{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T04:23:44Z","timestamp":1792038224242,"version":"4.4.0"},"reference-count":13,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2018,4,18]],"date-time":"2018-04-18T00:00:00Z","timestamp":1524009600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100009053","name":"Wellcome Trust\/DBT India Alliance","doi-asserted-by":"publisher","award":["IA\/I\/13\/1\/500879"],"award-info":[{"award-number":["IA\/I\/13\/1\/500879"]}],"id":[{"id":"10.13039\/501100009053","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004828","name":"Grand Challenges Canada","doi-asserted-by":"publisher","award":["0524-01-10"],"award-info":[{"award-number":["0524-01-10"]}],"id":[{"id":"10.13039\/501100004828","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["wellcomeopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Wellcome Open Res"],"abstract":"\n Background:<\/ns4:bold>\n There are large gaps in the delivery of mental health care in low- and middle-income countries such as India, and the problems are even more acute in rural settings due to lack of resources, remoteness, and lack of infrastructure, amongst other factors. The Systematic Medical Appraisal Referral and Treatment (SMART) Mental Health Project was conceived as a mental health services delivery model using technology-based solutions for rural India. This paper reports on the operational strategies used to facilitate the implementation of the intervention.\n <\/ns4:p>\n \n Method:<\/ns4:bold>\n Key components of the SMART Mental Health Project included delivering an anti-stigma campaign, training of primary health workers in screening, diagnosing and managing stress, depression and increased suicide risk and task sharing of responsibilities in delivering care; and using mobile technology based electronic decision support systems to support delivery of algorithm based care for such disorders. The intervention was conducted in 42 villages across two sites in the state of Andhra Pradesh in south India. A pre-post mixed methods evaluation was done, and in this paper operational challenges are reported.\n <\/ns4:p>\n \n Results:<\/ns4:bold>\n Both quantitative and qualitative results from the evaluation from one site covering about 5000 adults showed that the intervention was feasible and acceptable, and initial results indicated that it was beneficial in increasing access to mental health care and reducing depression and anxiety symptoms. A number of strategies were initiated in response to operational challenges to ensure smoother conduct of the project and facilitated the project to be delivered as envisaged.\n <\/ns4:p>\n \n Conclusions:<\/ns4:bold>\n The operational strategies initiated for this project were successful in ensuring the delivery of the intervention. Those, coupled with other more systematic processes have informed the researchers to understand key processes that need to be in place to develop a more robust study, that could eventually be scaled up.\n <\/ns4:p>","DOI":"10.12688\/wellcomeopenres.14524.1","type":"journal-article","created":{"date-parts":[[2018,4,18]],"date-time":"2018-04-18T04:35:06Z","timestamp":1524026106000},"page":"43","update-policy":"https:\/\/doi.org\/10.12688\/wellcomeopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":9,"title":["Operational challenges in conducting a community-based technology-enabled mental health services delivery model for rural India: Experiences from the SMART Mental Health Project"],"prefix":"10.12688","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6835-6175","authenticated-orcid":false,"given":"Pallab K.","family":"Maulik","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sudha","family":"Kallakuri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siddhardha","family":"Devarapalli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2018,4,18]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"1575-86","DOI":"10.1016\/S0140-6736(13)61611-6","article-title":"Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010.","volume":"382","author":"H Whiteford","year":"2013","journal-title":"Lancet."},{"key":"ref-2","article-title":"The World Health Report 2001- Mental Health: New Understanding, New Hope.","year":"2001"},{"key":"ref-3","doi-asserted-by":"publisher","first-page":"2581-90","DOI":"10.1001\/jama.291.21.2581","article-title":"Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.","volume":"291","author":"K Demyttenaere","year":"2004","journal-title":"JAMA."},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"e13","DOI":"10.1017\/gmh.2015.11","article-title":"Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Programme for providing innovative mental health care in rural communities in India.","volume":"2","author":"P Maulik","year":"2015","journal-title":"Glob Ment Health (Camb)."},{"key":"ref-5","doi-asserted-by":"publisher","first-page":"010408","DOI":"10.7189\/jogh.07.010408","article-title":"Increasing use of mental health services in remote areas using mobile technology: a pre-post evaluation of the SMART Mental Health project in rural India.","volume":"7","author":"P Maulik","year":"2017","journal-title":"J Glob Health."},{"key":"ref-6","doi-asserted-by":"publisher","first-page":"565-75","DOI":"10.1017\/S0033291716002804","article-title":"Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach.","volume":"47","author":"P Maulik","year":"2017","journal-title":"Psychol Med."