The effectiveness of Technology-assisted Cascade Training and Supervision of community health workers in delivering the Thinking Healthy Program for perinatal depression in a post-conflict area of Pakistan—study protocol for a randomized controlled trial
Open accessAbstract
BACKGROUND: Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women's health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision. METHODS/DESIGN: This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status. DISCUSSION: Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP. TRIAL REGISTRATION: Registered with ClinicalTrials.gov as GCC-THP-TACTS-2015, Identifier: NCT02644902 .
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TACTS consists of a tablet-based package with five training sessions covering core techniques and principles of the Thinking Healthy Program, using animated avatars and interactive role-plays.
“TACTS consists of a tablet-based package with five training sessions covering core techniques and principles of the Thinking Healthy Program. Animated ‘avatars’ depict culturally appropriate characters that narrate the sessions and convey the instructional content. The sessions are interactive, and include role-plays to address real-life challenging situations and to reinforce the content and key”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [25]
TACTS is a digital tablet-based program for supporting training of community health workers, called lady health workers, in Pakistan to deliver the Thinking Healthy Program for perinatal depression.
“The Technology-assisted Cascade Training and Supervision (TACTS) is a digital tablet-based program for supporting the training of community health workers, referred to as lady health workers in Pakistan, to deliver the evidence-based Thinking Healthy Program for perinatal depression.25”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [25]
TACTS is currently being evaluated against in-person training by mental health specialists in a non-inferiority randomized controlled trial in post-conflict rural Pakistan, with lady health worker competence as the primary outcome.
“This program is currently being evaluated compared to in-person training delivered by mental health specialists as part of a non-inferiority randomized controlled trial in a post-conflict rural area of Pakistan. The primary outcome is competence of the lady health workers for delivering the intervention.25”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [25]
For three of the interventions summarized, large-scale evaluations of effectiveness are currently ongoing.
“Importantly, for three of the interventions using digital technology that we summarized here, large-scale evaluations of effectiveness are currently ongoing (published protocols for these studies were included).25,34,37”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [25]
In Pakistan, community health workers are currently being trained via a tablet-based system to deliver the Thinking Healthy Program for perinatal depression.
“In another example, a tablet-based system is currently being used to train community health workers to deliver the evidence-based and culturally tailored Thinking Healthy Program involving psychological treatment for perinatal depression in Pakistan.25”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [25]
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- Authors
- Zafar, S., Sikander, S., Hamdani, S. U., Atif, N., Akhtar, P., Nazir, H., Maselko, J., & Rahman, A.
- Affiliations
- Human Development Research Foundation (PK)
- Duke University (US)
- Corresponding author
- Zafar, Shamsa
- ORCID
- Venue
- Trials
- Published
- 2016-04-06
- Volume
- 17
- Issue
- 1
- Pages
- 188-188
- ISSN
- 1745-6215 (ISSN-L)
- PMC
- PMC4822299
- OpenAlex
- W2331896342
- Cited by
- 41
- References
- 28
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 2 · 2023: 8 · 2022: 8 · 2021: 5 · 2020: 4 · 2019: 6 · 2018: 4
- FWCI
- 3.31
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Trials (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion)
- UNC Libraries
- Funders
- Grand Challenges Canada (0596-04)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- perinatal depression, community health workers, Lady Health Workers, tablet-based training, scaling up interventions, post-conflict societies, SWAT, health worker competence
- MeSH terms
- Armed Conflicts, Clinical Protocols, Community Health Workers, Community Mental Health Services, Computer-Assisted Instruction, Delivery of Health Care, Developing Countries, Female, Humans, Inservice Training, Mental Health, Pakistan, Pregnancy, Psychiatric Status Rating Scales, Research Design, Time Factors, Single-Blind Method, Treatment Outcome, Perinatal Care, Depression, Postpartum, Computers, Handheld
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