Delivery by “trained hospital-based health workers” of “family psychoeducation package” to caregivers of patients with schizophrenia through “task-sharing” strategy

Shikha Tyagi; Nitin Gupta; BS Chavan; Harneet Kaur; Vikas Sharma

doi:10.4103/WSP.WSP_14_19

ORIGINAL ARTICLE

Year : 2019 | Volume : 1 | Issue : 1 | Page : 70-81

Delivery by “trained hospital-based health workers” of “family psychoeducation package” to caregivers of patients with schizophrenia through “task-sharing” strategy

Shikha Tyagi, Nitin Gupta, BS Chavan, Harneet Kaur, Vikas Sharma
Disability Assessment Rehabilitation and Triage Services, Mental Health Institute, Government Medical College and Hospital, Chandigarh, India

Date of Submission	05-Jul-2019
Date of Decision	11-Jul-2019
Date of Acceptance	11-Jul-2019
Date of Web Publication	27-Sep-2019

Correspondence Address:
Dr. Nitin Gupta
Disability Assessment Rehabilitation and Triage Services, Mental Health Institute, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/WSP.WSP_14_19

Abstract

Background: In India, there is an urgent need to evaluate cost-effective methods providing basic awareness on mental illness. Family psychoeducation (FP) for caregivers of patients with severe mental illnesses (SMIs) is one such important intervention. Due to high treatment gap, concepts of “scaling up” and “task sharing” have been advocated; evidence is available through the use of “community lay workers.” However, there is no evidence for the delivery of FP by lay persons in a hospital setting. Objectives: The study had the following objectives, namely (i) to compare the effectiveness of delivery of “FP package” (FPP) to caregivers of persons with schizophrenia using different professionals versus hospital-based health workers (HHWs) and (ii) to see whether FPP brought any change in the level of knowledge, burden, needs, and effect for the caregivers. Methodology: The study was conducted at the Disability Assessment Rehabilitation and Triage Services, Mental Health Institute, Government Medical College Hospital 32, Chandigarh, using the “Service Evaluation Framework.” Twenty-two caregivers of patients with SMI, attending the Family Intervention Services, were divided into three groups and provided FPP (NIMHANS Manual) by pair of psychiatrists, psychiatric social workers (PSWs), and trained HHW, respectively. The three groups were assessed using Assessment Questionnaire (AQ) and then compared across and pre–post intervention as per identified objectives. Results: All the three groups were comparable across relevant socioclinical variables. At baseline, all three groups were comparable on the AQ; post-FPP delivery, they remained comparable. In addition, FPP, as an intervention, did not improve the level of knowledge, burden, needs, and effect for the caregivers in any of the three groups. Conclusions: HHWs, after receiving appropriate and adequate supervision, are able to deliver FPP using “The Manual” as effectively as other mental health professionals (psychiatrists, PSWs). However, this is not able to bring about effective change in the level of knowledge. Nevertheless, this adds to the evidence base of use of “lay workers,” “task-sharing strategy,” and “scaling-up approach” from low- and middle-income countries such as India.

Keywords: Caregivers, family psychoeducation, scaling up, severe mental illnesses, task sharing

How to cite this article:
Tyagi S, Gupta N, Chavan B S, Kaur H, Sharma V. Delivery by “trained hospital-based health workers” of “family psychoeducation package” to caregivers of patients with schizophrenia through “task-sharing” strategy. World Soc Psychiatry 2019;1:70-81

How to cite this URL:
Tyagi S, Gupta N, Chavan B S, Kaur H, Sharma V. Delivery by “trained hospital-based health workers” of “family psychoeducation package” to caregivers of patients with schizophrenia through “task-sharing” strategy. World Soc Psychiatry [serial online] 2019 [cited 2023 Mar 27];1:70-81. Available from: https://www.worldsocpsychiatry.org/text.asp?2019/1/1/70/267961

Introduction

Due to limited mental health resources, a large number of economic, legal, social, and physical issues and disability-adjusted life years arising out of mental, neurological, and substance use disorders remain unaddressed among patients who seek treatment.^[1],[2],[3] Majority of mental health facilities in India address only acute care through medicines, and psychosocial issues remain undiagnosed and untreated. These unresolved psychosocial issues lead to poor treatment outcome, high relapse rate, and poor quality of life, both for the patient and family members.^[4] In a low- and middle-income countries (LAMICs) such as India, there are just 0.3 psychiatrists per 100,000 people,^[5] and the number of clinical psychologists, psychiatric social workers (PSWs), and psychiatric nurses is abysmally low with significant resource deficits.^[6]