},{"key":"ref-7","article-title":"Patient Health Questionnaire-9","author":"I Pfizer","year":"2013"},{"key":"ref-8","article-title":"Generalized Anxiety Disorders-7","author":"I Pfizer","year":"2013"},{"key":"ref-9","article-title":"Instructions for Patient Health Questionnaire (PHQ) and GAD-7 measures.","author":"I Pfizer","year":"2013"},{"key":"ref-10","article-title":"WHO Mental Health Gap Action Programme (mhGAP).","year":"2011"},{"key":"ref-11","doi-asserted-by":"publisher","first-page":"385","DOI":"10.1186\/s12888-017-1525-6","article-title":"Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India.","volume":"17","author":"A Tewari","year":"2017","journal-title":"BMC Psychiatry."},{"key":"ref-12","article-title":"New Pathways New Hope National Mental Health Policy of India","year":"2014"},{"key":"ref-13","article-title":"Mental Health Action Plan 2013-2020","year":"2013"}],"container-title":["Wellcome Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2019,10,10]],"date-time":"2019-10-10T14:22:30Z","timestamp":1570717350000},"score":1,"resource":{"primary":{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,4,18]]},"references-count":13,"URL":"https:\/\/doi.org\/10.12688\/wellcomeopenres.14524.1","relation":{"has-review":[{"id-type":"doi","id":"10.21956\/wellcomeopenres.15811.r32935","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.15811.r32937","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.15811.r32939","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.15811.r32935","asserted-by":"object"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.15811.r32937","asserted-by":"object"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.15811.r32939","asserted-by":"object"}]},"ISSN":["2398-502X"],"issn-type":[{"value":"2398-502X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,4,18]]},"assertion":[{"value":"Indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/wellcomeopenres.15811.r32939, Julian Eaton, Centre for Global Mental Health\u00a0, London School of Hygiene and Tropical Medicine, London, UK, 08 May 2018, version 1, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1#referee-response-32939","order":0,"name":"referee-response-32939","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"Pallab K Maulik<\/b>; \nPosted: 13 Jun 2018<\/i>; This succinct article outlines the findings related to operational challenges, as part of a wider process and preliminary outcome evaluation of a multifaceted, task shifting, stepped care intervention to address the treatment gap for mental disorders in rural villages in India. Understanding such challenges is an important part of further refining interventions, particularly at the stage of development here - in preparation for scaling up and larger-scale formal evaluation.   1. While the paper provides a fair amount of detail about the intervention, the details of the research evaluation methods and analysis used was so brief as to make it very difficult to judge rigour. Reference was made to an earlier paper, but it would be helpful to have more detail about how the results were reached.  \nResponse: <\/b>The study had a formative phase where we were able to identify some barriers and facilitators for implementing the project. Following that we took remedial action and then rolled out the interventions. The interventions involved task sharing, using technology-enabled solutions for providing mental health services and rolling out an anti-stigma campaign. Following the intervention, a mixed methods process evaluation was done.  It involved collection of information on the impact of the intervention that was implemented in the community. The qualitative data collection was collected from h different stakeholders such as community leaders, lay village health workers (ASHAs), primary care doctors and policy makers. The key objectives were to understand the challenges they faced and identify barriers and facilitators. Since this was, a pre-post study the post intervention quantitative data collection helped to understand the change in the mental health service utilisation and the change in the levels of stigma. The quantitative information about usage of services and different mobile applications was accessed from the backend systems to generate usage analytics. The data were collated to understand the barriers and facilitators of the intervention that was implemented in the community using Anderson\u2019s Behavioural Model. In this paper we do not focus on the process evaluation component as they had been reported already, instead wanted to highlight the daily operational issues which research staff and field staff faced on a routine basis and managed accordingly. The aim was to provide practical knowledge about implementing similar projects in the field. We believe these supplements the process evaluations done both at formative and post-intervention phases. 2. The important point about decisions that need to be made by process evaluators about when to intervene to iteratively improve an intervention, and when to merely measure dispassionately, was not adequately developed. Such reflection is key to real-world evaluation and should have been discussed further (this point is made in the MRC Guidelines to Process Evaluation\n1<\/sup>), particularly as this paper is itself about operational challenges and interventions to overcome them.  