.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Young generation faces considerable anxiety. If a portion of college/high school teachers could be trained (in mPareshan app), it might be beneficial in the future.\u0026rdquo; (LHS, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Breathing exercises were explained through audios. Incorporating more videos/visual aids would have enhanced clarity, especially for less literate (SPs).\u0026rdquo; (LHW, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFactors facilitating implementation roll-out\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupportive supervision by LHSs during implementation was considered positively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Working as a team with our LHSs was more effective than us going alone. Presence of LHSs helped in answering participant queries and motivating (SPs) to take part in intervention.\u0026rdquo; (LHW, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When Baji (LHS) is with us, our responsibilities diminish. Baji takes care of the technical aspects, and we know we can rely on her for guidance.\u0026rdquo; (LHW, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Due to our presence, LHWs did well and got a positive response from SPs, reinforcing our role as supervisors.\u0026rdquo; (LHSs, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIt was highlighted that LHWs felt supported in the presence of LHSs, especially when counselling male SPs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Since my LHW deals with all male SPs, having a supervisor (like me) present during her sessions provides her courage and a sense of ease.\u0026rdquo; (LHS, IDI, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne SP conveyed his perspective regarding the feasibility of the counselling session.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Duration of counselling is appropriate. It didn\u0026apos;t interfere with our daily work; in fact, it was quite effective.\u0026rdquo; (SP, FGD, Post-intervention)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants undergoing intervention showcased their optimistic response regarding the improvement of their mental well-being.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Video counselling was particularly helpful, guiding us to alleviate anxiety. We diligently followed the advice presented in the videos, which were further reinforced by visits from the LHS and LHW.\u0026rdquo; (SP, IDI, Post-intervention)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is among the first of its kind to explore perceptions about acceptability and appropriateness of a digital mental health intervention prior to implementation and identify barriers and facilitating factors for smooth implementation roll-out.\u003c/p\u003e \u003cp\u003eAll stakeholders displayed a comprehensive understanding of mental health, emphasizing its importance. They agreed that it significantly contributes to the disease burden and expressed concerns that mental health issues are rising. Various determinants of mental illnesses were identified including poverty, stigmatization in seeking care and large family sizes etc. These findings align with literature from other LMICs like Indonesia, Iran, and Nepal where similar determinants have been noted [\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the current study, both policy makers and community participants considered LHWs as a trusted human resource to deliver mental health services. A previous study in India and Pakistan showed that community participants favoured frontline workers who were residents of the same area [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In the absence of specialized workers, similar findings reported in Pakistan and Africa show that these frontline workers are trusted as peers and empower their communities [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLHWs demonstrated a willingness to deliver the services while the community indicated their acceptability to receive it. The intervention was timely and appropriate given the rural context where mental health services are neither available nor easily accessible. Evidence from the Eastern Mediterranean Region shows that rural areas remain limited in terms of mental healthcare access [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. A previous narrative review from LMICs has supported the role of frontline non-specialist workers to bridge this mental health treatment gap by delivering low-intensity psychosocial interventions [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe task-technology shift of delivering digital mental health services through LHWs was found to be relatively feasible. The technology was easy to adopt since LHWs are already using smartphones for maternal and child healthcare and are familiar with digital data entry systems [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Earlier studies in rural Sindh have demonstrated successful implementation of mHealth applications by LHWs for home-based pregnancy care and tackling childhood diarrhoea [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Similarly, a pilot study in rural Tanzania showed that health workers effectively used a tablet-based platform for preventing mother-to-child transmission of HIV services [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, these results should be interpreted with caution. Concerns about the heavy workloads of LHWs were voiced by the stakeholders. There were also some issues with sub-optimal coverage and accessibility of health workers in remote areas. Similar challenges have been highlighted before in studies in Pakistan and Myanmar, where conflicting pressures often lead them to become agents of the state, burdened with directives and programmes without adequate training and equipment [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Another study in Niger also showed the geographical coverage of CHWs being less than optimal despite efforts to upscale [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. To counter these challenges, deployment strategies need to be revisited by the government to streamline the integration of additional responsibilities with LHW\u0026rsquo;s routine work.\u003c/p\u003e \u003cp\u003eSome issues with internet connectivity were noted which were resolved with prior downloading of content and uploading of data when connectivity resumed. Previous studies from Pakistan and Africa have highlighted similar concerns [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing insights from stakeholders prior to intervention, the app content was designed in Sindhi language. Hence, language did not appear as a barrier during intervention roll-out. However, it was suggested that for future, the video content should replace some of the audio sessions. This is understandable given the greater penetration and impact of the latter, especially amongst low-literacy populations.