Thank you so much for the invitation and chance to speak, I'm not going to speak about the act.
I'm here to speak about another programme that we we run.
It's called Murtha, and the word Murtha in many Indian languages means empathy.
And it's a programme that we've developed over the last five to six years with
a lot of formative work that went on before what I'm going to present to you,
which which appears like a fully formed programme.
But there's a whole host of work in terms of formative work in designing it that went on many years prior to that.
Before I start, I just want to thank our funders,
which was the Grand Challenges Canada and Marijuana Health Initiative, which continue to fund our programme.
The purpose behind me really is is multiple.
One is to move away and shift the paradigm of mental health, you know, to what we call what we like to call as democratising mental health.
We want to get away from a notion of mental health as being a health and an illness condition,
but much more something that affects all parts of your life and which needs to be integrated into an entire whole,
as opposed to be seen as something to be dealt by professionals alone.
The second thing that we wanted to do is we realise, as L.A. docs showed you,
that there's a lot of social capital in our communities and we want to tap into that social capital.
You know, there's always this notion that government should provide things or where will the money come from?
But there's actually a lot of social capital which we could tap in very easily.
We don't use any mental health metaphors in our in our programmes, as you will see, actually, I mean,
although I've said community led mental health initiative, that's the description we use when talking to professionals.
What we call it is something about promoting wellness and reducing distress on our programme
does not actually have anywhere in the entire thing on mental health that talks about distress.
It talks about stress. We use a lot of local metaphors, so people use metaphors like tension.
So we say, Look, we here, the programme will help you deal with tension. It will help you deal with stress.
It helps you deal with day-to-day issues. It's not a mental health programme.
And you know, the most important thing is that this whole programme has a certain degree of community ownership.
So we work with Village Council to juggle budgets. We get into a village, we talk to the village franchise, we get them involved,
and we use their help in identifying volunteers within the programme within how we start work.
So. So who? Who delivers what we do? This is what we call them champions.
And this is one of our champions. McSwain, who lives in a village in Maisano district, is as many of our champions are not very highly educated.
She I think she was educated about eight standard and her husband supports her work.
What she does. All of our champions are volunteers. So nobody gets paid for doing the work.
They they they work about roughly two hours a day,
and that's about the work they do for the programme and the rest of the time they do other things in their lives,
which is what might be farming their rural communities.
So there's a lot of farming activity, people out, household work to do, and they do all of that.
And in addition, they'll probably do eight to 10 hours of work for the programme.
And McSwain always says that it's given her a chance to help her village and made her a very confident woman.
This is very interesting because when we first tried to talk to McSwain, she wouldn't talk to us like us.
I'd be photographs. She wouldn't even allow us to talk to us without kind of looking away from us.
And then over a period of time, she's now become confident enough to stand there and be photographed for this particular picture.
So what do we cover? We cover about we cover our district called Manzanar, which is in in Gujarat,
very close to the border, then Gandhinagar, which is way the state capital is.
It's a district with about two million population, of which about one and a half million is rural population.
And in that one and a half million, it's a one to one million adult population.
So that's the population we cover. There are four hundred and fifty two villages and our programme is being scaled up.
So at the moment we reach about 450 villages.
By the end of the year, we will probably have covered every single village, so we will have some service that we provide in every single village.
We currently have about six hundred and fifteen champions and the number will go up to about 800 to 900 by the end of the year.
So this is a programme which runs at scale to answer, perhaps question what happens when you try to run programmes at scale?
Are they sustainable? Can they continue and do they actually deliver what they promise to deliver?
So what? What champions do? We don't see them as non-specialist health workers.
As I said, we try to get out of this health worker health domain.
So one of the things they do is if they identify people who have a common mental health problem,
which is our which is me trying to explain to you a common mental disorder.
That's not how they see it. They see it as a certain set of symptoms.
They will provide them with four to six sessions of counselling if they saw somebody who had what is called as a very severe mental health problem,
which would be something like psychosis or bipolar disorder.