In a country like India, where >80%–90% patients suffer with mental illness and are not receiving any treatment,^[7] there is an urgent need to design cost-effective methods to provide basic awareness on mental illness. Family psychoeducation (FP) for caregivers of patients with severe mental illnesses (SMIs) is one such important intervention in the field of mental health. Historically, the delivery of psychosocial interventions in India has been directly or indirectly through psychiatrists and some others being through other mental health professionals (clinical psychologists and PSWs). It has been pointed out that, unfortunately, this treatment modality has not been able to reach the masses.^[8] In addition, keeping in mind that there is no such foreseeable solution to bridge this “treatment gap” in the immediate or near future through an adequate number of mental health professionals,^[6] alternative methods of delivery of care need to be explored and implemented.^[9]

Recently, Patel et al. (2015)^[10] highlighted that basic mental health interventions can be provided through a brief training of the community members, whereas the concept of “scaling up” of services and “task sharing” was advocated by Eaton et al.^[9] Evidence using this approach successfully in the community was provided in the recently concluded study from India by the name of-community-based intervention for people with schizophrenia and their caregivers in India (COPSI) trial.^[11]

FP has principally been advised to be delivered by professionals with a training and degree in mental health,^[12] and there is no literature of it use by community members or lay persons.

With this background and perspective, the present study was planned using a “service evaluation framework”^[13] and attempted to compare the effectiveness of this psychosocial intervention (FP) in a group setting provided by senior psychiatrists, senior PSWs, and lay members from the community (after undergoing brief training under supervision).

Aim and Objectives

The objective of the study was as follows:

To compare the effectiveness of delivery of “FP package” (FPP) to caregivers of persons with schizophrenia (PWS) using different professionals versus hospital-based health workers (HHWs)
To see whether FPP, as an intervention, brought any change in the level of knowledge, burden, needs, and effect for the caregivers.

Methodology

Type of the study

The study design involves interventional assessment, pre-assessment, and post-assessment (using the “Service Evaluation Framework”^[13]).

Study period

The study period was April–June 2017.

Duration of the study

The study was conducted over 10 weeks. This was divided into six phases which are detailed further under “procedure.”

Site

The study was conducted at the Disability Assessment and Rehabilitation Triage (DART) Center, under Mental Health Institute, Government Medical College Hospital 32 (GMCH-32), Chandigarh. DART is a general hospital psychiatric unit-based rehabilitation service being in vogue since December 2012; inpatient services being introduced from January 2017.

Setting

There is a regular clinic, Family Intervention Services (FIS) run on once/weekly basis where various psychosocial issues are assessed and managed, with special attention being provided to family- and caregiver-related aspects. The overall administrative and clinical in charge of the FIS are the consultant PSW, having posting of a PSW and a clinical psychologist along with. In addition, at any given time, variable number of (ranging from 4 to 6) M. Phil (PSW), M. Phil (clinical psychology), and MD (psychiatry) trainees are working in the service as a part of their training program wherein they assess and manage cases under direct supervision. There is also input from specific consultant psychiatrist(s) working in rehabilitation as a part of multidisciplinary team functioning for formulation of the case and its management plan and intervention.

One of the key components of the FIS clinic is to deliver FP. This is routinely done using a structured approach by different professionals (mainly PSWs and psychiatrists; either separately or conjointly) as advocated in the Family Intervention Manual.^[12] Using this manual, a FPP comprising six modules, i.e., assessment, psychoeducation, basic interventions with the family, assessing and managing difficult problems, handling communication and emotions, and termination and follow-up^[12] is typically delivered over seven sessions at a frequency of once/week.

Selection criteria

The following criteria were kept for participation in the study, namely as followa:

Inclusion criteria

To be categorized as a “primary caregiver (PC)” of person suffering with schizophrenia, as per the ICD-10, the family member should have been staying with the patient for at least past 1 year^[14]
Family member should be at least 18 years of age
Family member who could attend a session once a week for 7 consecutive weeks
Family member should be willing to participate in the study and provide written informed consent.

Exclusion criteria

Family member having mental illness, substance abuse, or organic brain disorder (as per the ICD-10)
Family member who expressed unwillingness to attend all the FP sessions.

