Assessing the Efficacy of Mental Health Assessment Training for Accredited Social Health Activists Workers in Rural India: A Pilot Study

Background Mental health issues are a major concern in rural India, but the lack of trained professionals limits access to care. In this pilot study, we evaluated the efficacy of a mental health assessment training program for Accredited Social Health Activists (ASHA) in rural Maharashtra, India. Aim and objective To conduct a pilot study to evaluate the feasibility and potential efficacy of Mental Health Assessment Training by using the Global Mental Health Assessment Tool-Primary Care Marathi Android version (GMHAT/PC-M) on ASHA workers in the Wardha district to identify mental health problems. Methods The study enrolled 12 ASHA workers from two rural health centers in Maharashtra. The workers completed a pretest and then received training in mental health assessment using the GMHAT/PC Marathi Android version. Mental health knowledge and global mental health assessment tool checklist scale scores were assessed on day seven, month one, and month three after training. Results The ASHA workers had a mean age of 42.2 years and a mean experience of 9.6 years. The majority were Hindus (50%), with the remaining workers being Buddhist. Of the 12 workers, only four had prior mental health training. Mental health knowledge and global mental health assessment tool checklist scale score significantly improved from the pretest to day seven (p<0.001), and the scores continued to improve at month one and month three with a 0.001 level of significance. At the end of the study, the mean mental health knowledge score was 15.2 (out of 20), and the mean global mental health assessment tool checklist scale score was 55.5 (out of 60). Conclusion Our pilot study demonstrated the effectiveness of a mental health assessment training program for ASHA workers in rural Maharashtra, India, using the GMHAT/PC Marathi Android version. The training program improved the mental health knowledge and GMHAT checklist scale of the ASHA workers, suggesting that such programs can help bridge the gap in mental health care in rural areas. Further studies with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness of this training program.


Introduction
Mental health disorders are a significant public health concern worldwide, with approximately one in four people affected at some point [1]. In low-and middle-income countries (LMICs), mental health disorders profoundly impact individuals, families, and communities. However, the resources to address these issues are often scarce, particularly in rural areas [2]. The situation is particularly challenging in India, where the prevalence of mental health disorders is estimated at 10-20% of the population [3]. Still, there is a severe shortage of mental health professionals, particularly in rural areas [4].
In India, the Accredited Social Health Activist (ASHA) program was launched in 2005 to improve the health of rural populations by providing a link between community members and the health system [5]. ASHAs are female community health workers who are trained to provide basic health services, health education, and referrals to primary health care facilities. However, ASHAs are not trained to identify or manage mental health disorders, despite the high prevalence of these disorders in rural areas. As a result, there is a need to develop and implement mental health training programs for ASHAs to improve their capacity to identify and manage mental health disorders.
In recent years, several studies have evaluated mental health training programs for community health workers in LMICs [6][7][8][9]. However, these studies have primarily focused on training programs for nonspecialist health workers, such as lay counselors or community health volunteers. Few studies have evaluated mental health training programs specifically for ASHAs in India. Moreover, most of the studies have used self-reported measures to assess the effectiveness of the training programs, which may be subject to social desirability bias and may not accurately reflect changes in knowledge or skills [10].
To address this gap, we conducted a pilot study to evaluate the effectiveness of a mental health assessment training program for ASHAs in rural India using the Global Mental Health Assessment Tool-Primary Care Marathi Android version (GMHAT/PC-M) [11]. The GMHAT/PC-M is a validated tool used to assess mental health disorders in primary care settings in LMICs [12]. We used a pre-and post-test design to evaluate changes in mental health knowledge and GMHAT/PC-M scores among ASHAs who received the training program.
This pilot study is a crucial first step in developing and implementing effective mental health training programs for ASHAs in rural India. By improving the capacity of ASHAs to identify and manage mental health disorders, we can improve the health outcomes of individuals and communities in rural areas and reduce the burden of mental health disorders in India.