\u003c/p\u003e \u003cp\u003eSupportive supervision provided by the LHSs to LHWs was perceived as an important facilitating factor to implementation, particularly while dealing with male SPs. Such supportive supervision by LHSs has shown to work well previously in rural Pakistan [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the limitations of the study was the inability to conduct IDIs with policy makers post-intervention, due to their involvement in disaster management of floods in the district. The \u003cem\u003emPareshan\u003c/em\u003e trial used mixed methods of data collection. This paper only reports on the qualitative inquiry. Hence, the effectiveness of the intervention can only be judged once the complete study results are published, and findings are triangulated.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUsing the RE-AIM implementation outcomes, the formative (pilot) assessment in the pre-intervention phase of this qualitative inquiry helped to co-design the mHealth intervention with input from relevant stakeholders. Meanwhile, the post-intervention assessments assisted in understanding the barriers and facilitators to implementation roll-out in the real-life setting. Given the lack of resources, we believe that the task-technology shift (as demonstrated by \u003cem\u003emPareshan\u003c/em\u003e project) of utilising LHWs in delivering mental health screening and counselling services at community doorsteps is quite feasible, acceptable, and appropriate. It can be easily adopted within the context of LHW-P. Implemented at scale, this intervention has the potential to improve mental health at the primary care level.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003eCHWs: Community Health Workers; CPs: Community Participants; FGDs: Focus Group Discussions; FHWs: Frontline Health Workers; IDIs: In-Depth Interviews; LHSs: Lady Health Supervisors; LHW-P: Lady Health Worker Programme; LHWs: Lady Health Workers; LMICs: Lower middle-income countries; PMs: Policy Makers; RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance; SPs: Screen Positives.\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Review Committee of Aga Khan University (ERC# 2021-6570-20015).\u0026nbsp;All participants provided written informed consent before starting interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant from the Brain \u0026amp; Mind Institute (BMI), Aga Khan University (Grant Brain \u0026amp; Mind-FR-11E-mPareshan App 83000).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative inquiry is nested within the larger \u003cem\u003emPareshan\u003c/em\u003e trial. The authors would like to thank the overall members involved in the implementation of this trial. Special gratitude is expressed to the study participants that took part in this qualitative assessment including members of the LHW-P, policy makers and community participants. Muhammad Shahid Khan (PhD Population \u0026amp; Public Health Scholar, Aga Khan University) is also acknowledged for assistance in data collection at the pre-intervention stage.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHussain SS, Khan M, Gul R, Asad N. Integration of mental health into primary healthcare: Perceptions of stakeholders in Pakistan. East Mediterr Health J. 2018;24:146\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. 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BMC Public Health. 2014;14:188.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acceptability, appropriateness, adoption, mHealth, mental health, Lady Health Workers","lastPublishedDoi":"10.21203/rs.3.rs-4437031/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4437031/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWith a shortage of mental health specialists and a significant rural population in Pakistan, leveraging community-based healthcare workers becomes crucial to address mental health needs. Equipping the healthcare workers with digital tools such as mobile applications have the potential to increase access to mental health support in low-resource areas. This study examines the acceptability, appropriateness, barriers, and facilitators to implementing a technology-assisted mental health intervention (\u003cem\u003emPareshan\u003c/em\u003e) delivered by Lady Health Workers (LHWs) in rural Pakistan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a qualitative study embedded within a larger implementation research trial assessing the feasibility of an mHealth intervention aimed at improving anxiety and depression. 8 focus group discussions and 18 in-depth interviews were conducted. Perceptions were sought before and after intervention from stakeholders comprising of policymakers, LHWs, Lady Health Supervisors (LHSs), and community participants. Data underwent thematic analysis using the RE-AIM framework.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix main themes emerged from the data. All participants had realization of rising burden of mental illnesses and identified key determinants for mental ill-health. Delivery of mental health counselling by LHWs through a technology-assisted intervention was deemed acceptable and appropriate. LHWs were considered capable and trustworthy by the community to deliver a home-based mHealth intervention, given their easy accessibility as residents of the same community. The technology demonstrated potential for easy adoption as these frontline health workers were already familiar with smartphone technology. Some barriers identified during implementation roll-out included heavy workload of LHWs and difficulty in internet connectivity. Use of videos for counselling, and supportive supervision by LHSs emerged as key facilitators for implementation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights that a technology-focused mental health intervention is feasible, acceptable, and appropriate to be implemented by community frontline workers in resource-constrained rural Pakistani settings. The \u003cem\u003emPareshan\u003c/em\u003e intervention can be easily adopted within the LHW-P. Further research should investigate how implementation barriers can be addressed for successful delivery.\u003c/p\u003e","manuscriptTitle":"A qualitative study assessing acceptability and appropriateness of a technology-assisted mental health intervention by community frontline workers: mPareshan implementation research in rural Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 18:37:36","doi":"10.21203/rs.3.rs-4437031/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-30T04:26:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-27T07:52:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-27T07:52:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-05-17T13:27:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7fae2a8-e689-4526-b3c4-eb8477aad575","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T16:09:10+00:00","versionOfRecord":{"articleIdentity":"rs-4437031","link":"https://doi.org/10.1186/s12888-024-06459-8","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-01-06 15:57:28","publishedOnDateReadable":"January 6th, 2025"},"versionCreatedAt":"2024-06-11 18:37:36","video":"","vorDoi":"10.1186/s12888-024-06459-8","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06459-8","workflowStages":[]},"version":"v1","identity":"rs-4437031","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4437031","identity":"rs-4437031","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}