Instruments used

Sociodemographic sheet: The one used routinely in the Department of Psychiatry, GMCH-32, to collect information on various sociodemographic variables (age, gender, marital status, occupation, and education) was taken for the study to collect information regarding caregivers
Socioclinical profile sheet: This was specially designed by the investigators to collect the relevant information regarding the patients whose caregivers were taken up as the sample for the study. The primary source of this information was the profile sheet already being used in the FIS
Manual entitled “Family Intervention and Support in Schizophrenia: A Manual on Family Intervention for the Mental Health Professional”^[12] subsequently referred to as “The Manual:” This manual has been developed for use by persons with a postgraduate degree and training in different areas of mental health (counseling, psychology, social work, psychiatry, psychosocial rehabilitation, and nursing). There are certain prerequisites for the person before using the manual, namely preferably having some prior experience in counseling and interviewing families of persons with mental disorders, preferably having attended training workshops to learn the required techniques and skill, and must know the contents of this manual thoroughly before beginning any intervention. The manual consists of 11 chapters. The chapters in this manual are arranged in the preferred order of conducting the sessions. However, this may not always be practically possible, and hence, the intervention worker should be familiar with the content of all the sessions and should be prepared for such circumstances. The format of the intervention can vary from providing information to individual family members to a group of family members of one or more affected members, from structured to unstructured (when the family member visits during a crisis) and with/without the use of audiovisual aids.^[12]

Procedure

Phase I (identification of participants and trainers)

Based on the selection criteria, a list of all the family members of patients with SMI attending the FIS was drawn up, and 22 family members were identified. Simultaneously, in parallel, two lay volunteers who had been associated with the FIS in various nonpharmacological programs previously were identified and inducted as HHWs. In addition, the other professionals, i.e., psychiatrists (BSC, NG) and PSWs (ST– in charge of FIS and a colleague PSW working in the same clinic), were also identified.

Phase II (training of hospital-based health workers)

The HHWs were provided an electronic copy of “the manual” with which they familiarized themselves thoroughly as per its requirements.^[12] After 1 week of this process of familiarization and self-training, the HHW was provided hand-on training and supervision in week 2 by a consultant psychiatrist (BSC) and a consultant PSW (ST). This supervision occurred over two separate sessions of 1 h each, comprising going over the contents of “the manual” in detail, addressing the point-wise list of queries of the HHW, clarification of terminologies and words/phrases, role-play and remodeling with remedial techniques, and feedback techniques. To ensure that the HHWs were adequately trained, prepared, and comfortable in their newly learned/acquired professional roles, clinical demonstration in the form of a mock drill was conducted in front of the supervisors to be deemed satisfactory by them.

Phase III (formation of groups)

The 22 family members, i.e., PCs identified earlier, were divided into three groups; one each led by pair of psychiatrists, PSWs, and HHWs. To minimize bias and ensure as much homogeneity as possible, the PCs were allocated using “simple random sampling.” All the three groups were explained the basic principles of how the groups were to be conducted. All PCs were administered instruments 1 and 2 at this stage.

Phase IV (preintervention assessment)

To be able to have an understanding of the level of knowledge that the family members have about the affected member's illness, and how it has affected their functioning as a family, “the manual” has a section on assessment. This assessment taps into the following areas, namely knowledge of schizophrenia, burden experienced, needs, social supports, responses, and illness effects on affected member. This was carried out before the start of the intervention, wherein all the 22 PCs across the three groups were given this “assessment questionnaire” (AQ) in one sitting, i.e., Session 1 of the FPP [The detailed AQ is provided in the [Appendix].

Phase V (intervention)

As advocated in “the manual,” subsequent five sessions (Sessions 2–6, i.e., psychoeducation, basic interventions with the family, assessing and managing difficult problems, handling communication, and emotions) were conducted at frequency of once/week.

Phase VI (postintervention assessment)

Following Session 7, i.e., termination and follow-up (which was conducted a week after Session 6), the AQ was re-administered immediately after completion of the session.

Ethical considerations

Written informed consent was taken. Timings and day of the sessions were fixed as per convenience of the participants. Anonymity and full confidentiality were ensured. Approval from the institute ethics committee was not required as the study design, and execution was done using the “service evaluation framework.”^[13]

Statistical analysis

Statistical analysis was carried out using SPSS version 22.0 (IBM Corp., SPSS Armonk, NY: USA). Data were analyzed in which frequency generation, percentages, mean, and standard deviation (SD) were calculated. Univariate analysis in the form of Chi-square test for across group comparison was done for nominal variables. For pre–post within-group comparisons, Wilcoxon signed-rank test was conducted keeping in view nonnormality and small sample sizes across each group. Statistical significance was kept at P < 0.05 for all tests.

