The project will refine and improve the digital training program developed as part of the ESSENCE program, contextualize and adapt it for use in PHC settings in Gujarat (EMPOWER Gujarati version of HAP and the accompanying competency tools), and assess feasibility and acceptability by frontline health workers.
To refine and improve the existing digital training program developed as part of ESSENCE, we organized design workshops with ASHAs and other non-specialist health workers (such as ASHA facilitators, ANMs, and other non-specialist health workers) and conducted informal group discussions to get their feedback and insights on the digital learning content and features in order to enhance engagement and effectiveness of the existing digital training platform (and to make the program more interesting for participants) at SEWA Rural, Jhagardia.
The specific steps involved in contextualization are:
- Adaptation and translation of the existing content (16 ESSENCE modules + competency assessment)
- Feedback from stakeholders and users for Gujarati content
- Dubbing and subtitling of the content
- Integration of the content them into the existing TeCHO platform, followed by initial pilot testing of the adapted program to ensure feasibility and acceptability
Adaptation and translation of the existing content (16 ESSENCE modules + competency assessment)
An important reason to conduct the adaptation work specific for Gujarat because there are limitations associated with universal applicability of the psychological treatments despite extensive evidence of their effectiveness. Every psychological treatment is developed in a cultural context, thus there is need to adapt the treatment in another cultural context to preserve the efficacy of the treatment. Adaptation process includes incorporating contextually relevant and meaningful elements for the treatment to increase acceptability, patient satisfaction and, ultimately, treatment effectiveness (Bernal & Scharrón-del-Río, 2001; Sue, 2003; Castro et al. 2010). There have been various systematic reviews of adaptations of mental health interventions (Griner & Smith, 2006; Huey & Polo, 2008; Benish et al. 2011; Smith et al. 2011).
A systematic review for adaptation of psychological treatment conducted by Chowdhari et. al., emphasized the importance of a systematic procedure in the cultural adaptation of psychological treatment and adaptations in the implementation of the treatments rather than their content. The Healthy Activity Program (HAP) was designed for lay counsellors and was evaluated in Goa as part of the PREMIUM trial. It was then adapted to the local context of Madhya Pradesh and adapted for training using a digital platform as part of the ESSENCE project. The context of these states is very different than that of Gujarat. Both these states not only have different languages and culture, but there is a marked difference in human development indicators as well as functioning of the public health system. Therefore, it is necessary to carry out systematic adaptation of the digital training program.
The intervention adaptation process involved first translating the existing digital training program content (17 modules) and competency assessment measure developed as part of ESSENCE from English/Hindi into Gujarati (the ESSENCE program initially involved combining the content from the Healthy Activity Program (HAP) manuals, that were in English, and adapting this content to the local context in Madhya Pradesh and translating this content into Hindi). Following it, the quality and fidelity check for the translations was done by HAP consultant and content expert to ensure that we don’t deviate from the original script. In addition to this, the content was also reviewed by the SEWA Rural team to get further suggestions to make it more user friendly.
Feedback from stakeholders and users for Gujarati content
The formative research to adapt the existing digital training intervention content adopted a series of workshops with non-specialist health workers at SEWA Rural, Jhagadia. The aim of the workshop was to orient the participants with the Healthy Activity Program (HAP) script, gain feedback on language clarity and to make the content more comprehensive & palatable. All the feedback received were incorporated and final adapted content packages are derived ready to be dubbed and subtitled.
“It is really a good work and helpful for everyone. Now, we know what is depression”
– ASHA Worker, SEWA Rural (Workshop 1)
“Till today we thought mental means mad only and mental health as “crowd of mental people”. But we are fortunate enough to learn the actual meaning of it. Thus, we can help people specially friends and family who are suffering from mental health problems.”
– ASHA Supervisor, SEWA Rural (Workshop 1)
Dubbing and subtitling of the content in Gujarati
This process started with the identification and selection of the agency. All the identified agencies were contacted via email and phone calls and were briefed on service requirements. Contacted agencies were asked to provide a sample of their prior work and create a 1 min HAP video from Hindi to Gujarati. All the samples received were assessed and compared for quality, tonality, delivery, dubbing, subtitling and editing by team. The finalized recording agency then dubbed and subtitled all the videos for 17 modules (16 HAP Modules + 1 COVID Module) in Gujarati.
Following the creation of videos in-person workshops were conducted at SEWA-Rural, Jhagadia and Gujarat Institute of Mental Health, Ahmedabad, to get the feedbacks on the Gujarati HAP content. The aim of the workshop was to get feedbacks on content, quality, pace of the videos, make the content more comprehensive & palatable. This involved review of the content for modifying the language that was most acceptable to the target group. Feasible changes were incorporated to the HAP content. The course was then finalized and locked for integration into Sangath and TeCHO platform.
“The videos will help us a lot, for example, if you are in the community today and you have encountered a female with similar symptoms. We can come back, see the videos and go and talk to them on the next day.”
Field supervisor, SEWA Rural (Workshop 2)
“After seeing the videos here, if I see it for one-two time times more, I will be able to memorise it, along with this if we work in field with this, it will easier to remember and after that if I see anyone with similar symptoms or in similar situation, I will be able to recall that this is similar to what we have seen in the videos.”
ASHA Worker, SEWA Rural (Workshop 3)
Integration of the content them into the existing TeCHO platform, followed by initial pilot testing of the adapted program to ensure feasibility and acceptability
All the videos were compressed to save space and for faster streaming in smartphones. The research assistants were oriented and trained on Sangath Learning Management system and TeCHO platform. This included structure development of the Sangath LMS/TeCHO containing compressed videos, post video quizzes, reading material, end module assessment quizzes, grading system, features of completion and restriction access. Subsequent to the course formation, it was thoroughly checked by the experts and changes were updated. The final Sangath LMS/TeCHO platform is now ready for pilot testing of the adapted program with a group of 20 ASHAs and 10 CHOs to ensure feasibility and acceptability at SEWA Rural, Jhagadia in Gujarat.
The project will ensure that the enhanced digital platform can be accessible in a completely offline format.
The entire Healthy Activity Program (HAP) Gujarati e-learning course has been uploaded and is available to use on twi platforms in a completely offline format.
The Sangath Learning is a Moodle-based Application which can be accessed through the website and the mobile app. It allows tracking a learners’ progress, managing access to course activities and generating performance reports. Specific features from the Moodle platform that have been used to support the digital training intervention for this study include: accessible content from a smartphone application; learner performance tracking and metrics; customizable interface; user-friendly dashboard; and content that can be accessed without internet connection, which is especially important for delivering a training program in rural areas of Gujarat where connectivity is often poor.
The 17-module course which comprises of expert lecture videos, role-play videos showing clinical scenarios, PowerPoint presentations, reading materials, interactive quizzes embedded within the modules, and assessment questions has been uploaded in Gujarati on the Sangath Learning Management System. The application has been tested iteratively and is ready to use.
TeCHO Platform (“Technology enabled Community Health Operation”)
TeCHO is a web and mobile based application which is used by all the healthcare workers in public health system across the entire state of Gujarat. The users are provided credentials as per the cadre and gets the accessibility as per the role. The platform generally used for digital health data transformation and reporting now also serves as a learning platform for healthcare providers where they can access the courses they are enrolled in. The platform also generates reports and alerts for the due work and the new assignments allocated.
As part of the project we have leveraged the use of TeCHO platform and created the HAP course on TeCHO production platform with assessment questions. The aspects of report generations and participant’s progress tracking for the participants are under development