EMPOWER: BUILDING THE WORLD’S MENTAL HEALTH WORKFORCE

EMPOWER builds the capacity of health care and community support systems to address the  mounting burden of mental health problems by deploying provider-facing digital training, supervision and quality assurance tools and data science approaches to enable frontline workers to learn, master and deliver evidence based psychological interventions and promote self-care.

Vikram Patel, The Pershing Square Professor of Global Health, Harvard Medical School; Secondary Professorial appointments, the London School of Hygiene & Tropical Medicine and the Public Health Foundation of India.

EMPOWER addresses the large and increasing burden of depression, anxiety and trauma related mental health problems in pandemic affected communities. Even before the pandemic hit, these mental health disorders were a leading cause of the Global Burden of Disease and cost the global economy over $2.5T (projected to rise to $6T by 2030). Over the past year, over 25% of the global population have been affected, and young adults (amongst whom, rates of depression and anxiety exceeded 50% in the US) and populations which are disadvantaged, for example low income, sexual minority or refugee groups, are at much higher risk. These conditions are a major driver for the mounting ‘deaths of despair’, which have led to an unprecedented reduction in the life expectancy of working-age Americans. Suicide mortality rates in young Americans rose by more than 50% in the past decade and is the leading cause of death in young people in India. Yet, the vast majority of those who suffer do not have access to psychological treatments, recommended as the first line of intervention by the WHO; the unmet needs for care for these common mental health conditions exceeds 95% in low income countries.

EMPOWER has two primary target audiences: 

1. Individuals in need of mental health care: persons with depression or anxiety or who are facing acute psychosocial/traumatic crises, such as bereavement, violence, acute indebtedness and suicidal attempts. This need is inequitably distributed, particularly affecting the poor, women, young people and historically disadvantaged communities.   

2. Frontline  workers: this group ranges from Accredited Social Health Activists (or ASHA) and Community Health Officers in India, to community health workers and nurses in the US. These workers tend to be overworked; however, little attention has been given to their own mental health which is adversely affected by work demands, low compensation, exposure to infection and being at the bottom of health system hierarchies. 

Both audiences have been engaged throughout the development of EMPOWER, and we have demonstrated the high levels of acceptability of digital platforms for training and supervision. We will continue to engage both audiences in service design, through workshops and ongoing evaluation efforts. By reaching these two audiences, we are ultimately strengthening the capacity of the health system to reduce the burden of mental health problems deploying existing human resources, and the data we generate will inform the health system of population level impact.

Good mental health is critical for the attainment of the UN’s Sustainable Development Goals. However, healthcare systems have largely failed to meet this fundamental need globally. According to The Lancet Commission on Global Mental Health, a major contributor to this crisis is the conventional approach to addressing mental health problems through a narrow biomedical lens, which prioritizes diagnosable mental disorders and specialist care. Combined with the large evidence base demonstrating how low-intensity interventions could be effectively delivered by existing human resources in community settings, the Commission argued for a reframing of mental health as a global public good, important to people in all countries, and particularly so for youth and disadvantaged groups. Improving the mental health of individuals, by scaling up evidence based interventions and delivery strategies, would not only transform the lives of individuals, but also their families and the wider community, contributing to better health and, consequently, social and economic outcomes at every level. Through generating evidence on how technology innovations can catalyze this scale-up and the leveraging of rich data on how health systems could deploy the solution and enhance its effectiveness in iterative feedback loops, EMPOWER will realize the aspiration of the Commission.

EMPOWER’s goal is to transform the approach to mental health globally, through increasing demand for mental health care, improving recovery rates for people with mental health problems, reducing mental health disparities (especially for young people and disadvantaged groups), reducing the down-stream adverse consequences of these problems (for example, on reducing ‘deaths of despair’) and contributing to the overall development of communities.  As described elsewhere in this proposal, the solution builds on over a decade of pioneering research, which has reframed the narrative of global mental health.  The primary mechanisms through which our solution will effect these ambitious aims, hitherto resistant to all existing efforts, is to dramatically increase the number of skilled front-line health workers to deliver evidence based interventions for the most common mental health problems in community settings, to implement continuing quality assurance with built-in feedback loops, to promote the well-being of the front-line workers,  and to generate data which can inform health systems on the impact and lead to refinement of the solution interventions.  At its heart, the solution emphasizes low-cost, existing human resources and technologies so that the funds to help grow the solution will lead to a much greater scale of impact in the future.