Results

A total of 22 PCs of the patients with the ICD-10 criteria of schizophrenia, and regularly attending the FIS, were selected as per defined inclusion and exclusion criteria, after obtaining written informed consent.

Primary caregivers

Regarding their demographics (n = 22), the mean age was 55.59 (SD = 13.85) years. About 59.1% were male; 90.9% had educational status above matric; and 90.9% of the caregivers belonged to urban background. Regarding the related clinical characteristics, total duration of stay was >20 years in 90.9% of cases, while 9.1% accounted for total duration of stay between 10 and 20 years. In addition, the duration of care with their patient was >20 years in 86.4% and between 10 and 20 years in 13.6%.

Patients

Regarding their demographics (n = 22), the mean age was 33.27 (SD = 8.21) years. About 72.7% were male; and 81.8% were educated above matric. Regarding the related clinical characteristics, the total duration of illness was <10 years in 6.8%, between 10 and 20 years in 6.8%, and >20 years in 86.4% of the patients.

As per objectives and design of the study using the “service evaluation framework,”^[13] the PCs were divided into three groups, as mentioned under phase III of “procedure” (as above), that is,

Group A run by two consultant psychiatrists with at least 20 years professional experience each (n = 8)
Group B run by two PSWs with at least 10 years of professional experience each (n = 8)
Group C run by two HHWs with no professional experience (n = 6).

These three groups were comparable on the various available sociodemographics (e.g., patient's age, gender, and education) and clinical variables (e.g., duration of care of the patient and duration of stay with the patient).

To compare the effectiveness of FPP to caregivers of PWS using different professionals versus HHW, the baseline (preintervention) scores across the three groups receiving intervention by psychiatrists, PSWs, and HHWs were compared. All the three groups were comparable on all 35 items of the AQ before the study intervention, i.e., FPP [Table 1]. Subsequently, postintervention scores for all 35 items of the AQ were compared across the three groups. It was seen that, despite the study intervention (FPP), all the three groups were comparable on all 35 items of the AQ [Table 2].

Table 1: Preintervention (family psychoeducation package) values across the three groups

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Table 2: Postintervention (family psychoeducation package) values across the three groups

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The total samples of 22 PCs were assessed on all 35 questions of the AQ before the initiation of the FPP. After completion of the FPP, repeat assessment was done using the same questionnaire. It was observed that they were comparable, both pre- and post-assessment, on all 35 questions/items in each of the six domains, i.e., knowledge about the illness, burden, family needs, social support, family response, and effect of illness on the affected member.

[Table 3] shows the comparison of AQ findings for the three groups of PCs who underwent the FPP by psychiatrists, PSWs, and HHWs. There were no significant differences which emerged on the 35-item AQ for each of the three groups; except for significantly higher scores on question 1 (i) “What do you know about the medicines of schizophrenia?” for Group A and question 3, (b) “Does the family has access to services such as telephone/transport/education/medical care/benefits” for Group C.

Table 3: Comparison of Assessment Questionnaire findings, pre- and post-family psychoeducation in the three subgroups

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Discussion

At the outset, it will be important to clarify that this study had been planned using a “service evaluation framework,” keeping in mind that to the best of our knowledge, (i) there are very few centers offering a PSW consultant-led specialized FIS across the country and (ii) also there is lack of data regarding monitoring of such services.

Due to these reasons, it was deemed imperative to develop an understanding whether our recently setup FIS is delivering FPP not only as advocated in “the manual,” i.e., by persons with a postgraduate degree in psychiatry, social work, and psychology^[12] but also whether it can be delivered by individuals who know the contents of “the manual” and have undergone training also for it (Page 4).^[12] Hence, we put forward the following hypotheses, i.e., (i) HHWs, under supervision, can deliver FPP as effectively as mental health professionals (either psychiatrists or PSWs) and (ii) FPP, as an intervention, improved the level of knowledge, burden, needs, effect for the caregivers.