They will then make a referral to them to the psychiatric services of this district, and they normally make that effort to actually accompany them.
They go with them, they help them navigate the health system. They will ensure the follow up happens with them.
The third thing that they do is they they try to increase awareness in the community around stress and mental health issues by showing films.
We give these champions a mobile phone, which is like a, you know, a smartphone like this, which has four films loaded on it.
And these films are not about mental illnesses. They are about what we call antecedents of mental illnesses.
So they are friends on unemployment. They are a film on marital discord.
There's a film on interpersonal violence, and there is a film on alcohol use and its effects on the family.
And these are 10 minute films.
We designed them using a director from Bollywood, and so they are designed and are going to Bollywood style, song and dance.
They're not documentaries. They don't try to preach to you. They tell you a story.
They're meant to be interesting. They're meant to be fun. And these films are only 10 minutes long.
I mean, you can go on Google and check them up. They're they're on YouTube.
The films are loaded on YouTube. They are. They've also been.
Subtitled in English for you to understand if you wish, but we use them, and they were developed after a lot of field testing,
piloting and informative work that went into it and they tell a story, and the films are meant to be shown to small groups of four or five people.
So you know what? A champion will collect four or five people, and we call it, we don't call it broadcasting.
We call it narrowcasting. So we're not trying to broadcast. We won't actually do narrowcasting, have four or five people sit there.
Every film will stop it. Every two minutes, it'll pause at two minutes automatically.
The champions will ask questions, will raise a discussion and the idea is to be not a passive observer of a film,
but to get actively involved in understanding what happens.
And and that actually provides a lot of help to our champions to identify people in the village who might need help.
Somebody says, Well, you know, my neighbour, she's got the same problem as this film is showing, and then they kind of approach that person.
The other important thing that our champion does is that they enable access to social benefits.
So the whole bunch of social benefits that the Indian government offers widows, pensions, disability, pensions,
all sorts of things which are impossible to access because getting access to those pensions are getting access to those benefits requires paperwork,
which is very difficult to navigate. I mean, if you ever go down there, you realise how hard it is to actually get the paperwork ready.
Champions have an app which is on their mobile phone, which if they enter some details about you into it,
the app will tell them which benefits you might be entitled to.
And they are trained in how to fill up the forms so that for all these benefits,
they'll take the forms and get you to fill up and they'll go and submit the collector's office.
Most of the time,
you need to submit something in the collector's office and then chase it up with the collector's office to ensure that that benefit is delivered.
So they do a lot of social care, not just health care.
And finally, they use a smartphone to document their work.
So, you know, they kind of put in how many people they've seen when they've seen, who they've seen, who they worked with.
And what are these sessions, these sessions, largely the six sessions of counselling that they do, are largely based on three techniques.
They're based on active listening problem-solving techniques and behavioural activation, again,
stuff that has been shown to be effective in research studies and that there's a structure of these sessions.
It's important to understand that these sessions are not delivered in a clinical setting.
They are delivered in the community very often at the person's home,
sometimes in public areas like I remember this champion telling us which I thought a very fascinating.
She said that she delivered one of the session to this woman while women, while they were both at the, well, getting some water.
And she said, I sat her down and we had a 20 25 minute session and it worked very well.
So, you know, they're delivered at different places that deliver what people want.
People say I would rather come to a place, not be at home than fine. That's equally OK.
And they deliver five to six such sessions, it doesn't stop them from doing more, but we tell them to try and keep it time limited.
And these champions receive about seven days of training. It's around thirty five hours of training that they receive.
The training again again has been developed with a lot of formative work which went in.
So our training is called animation training. We don't have any lectures.
We don't have any PowerPoints, and everything is done in the form of the entire.
Training is done in the form of a rule play because many of our champions are not literate, you know, and they're not sat in the classroom.
So if you did a forty five minute lecture for them, there's no way we're going to get their attention. So a lot of it is role play.
A lot of it is about working out scenarios and how will you deal with them?
What will you do? There's a lot of observational learning that happens, and usually the training is divided over two days at a time.