The researchers might clarify what rules\/principles they used to decide when to adapt the intervention, and when not to. Was this, for example based on how far (time-wise) into the study they had reached, limiting intervention to early in a formative phase, or did they continue throughout, and in which case, how would they draw conclusions about the effects of changes to the implementation within the study period?  \nResponse: <\/b>Before the intervention was rolled out a formative phase was done to understand if the tools that were developed were acceptable and the technology enabled platform was feasible to be implemented in a community setting. There was a qualitative phase as well during this formative stage where we got a lot of insight about beliefs and practices to handle mental illnesses prevalent in the community and what are the preferred ways to create awareness about mental health. This helped us in developing the anti-stigma campaign and modify the tools.  It was only after this phase that the interventions were rolled out.  Majority of the operational challenges faced were resolved at the formative stage.  However, some operational challenges were identified after implementing the intervention, e.g., improving recruitment of members, especially male members who were often out in the field, coordinating the organization of health camps and ensuring that the process is coordinated, improving network connectivity. Corrective active measures had to be taken on a continuous manner to ensure project fidelity and ensure that the intervention is delivered as planned. 3. The results - operational challenges identified - certainly rang true, and the responses were very pragmatic. It is not clear however, what the impact of the responses to challenges were (this does not seem to have been measured formally).  \nResponse:<\/b> While we accept that not all the operational challenges mentioned were evaluated, some of the major ones listed \u2013 coordinating organization of health camps, conducting an anti-stigma campaign, ensuring followup and treatment adherence, monitoring of ASHA activities and data collection - were all evaluated as part of the mixed methods process evaluation done at the end of the study and reported earlier. \n5,6,11<\/sup> We could maximize the impact of the interventions as was evident from our quantitative and qualitative results. Some challenges such as those related to identifying good quality field staff were not evaluated formally. 4. The brief discussion focuses in part on conclusions drawn from the wider study outside of this paper, though they do set the more restricted outcomes of this paper in context. Limitations to the paper were not discussed, but are detail is in linked papers. \nResponse:<\/b> We agree, as we had planned to limit this paper and not repeat what was published earlier.   Overall, the issues raised in the paper are important, and it would be informative for any researchers or implementers undertaking to deliver well-evidenced services. ","URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1#referee-comment-3630","order":1,"name":"referee-comment-3630","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/wellcomeopenres.15811.r32935, Gitanjali Narayanan, Ratnesh Chopra, Department\u00a0of\u00a0Clinical Psychology, National Institute\u00a0of\u00a0Mental Health\u00a0and\u00a0Neuro Sciences\u00a0(NIMHANS)\u00a0, Bengaluru, India, 08 May 2018, version 1, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1#referee-response-32935","order":2,"name":"referee-response-32935","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/wellcomeopenres.15811.r32937, Atul Ambekar, National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi, India, 14 May 2018, version 1, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1#referee-response-32937","order":3,"name":"referee-response-32937","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"Pallab K Maulik<\/b>; \nPosted: 13 Jun 2018<\/i>; I agree with your broader concerns and we hope some of the experiences fro this and other research will help to improve things and plan better. As for the paper this should be seen as a supplement to the process paper which has already been published. Here we wanted to highlight some of the routine issues that we faced in the field. Some of them were anticipated and we had taken corrective measures during both the formative stage and planning stages. Some others were issues that we had to overcome as part of logistics and operations. We see this paper as more of a 'hands on' operations paper which researchers might find useful while conducting similar research. Some of our actions were evaluated as part of the process evaluation.","URL":"https:\/\/wellcomeopenresearch.org\/articles\/3-43\/v1#article-response-3631","order":4,"name":"article-response-3631","label":"Article Comment","group":{"name":"article-comments","label":"Article Comments"}},{"value":"This project was supported by the Wellcome Trust \/ DBT India Alliance Fellowship (Grant No: IA\/I\/13\/1\/500879) awarded to PKM and a Grand Challenges Canada Grant (No: 0524-01-10), on which PKM was the Principal investigator. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":5,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}