An evaluation of the delivery of the FPP (with a secondary broader objective of evaluating existing structure and functioning of the FIS) was deemed necessary as that would help in planning for the future development and delivery of the rehabilitation services in DART, and also, it would fit in with the WHO and Lancet Global Mental Health Concept of “scaling up” of services that should be both evidence based and locally relevant so that conclusions can be implemented and disseminated in a practical way.^[9],[15]

The mean age of the patients suffering with SMI was around 33 years, with over two-third being male. This is not very different to that reported from previous studies on “family intervention/psychoeducation” from India,^{[16],[17],[18]} though comparable data on duration of illness were not available. The demographic profile of the PCs in our study was quite similar to that reported by Chakraborty et al. (2013),^[17] though other studies have not mentioned in detail about the same;^[16],[18] in addition, no comparable data are available for the variables such as duration of care or stay with the patient. Nevertheless, the predominant percentage of PC sample was staying with their patients for over 20 years, and also providing care for their SMI indicating not only an intimate level of involvement but also a potentially in-depth level of caregiving and understanding so being provided.

Objective 1: To compare the effectiveness of family psychoeducation package to caregivers of persons with schizophrenia using different professionals versus hospital-based health worker

FP is a time-honored component of clinical practice in the field of mental health and has been around in India for over half a decade.^[8],[12] However, the dependability regarding delivery of such interventions will usually hinge on the availability and competence of professionally trained mental health workers (psychiatrist, PSW).^[8] This has been specifically advocated for “the manual,” wherein FP is supposed to be delivered by those with a postgraduate degree and training in the area of mental health counseling, psychology, social work, psychiatry, psychosocial rehabilitation, and nursing.^[12]

Does that mean that “the manual” cannot be used by lay workers? This assertion cannot be made with certainty, and we were unable to find any such supporting evidence. In addition, there is growing evidence that lay people and health workers can also provide care traditionally delivered by psychiatrists, through the concept of “task sharing/task shifting.”^[11] Most recently, the COPSI trial provided rigorous evidence about the effectiveness of use of supervised community health workers in provision of accessible, community-based services to people with schizophrenia, i.e., effective task sharing.^[11],[19] Coupled with this is the WHO's Mental Health Gap Action Programme where one main objective is to achieve increased coverage of evidence-based interventions, especially in LAMICs.^[9],[20]

Hence, based on the above argument, we sought to expand the delivery of our FIS further by involving “lay workers” (i.e., HHW) in the delivery of the FPP as a part of routine service. This was subjected to the evaluation by comparing the effectiveness of FPP to caregivers of PWS using different professionals (psychiatrists and PSWs) versus HHW.

Initially, the baseline (preintervention) scores across the three groups receiving intervention by psychiatrists, PSWs, and HHWs were compared. All the three groups were comparable on all 35 items of the AQ before usage of FPP [Table 1]. This finding reflects that there were no differences in the level of knowledge, burden experienced, needs, social support, responses, and illness effects across the three groups of PCs before receiving the FPP from either psychiatrists, PSWs, or HHWs. Subsequently, post-FPP scores for all 35 items of the AQ were compared across the three groups. All the three groups were comparable on all items [Table 2]. This finding reflects that there were again no differences in the level of knowledge, burden experienced, needs, social support, responses, and illness effects across the three groups of PCs after receiving the FPP from either the psychiatrists, PSWs, or HHWs.

Before discussing these findings, it will be important to mention the approach adopted in analysis, i.e., not taking the mean difference in the post- and pre-FPP scores for each item. This was done as the mean difference values were too small in magnitude to be reflective of any actual change, and further, due to the high number of comparisons, the probability of type I error would have been increased. In addition, by being able to demonstrate that the baseline scores for each group were comparable, it further lends credence to the findings so obtained at a post-FPP level, i.e., whatsoever findings so obtained will be a product of the FPP and not otherwise.

In fact, all three groups were comparable for all the baseline parameters, namely related to sociodemographic, clinical profile, and the AQ items. Hence, it can be said with reasonable certainty that all three groups of PCs did not only have a similar demographic (including educational) profile for their patients, and for their pattern of caregiving but also for the level of knowledge that the PCs have about the affected member's illness and how it has affected their functioning as a family.

