By: Preetika Banerjee

“What mental health needs is more sunlight, more candor, and more unashamed conversation.” – Glenn Close

Mental health represents a growing global public health concern. Given its nature, it requires tailored approaches that are sensitive to the individual’s needs and promote their sustainable growth and healing. Community health workers (CHWs) are an emerging resource for reaching out to individuals in underserved populations in both the US and other countries with mental health services. The 10th October was World Mental Health day. In recognition of this event, we at CHW Central would like to end the month with an overview of the current literature on, and relevant recent CHW-led approaches for, addressing mental health.

The provision of mental health services is an important concern in the CHW community. CHW Central has links to over 80 resources on CHWs and mental health services; that’s nearly 7% of our available resources. These links highlight a range of CHW programs that have been piloted and implemented in Low and Middle Income Countries . They involve building on CHW knowledge regarding the mental health of their patients, training CHWs to manage cases of domestic violence, and preparing CHWs to support and link patients to services for depression.

One such resource, Barnett et al.’s 2018 systematic review “Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations”, identified 39 trials involving CHW delivery of mental health interventions. Based on the evidence, the authors note: “CHWs have been involved in delivering mental health interventions to address a range of clinical disorders, including depression, anxiety, psychological trauma, and disruptive behavior disorders.” They conclude: “Given accumulating evidence that CHWs can effectively deliver evidence-based and informed practices, training and supporting CHW to address mental health disparities seems like a promising approach to improve care for underserved communities.”^[1]

In our 2017 feature, Tomorrow’s CHWs: Promoting mental health and wellbeing, Dr Alison Schafer discussed task sharing of mental health services to CHWs, its effectiveness for addressing mental health needs, and various global endeavors that have been focused around it. The PRIME (PRogramme for Improving Mental health carE) study, carried out in 2012, looked at one district each in five countries: Ethiopia, India, Nepal, South Africa and Uganda. It also concluded that task-sharing mental health services should be feasible across these countries^[2].

Considering that three-quarters of the global mental health burden exists in low- and middle-income countries where workforce shortages are often greatest, CHWs are an important resource for reaching those in need. ^[2] With tasks tailored to particular population and health system needs as well as appropriate training, CHW involvement in mental health service provision can be customized to suit specific country contexts.

Country Examples

Indonesia: CHWs in Indonesia are encouraged to examine mental health problems that pregnant women face. National policy documents “the Guidance of Integrated Antenatal Care^[3]” and the CHW Manual^[4] outline their role in mental health service provision for this population. A study assessing the feasibility of this practice in the Surabaya region of the country demonstrated that the health system and available resources provide suitable opportunities for CHWs to effectively detect and refer cases of perinatal depression to the integrated mental health care system.^[5]

South Africa: Often the only healthcare workers to see patients on a regular basis, CHWs regularly find themselves addressing mental health needs, even without the requisite training. In South Africa CHWs provide comprehensive chronic support to patients; this frequently includes treating mental illnesses. Yet, these workers do not receive any standardized training to provide these services. Efforts to address this gap show promise. In the Western Cape region one study observed that provision of structured mental health training to CHWs was acceptable and feasible. The CHWs displayed improved knowledge, confidence, and attitudes post the training.^[6]

Kenya: With only 23 psychiatrists in public service (of which only seven are deployed in the provinces), there are few options for most citizens to access mental health services from a qualified provider. In such contexts, building the mental health workforce to meet the needs of a growing population is essential.

The integration of CHWs into Kenya’s mental health taskforce has been a policy in the works for over two decades. In order to facilitate this, Jenkins et al. mapped prevalence of mental illness at district and health center levels and interviewed traditional healers and primary healthcare staff to better understand provider perspectives of mental health. Using these data, the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization Collaborating Center (WHOCC) developed and implemented a mental health training course for CHWs. Qualitative interviews conducted with CHWs post training indicate that the training was helpful and that it benefited CHWs in the diagnosis, management, treatment, and referral of mental illnesses.^[7]

The Road Ahead

Considering the growing evidence in support of shifting selected mental health service tasks to CHWs, program leaders need to consider formalizing their roles. This includes building the systems needed to support CHWs to provide selected mental health services, appropriate for the contexts in which they serve. It also needs to include integrating their roles into CHW job descriptions, evaluating the effect of adding this service on their workload, and training them to provide mental health services so they are appropriately equipped and accountable. Finally, suitable support systems, linkages, and supervision are needed to ensure the quality of CHW mental health services and enable CHWs to refer their patients for more specialized care as needed. Simply devolving selected services to CHWs without building the system around them to support higher-level care will leave CHWs in the situation of offering only a little of what patients require while telling them, whether directly or indirectly, that they can’t help them get the care they need to address their full mental health service needs. As CHW provision of mental health services expands, further research and monitoring of the impact of their work on patient outcomes is required.

[1] Barnett, M.L., Gonzalez, A., Miranda, J. et al. Adm Policy Ment Health (2018) 45: 195. https://doi.org/10.1007/s10488-017-0815-0

[2] Emily Mendenhall, Mary J. De Silva, Charlotte Hanlon, et al. Social Science & Medicine (2014) 118 https://doi.org/10.1016/j.socscimed.2014.07.057.

[3]Ministry of Health Republic Indonesia. Guidance for integrated antenatal care. Jakarta: Ministry of Health of Republic of Indonesia; 2010.

[4] Ministry of Health Republic Indonesia. Manual book for cadres of Posyandu. Jakarta: Promotion Centre of the Ministry of Health of Republic of Indonesia; 2012

[5] Endang R. Surjaningrum, et al. Int J Ment Health Syst. 2018; 12: 27. Published online 2018 May 31. doi: 10.1186/s13033-018-0208-0

[6] Goodman Sibeko, et al. BMC Psychiatry. (2018); 18: 191. https://doi.org/10.1186/s12888-018-1772-1​

[7] Rachel Jenkins, et al. Mental Health in Family Medicine. (2010), 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925163/