We do it over three weeks. It's only seven days, but it's not seven days in a row.
We find that our champions will not take that in if we try to do it all at seven days and then they get a refresher training every six months.
So they come back in for a day and we do some refresher training on what they are up to and how they can address specific issues.
And this is how the whole structure of the programme is organised.
So there's a project manager for a district who is up, who is an employed professional.
So we pay for them. They are on a salary. There are community facilitators and the community facilitators tend to be young people from within the
district who might have a social work background or a bachelor's in social work or a psychology bachelor's.
But people who live within that community. And again, they are paid a salary.
So these are the two paid kind of people in the programme.
The champions are the ones who actually deliver the programme and they are volunteers.
And there's also some another level called Mitra. And I'll explain to you what Mithras mean in the context in Gujarat.
But they don't do. They don't do a lot other than help the champions identify people who might be in need of treatment.
The reason why we did this innovation in Gujarat is because we found that in places like in Gujarat,
in the villages, the villages are divided by cost and religion very actively so that in a village of two thousand,
if I champion came from a particular caste, they would have actually never visited the other part of the village where some other caste,
which is amazing, but it's only a village of two thousand people. And so these metros tend to be from other parts of the village where they may
not have access to and so they can do a full coverage of the entire village.
So that's how the whole thing is organised and we do kind of track our champions progress.
So what I forgot to tell you is that the community facilitators meet with the champions every hour,
every fortnight, and they provide them with mentoring and supervision.
So they will actually say, OK, what are you? What are you working with? What are you doing?
Are you stuck somewhere? Where are the issues? OK, you have a problem. Maybe I'll come with you and see how we can solve it.
So sometimes this was a modelling of treatment that is done by the facilitators.
And obviously, this is how it will go as we we find that it takes our champions at least three to four
months before they feel confident enough to start dealing with things on their own.
So they get training. Then they have a bit of a hand-holding phase when the facilitators work with them to get them ready to work with other people.
And then we kind of monitor how well they are doing.
There are times when we ask people to leave, when we say, Look, we don't think are really suited for this,
and maybe you should not continue work and we actually ask them to go because we don't think they're doing the kind of stuff we would want them to do.
You would ask me what the attrition, because I think this is a volunteer driven programme, what's your attrition rate?
Our attrition rate across the last 12 months is about 20 percent, and the largest chunk of the attrition actually happens after phase one.
When the training is over, many people take the training and then they decide this is not actually what I wanted to do.
So you get the biggest chunk of attrition there.
You don't get much attrition afterwards and then you get an attrition towards the end after a year when people say, Look,
I've done my bit for society, I want to do something different or many of them have even gone on to do other things.
So like one of our champions at the end of the year, stood for elections to the local Punjab and became the Punjab chief and said,
Now I can't do this, I've got more important things to do and so quit doing our work.
But interestingly, then allocated twenty thousand rupees in her village for this work because she
was now the person who was in control of the finances at the at the Punjab.
So people do all sorts of interesting stuff. In the last hour, this is nine months of data which I've got here for you.
We reached out to about 9000 beneficiaries who have received counselling sessions, so that's and we expect to end the year with around 12000.
Hopefully by next year will be reaching around 15 to 20000 people.
That's about on an average of five sessions, so that's close to about 50000 sessions that have been delivered in the last one year.
Around 2000 people with severe mental disorders have been linked in with the psychiatric
service and maintained in the psychiatric service for follow up for treatment.
About 4000 people have received various kinds of social benefits, and around 45000 people have viewed these films that we have.
And this is again, this is like an ongoing thing.
So if I meet you after three months, these numbers will change because we continue to roll out and scale it up.
So you're going to see all of this is wonderful and nice, but where is the evidence that any of this works?
I mean, that's usually the thing. This is all wonderful. Nice thing.
Everyone feels good. Touchy feely stuff. Where is the evidence at work?
So I'm we actually. We actually did do. And this is something that we are interested in.
So we actually did do a proper control evaluation of what we were doing.