Study setting and design
The single-arm interventional study was conducted at the Primary Health Center (PHC) in Seloo, situated in the Wardha district of Maharashtra, India, between April to June 2022.

Study population
A total of 12 ASHA workers were included in this pilot study. The study included ASHA workers willing to participate and could read, write, comprehend Marathi, and use an Android phone. However, individuals who had already participated in a similar study within the past six months were excluded, as were those who did not use an Android phone.

Training program
The training program for mental health assessment aimed at ASHA workers included several modules. These modules included an introduction to mental health, recognizing the signs of a mentally healthy person, understanding the causes and symptoms of mental illness, common mental disorders along with their associated symptoms, an overview of GMHAT, identification of common mental disorders through GMHAT, and a practical demonstration. Furthermore, the program covered the referral system for patients with mental illnesses and a review of common mental disorder identification using GMHAT by ASHA workers.

Data collection
A structured knowledge questionnaire on mental health assessment was utilized to evaluate participants' knowledge. The questionnaire was designed to cover all aspects of mental health assessment, including the signs and symptoms of various mental disorders, the appropriate methods for conducting a mental health assessment, and the referral process and validation from experts in the subject area (Appendix 1).
In addition to the knowledge questionnaire, a checklist based on the global mental health assessment tool checklist scale was utilized to evaluate participants' skills. The checklist included various practical scenarios related to mental health assessment, and participants were required to demonstrate their skills by performing the appropriate actions for each scenario (Appendix 2).
The mental health assessment training was divided into a three-day module, which covered the following topics: On day one, participants were given a pre-test to assess their baseline knowledge of mental health assessment. They were also provided background information on mental disorders, per the Global Mental Health Assessment Tool -Primary Care Version (GMHAT/PC) Marathi guidelines. Additionally, participants were given instructions on how to use the tool and rate the symptoms, as well as an overview of the referral system.
On day two, participants observed a demonstration of mental health assessment through GMHAT/PC Marathi. This gave them a clear understanding of how to conduct a mental health assessment using the tool and an opportunity to ask questions and seek clarification.
On day three, participants had the opportunity to perform a redemonstration of their mental health assessment skills using the GMHAT/PC Marathi tool. This provided them with an opportunity to practice and improve their skills, as well as receive feedback from their peers and trainers. We were contacted t the ASHA workers monthly meeting to the PHC Seloo Wardha.
The knowledge questionnaire consists of a total of 20 questions. Each question is assigned a score of one for the correct option and zero for all incorrect options. The total score for all 20 questions is then categorized as follows: Poor (0-5), Average (6-10), Satisfactory (11)(12)(13)(14)(15), and Very Good (16-20).
The global mental health assessment tool checklist comprises 15 questions, each of which is assigned a score category of Never (0), Once in a while (1), Sometimes (2)

Statistical analysis
We analyzed demographic variables of ASHA workers such as age, education, marital status, and monthly income. Descriptive statistics were used to calculate ASHA workers' knowledge and skill scores before and after Mental Health Assessment training, with mean and standard deviation. Paired t-tests were used to compare pre and post-test scores. To evaluate the efficacy of the training, repeated measures Analysis of Variance (ANOVA) was used to compare scores at seven days, one month, and three months posttraining. We used SPSS version 26 (IBM Corp., Armonk, NY, USA) and considered a p-value <0.05 significant. Results are presented in tables and graphs.

Ethical consideration
Written informed consent was obtained from each participant after a careful explanation of the concept and purpose of the study. The study was approved by the Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) granted ethical approval (IEC/DEC-2019/8543). Table 1 presents the demographic characteristics of the 12 ASHA workers who participated in the study. The table includes information on their age, religion, educational status, type of family, marital status, total family members, population served, experience in years, income, a family member suffering from mental illness, and training regarding mental health and mental illness.