In the first year, EMPOWER will deploy hundreds of frontline workers in each of our two settings in India (Madhya Pradesh) and the US (Texas) to become skilled providers of psychological treatments for depression, and expand the curriculum for frontline workers by digitizing evidence-based interventions or acute crisis counselling and self-care. While we will prioritize our outreach to under-served communities badly affected by the pandemic, from Year 2 onwards we will work with our implementation partners to incrementally scale up the recruitment and training of front-line workers through community organizations and healthcare facilities in other populations. We will enable frontline workers to master the delivery of interventions with adequate quality through remote supervision; support frontline workers to promote their own mental health; and adapt the patient care app to be suitable for diverse populations. Throughout this process, we will iteratively assess the acceptability and feasibility barriers to engagement, responsively refining the solution delivery strategies. Over the subsequent years, we will  aim to scale up the solution in these settings and beyond, and implement the data science component of the solution to generate critical knowledge to enable ongoing transformation.

Our pilot evidence shows that with competency based training and supervision, front-line workers can deliver psychological treatments with fidelity and improve the mental health of three-quarters of persons with depression. Such community delivery is associated with a dramatic increase in demand for mental health care (Shidhaye et al, 2017), and these two outcomes together contribute to the reduction of the burden of mental illness  in the population. These outcomes are the benchmarks of success for the solution, which we will measure as we scale up and expand our interventions. Our measurement strategy includes both traditional descriptive methods for evaluating the implementation of health innovations as well as data science methods using data arising from the scale up of the innovation. Examples of key descriptive performance indicators, collated at six-monthly intervals, include: 

• # (%) of workers who achieve competency

• # of persons identified who need care

• # (%) of these persons who recover 

• frontline worker well-being 

By the end of three years, we will have established a  data pipeline linking provider, patient and system data, and report aggregate estimates of the impact of the solution on the population, and critical points in the pathway which drive this impact.

1. Ability to realize the digital tools in a timely manner: This risk is addressed through using digital tools which are already available (the LMS) whose funding has already been secured (the quality assurance tool being developed by DIMAGI). 

2. Digital literacy and access challenges: The proportions of front-line workers who own smartphones (60% India; 80% US) is growing, and India’s National Digital Health Mission, aims to provide all front-line workers with smartphones.  To address connectivity challenges, our learning content is accessible offline and quality assurance can be conducted asynchronously. 

3. Stakeholder buy-in: Our team has established collaborations with the Ministry of Health, Madhya Pradesh (since 2011) and with health systems in Texas (since 2020). We have observed high engagement of frontline workers. We are partnering with the American Psychological Association which has endorsed our approach. 

4. Financial sustainability: The solution is inherently sustainable as it uses low-cost, existing human resources and technologies. The key incremental cost is for technical guidance by the EMPOWER team to assist with implementation. As we demonstrate significant impact, we anticipate being able to harness the growing appetite to invest in mental health care to sustain and scale up our solution into the future.

• Harvard Medical School

• Sangath (India) 

• DIMAGI (US, India)

• Ministry of Health, Government of Madhya Pradesh, India

• Well Being Trust, US

• University of Toronto (Sinai), Canada

• Meadows Mental Health Policy Institute, Texas, US

• Koa Health B.V., a digital mental health company, Spain, US, and UK

EMPOWER was initiated just before the pandemic began and, despite the significant challenges which have limited our progress in the past year, we have been able to secure support from philanthropic donations and grants amounting to about $1.7M to launch our work. We have now reached an exciting milestone of our journey where, with our first two courses digitized, the design architecture for building the workforce mapped out, a multidisciplinary team in place, critical collaborations with implementation and knowledge partners established and, importantly, wide recognition of the importance of mental health presenting a historic opportunity to transform mental health care globally, we are poised to enter the growth phase of our initiative, rolling out mental health care in two diverse contexts, and generating the critically important lessons which will serve us in our ultimate goal of scaling up mental health care globally. The Trinity Challenge offers a unique funding opportunity to help us support at this critical milestone of our journey, not least as there are few other options for a mental health implementation venture such as ours; while the money will be crucial, so is the opportunity to collaborate with world-leading data scientists and technology experts (see below).

We would be particularly interested to partner with organizations (such as Palantir and Infosys) with expertise in data science to guide us in the protocol for the data science component of our plans, for example conducting prediction modelling linking provider, patient and system facing data across the data pipeline from training of individual providers to population level impacts of scaling up mental health care. Key questions, as outlined earlier, would include assessment of moderators and mediators of change. 

Additionally, we would welcome partnerships with digital technology experts who can guide us on innovative approaches to realize our goals, for example the automated generation of quality metrics through Natural Language Processing of audio-recorded sessions, and using these for real-time feedback cycles, which can continually inform providers on the quality of their care and how this can be strengthened. Amongst the partners listed on your website, we see such potential expertise from a number of institutions, including Microsoft, Infosys, Tencent, and Google. 

 In addition, we would welcome guidance on cybersecurity, including meeting security standards for PHI and regulatory compliance in the geographical regions of interest.