And I'm going to show you some results now. They're hot off the press.
The reason I say hot of the press, as in because are Sturbridge trial, which I'm going to talk to you or just ended in September.
So I only got hold of the results now. So I would request you to not either put these results that I'm going to show you in the public domain
because the paper is getting prepared and we'll be ready and published in the next month or two,
hopefully. So what did we do?
Most of the research that you've seen up to now were largely the research studies.
So, you know, if you go back to any of those studies that I've showed you about,
these programmes no longer exist, then our programmes, which continue to run, they were set up for a trial.
When the trial ends, they finish.
And as I've said, many of the things that were run by people who who are very motivated and it was about doing a trial.
Whereas what you have here is a real life programme which continues to run,
and the research has been kind of mounted on top of that real life programme.
So it's kind of doing it in the reverse order. So you have a programme and you evaluate an existing programme and kind of tries to
answer what Lakshmi was asking about what happens to programmes that you do run.
And so we used a step wedge cluster, randomised controlled trial design.
I won't get into the details of it, but this is a design which is well suited when you're trying to evaluate an implementation research design,
when you're trying to evaluate at scale programmes in real life settings.
And basically, what happens is that every cluster acts as its own control.
And by the time you finish the entire trial, you actually provided the service to everybody.
So ethically also, it tends to be good because the control also get the service that you're going to deliver.
And you're not just walking out without delivering the service to the control, especially with an effective service.
What we had was we looked for use GHQ 12, and the primary outcome was improvement on GHQ 12, and there's a whole host of secondary outcomes.
In particular, we are interested in outcomes such as increased social participation, satisfaction reduction and disability.
And that's a whole whole list of secondary outcomes of the trial.
Had the trials been registered with the trial registry of India and the question of enhanced use.
You know, the usual care, what is usual care.
And we said in the control group, people would get enhanced, usually get an order, then horns usually cleared.
Anyone who met our criteria for being what GHQ calls case, which is a terrible term.
But that's how GHQ called it a case. They would explain the effects of stress and courage to seek help and provided handouts
on how to access mental health services and also ask about utilisation of services.
Again, because this is a real life trial, we were not interested in controlling usual care because if you do that,
then you're back to the old research design. So I know I have five minutes.
I'm going to quickly run you through this. I'm going to highlight a couple of points.
The first is that although we use a GHQ cut-off of three, which is what is used to indicate common mental disorders in community settings,
the average scores, as you can see, are above six both in the control and the intervention side, and six is usually a clinical score.
OK, if you went to a clinic, people coming to a mental health clinic and if you did get scores on them,
people about six are most likely to have a common mental disorder. So, you know, you're you're looking at people who, even by clinic standards,
would have met a condition to be called as having a mental health condition.
The GHQ score is interesting because the scores of 12 to 14 are in the range of what is called as moderate depression.
So these are people who if you normally just saw them with a Q and rated them, they would have scored a moderate depression.
The of the two standard treatment for moderate depression is therapy or antidepressant.
So these are people who would have otherwise qualified to receive therapy or antidepressants.
The G8 the G8 scores are also in the moderate anxiety score level.
So what did we find at the end of three months? I'm not, I know I have a little time and I can talk about the trial in long detail.
But what do you find at the end of three months is that people who have recovered in in are people who received the intervention.
The likelihood of recovering the odds ratios are two point three at the end of three months.
OK, so that 2.3 times more likely to have recovered from this common mental disorder.
And at the end of eight months, which is very interesting because we did an eight month follow up to see four,
we were looking for sustainability of improvement, but what we found is actually an even further increase.
I know the kind of confidence intervals are large and all of that stuff, but there's actually an increase at the end of eight months.
If nothing else, at least these improvements tend to be sustained.
So if people get better, they not only get better, they remain better at the end of eight months.
And all of our continuous measures assure improvement at both three months and eight months,
and as you can see it, eight months, even the quality of life measures have started to improve,
which you don't see that quite the social participation measures which are not so good at three months start to improve at the end of five months,
eight months and even the disability scores have started to improve.