Discussion
This pilot study evaluated the effectiveness of a mental health assessment training program for ASHAs in rural India using the GMHAT/PC-M. The results showed a significant improvement in mental health knowledge and GMHAT/PC-M scores among ASHAs who received the training program. Our study is one of the few to evaluate a mental health training program specifically for ASHAs in India. It provides important insights into the effectiveness of such programs in improving the capacity of ASHAs to identify and manage mental health disorders in rural areas.
Our study found that the mental health assessment training program effectively improved the knowledge and skills of ASHAs in identifying and managing mental health disorders. The GMHAT checklist scores of ASHAs who received the training program showed a significant improvement in identifying and managing mental health disorders. These findings are consistent with previous studies that have evaluated mental health training programs for non-specialist health workers in LMICs [6][7][8][9]. The results of our study suggest that mental health training programs for ASHAs in rural India can be an effective strategy for improving the capacity of primary healthcare workers to identify and manage mental health disorders.
The GMHAT/PC-M is a validated tool used to assess mental health disorders in primary care settings in LMICs [12]. Our study used the GMHAT checklist to assess the effectiveness of the mental health assessment training program in rural India. Using a validated tool to assess changes in mental health knowledge and skills provides important evidence for the effectiveness of the training program.
The ASHA program was launched in 2005 to improve the health of rural populations in India by providing a link between community members and the health system [5]. However, ASHAs are not trained to identify or manage mental health disorders, despite the high prevalence of these disorders in rural areas. Our study suggests that mental health training programs for ASHAs can be an effective strategy for improving the capacity of primary healthcare workers to identify and manage mental health disorders.
Our findings are consistent with previous studies that have evaluated the effectiveness of mental health training programs for non-specialist health workers in LMICs. For example, a study conducted in Kenya found that a brief training program for lay counselors improved their ability to identify and manage depression [13]. Another study in Pakistan found that a community-based mental health intervention led by trained community health workers improved participants' mental health outcomes [14]. These studies suggest that community health workers can play an important role in addressing the burden of mental health disorders in LMICs.
Finally, our study highlights the potential for mobile health (mHealth) technologies to support mental health training programs for ASHAs in rural India. The GMHAT/PC-M tool used in our study is an Android app, allowing for easy and efficient assessment of mental health disorders in primary care settings. Using mHealth technologies could also support ongoing supervision and support for ASHAs, such as messaging platforms or video conferencing. Several studies have demonstrated the potential for mHealth technologies to support mental health service delivery in LMICs [15]. Our study suggests these technologies could also support mental health training programs for ASHAs in rural India.

Limitations
Our study has several limitations that should be considered. First, the study was conducted in a single district in Maharashtra, India, which may limit the generalizability of the findings to other regions of India or LMICs. Second, the study used a pre-and post-test design, which may be subject to testing effects and social desirability bias. Third, the study did not evaluate the long-term effectiveness of the training program or its impact on mental health outcomes. Future studies should address these limitations by conducting multi-site studies with longer follow-up periods and incorporating measures of mental health outcomes.

Conclusions
The study found that the training program was effective in improving the knowledge and skills of ASHAs in identifying and managing mental health disorders. Improving the capacity of ASHAs to identify and manage mental health disorders can improve the health outcomes of individuals and communities in rural areas and reduce the burden of mental health disorders in India. Further research is needed to evaluate the long-term impact of mental health training programs for ASHAs and to develop sustainable models for scaling up such programs in rural areas.  Asks appropriate questions to gain information about the intensity of symptoms 7

Appendices
Scores correctly for the items that are not asked. 8 Scores correctly for the items that are not responded by the patient. 9 Is able to control own emotions while collecting information.

10
Does not hesitate to ask questions related to sexual life, drug abuse and suicide information.

11
Is confident in handling the GMHAT-PC Marathi version.

12
Can use the GMHAT-PC Marathi version interview in sequential order.

13
Collects relevant information from informants/family members before scoring.
14 Interprets the information by patient correctly.

15
Records information in the GMHAT-PC android version correctly. of the study. The study was approved by the Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) and granted ethical approval (IEC/DEC-2019/8543). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.