So. So not only is improvement getting sustained,
but you're now seeing and this is something we anticipated that social participation and disability improvements will have a lag.
People get better and it takes time before they get better, then start actually being more functional.
And so after a lag of eight months, you start seeing people getting better like that.
And I know you kind of going to say, OK, this sounds all very good, but look what it what does it say?
As compared to other studies, Friendship Bench uses a very similar structure to ours and band uses badly health workers.
We don't use paid health workers, and these are some of their findings from their study.
Again, they did a very standard, randomised controlled trial with health workers who were trained and paid.
But if you look at the kind of improvement and if we look at our improvements at the end of eight months,
we have very similar kind of rates of improvement. These are adjusted mean differences at the end of eight months.
And then this is the one which I like most, which is if you look at it,
if you compare it to antidepressant studies because everyone thinks that antidepressants are the gold standard for treating depression.
Well, the odds ratios for antidepressant studies range anywhere from one point three to two point one one three or two point two.
We got an odds ratio of two point three. And if you think, Oh, this is carrying it too far,
then I think you need to really question yourself about what your beliefs about mental illnesses and antidepressant treatments and all are.
I think there's a lot of bias in our own minds about how we conceptualise depression and its treatment.
You know, I mean, difference on IQ scores is about one point nine points, and B HQ nine has a smaller range.
It's a zero to seven range. If you look at the antidepressant scores on the diet as the main differences are one point ninety seven,
and that's a scale with a range of fifty seven points.
So in a fifty seven point scale, you get a two point change on a twenty seven point scale, you get a two point change.
I believe we're doing far better or our champions are doing far, far better than even antidepressants would do.
And our effect sizes range from point three two point four, which is similar to what you get the effect sizes with antidepressants.
So how good are people at identifying people with common mental disorders?
And this is just a number to remember about 60 percent of the times they got it right.
If you took a standard measure, 60 percent of the times the standard clinical measure versus the R ID turned out to be right.
We I don't have a data on sensitivity because we didn't structure the trial for sensitivity.
We were interested in specificity.
Health care utilisation, as you can see, there's very little health care utilisation on the on our intervention group,
whereas on the control group, what you see is that there's a lot of effort is being made, but people don't go for treatment.
Got one minute and two more slides to get through these two slides are about what are health economics?
She told me. So I'm not very knowledgeable, but basically what our health economics said was if you look at the total savings,
which in savings to community savings, to individual savings to society and savings to government.
If you add up the total savings, then it adds up to what, forty five thousand rupees?
This is because of the less number of health care visits that you make, the the cost of OPD visits and all of that included together.
And those are people that we are now getting ready on the economic impact.
The other financial impact that we looked for in expenditure per household.
And as you can see that there's a huge amount of borrowing that are people who are not receiving treatment were doing for health care costs.
So people who are borrowing money to receive health care when they have some common mental disorder,
then very often these people are not identified as having a common mental disorder.
They go to a physician who orders lots of tests to give them some medicines, not necessarily receiving anti-depressants.
So there's a lot of challenges in how you do this and how do you sustain it?
We've now got funding from Marijuana Health Initiative to continue this for three more years, so we've got funding.
We will cover the whole district in three years.
We're now trying out our social franchising model, so we've tied up with the Maharashtra government agency, which is a neighbouring state,
to make this into a social franchise, which they could then implement, and we would actually monitor and provide evaluation on.
We are modifying it to use with young people. So we are working with two or large universities in Pune to try and modify this whole
thing so that it would be used in the college for young people within their own settings.
And finally, what we don't do very well is dealing with interpersonal violence or domestic violence,
and that's something that we are now planning to build more work on and try and do better.
We are also hoping we are also hoping to do a bit more graphic work on trying to understand the
context of how these people actually are effective because their effective is still a black box.
What we don't know is why is it effective and what is the stuff that works when people talk to other people?
So that's something that we are hoping to do in the next couple of years, and I'm to stop your I hope I didn't run over time.
Thank you so much.