As the three groups turned out to be similar after delivery of FPP on all 35 items of the AQ, it can be surmised that the level of knowledge that the PCs had about the affected member's illness (and how it has affected their functioning as a family) showed an increment/decrement of statistically equal magnitude across the three groups. In other words, the change of scores for each of 35 items of the AQ brought about by delivering FPP by psychiatrists was similar to that by PSWs, which was similar to that delivered by HHWs. Hence, there was comparable change in knowledge regarding the illness (and its effect on the family functioning) of the PCs after receiving FPP from either the HHWs or other mental health professionals.

This has important implications, as we are able to demonstrate that HHWs, after receiving appropriate and adequate supervision, are able to deliver FPP using “the manual” as effectively as other mental health professionals (psychiatrists and PSWs).

There have been reports from different LAMICs across the world of randomized trials reporting the benefits of FP and adherence management in improvement of outcomes in people with schizophrenia,^{[21],[22],[23],[24]} but the interventions were provided by specialists.^[11] The COPSI trial was unique in that not only it demonstrated effectiveness of use of supervised community health (lay) workers in provision of accessible, community-based services to people with schizophrenia, but also it used an FP module (i.e., COPSI manual) to deliver the same.^{[11],[19],[25]} Our findings are similar to that from the COPSI trial as in the effective use of “lay workers” and demonstration of the “task-sharing” strategy^[11] however differing in the fact that COPSI was community based whereas ours is hospital based. Hence, these findings, even though preliminary and of small magnitude, add to the evidence base of use of “lay workers” in being able to undertake the “task-sharing/shifting” strategy for pragmatic delivery of services using the “scaling-up” approach in a LAMIC such as India where specialist resources are few.^[11],[26]

It may be pertinent here to discuss the concept of “scaling up” and its applicability and relevance to our findings. “Scaling up” has been described by Lancet Global Mental Health Group (2007)^[15] as “deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis.”^[9],[27] As a specific objective, it carries with it conceptually numerous common components: an increase in the number of people receiving services (coverage); an increase in the range of services offered; services that are built on a scientific evidence base, usually with a service model that has been shown to be effective in a similar context; and services made sustainable through policy formulation, implementation, and financing (strengthening of health systems) and monitoring and evaluation.^{[9],[15],[28]}

Our findings demonstrate the following components, namely an increase in the range of services offered (by use of HHWs); services that are built on a scientific evidence base (by demonstrating effectiveness of HHWs), usually with a service model that has been shown to be effective in a similar context (using the well-established, evidence-based “the FP manual” by Varghese et al., 2002^[12] by mental health professionals). However, a proper and comprehensive “scaling-up” strategy needs to be effectively demonstrated for the future by showing that there is an increase in the number of people receiving FIS (increasing the coverage of PCs and other family members); FIS being made sustainable through policy formulation, implementation, and financing (strengthening of FIS within itself and its linkages with other components of the wider rehabilitation service being delivered to patients with SMI and their families), and monitoring and evaluation (by conducting regular service evaluations, along with service user and PC satisfaction evaluation). Hence, this is a target for the FIS for the future, with a specific focus on the effective delivery of FPP. It is acknowledged that the effectiveness of HHWs was demonstrable only because they were educated, motivated, and interested and had received effective and skilled supervision too.^{[9],[11],[18]}

Objective 2: To see whether family psychoeducation package as an intervention, brought any change in the level of knowledge, burden, needs, effect for the caregivers

To see whether objective 2 was met or not, and also if our hypothesis (FPP, as an intervention, improved the level of knowledge, burden, needs, effect for the caregivers) was tenable, the whole sample of PCs (n = 22) and the subsequent three groups were evaluated.

It was seen that there was no change in scores pre- and post-FPP intervention for the total sample of PCs (n = 22) on all 35 questions/items in each of the six domains, i.e., knowledge about the illness, burden, family needs, social support, family response, and effect of illness on the affected member. This can be a probable reflection of the chronicity of illness and long duration of caregiving, leading onto potential adaptation of the PCs to the illness of their patients with SMI.

On division into three subgroups [Table 3], the pre- and post-intervention AQ showed marginally variable results. In Group A (psychiatrist led), the pre- and post-FPP scores were comparable except for the item 1, (i) “What do you know about the medicines of schizophrenia?” The possibility of better/higher post-AQ scores for only one item, after delivery of AQ, could be due to psychiatrists being able to provide better knowledge and information about the medication for schizophrenia, a component lacking in the other two groups which were nonmedical led (by PSWs and HHWs). In Group B (PSW led), the pre- and post-FPP scores were comparable. Finally, in Group C (HHW led), the pre- and post-FPP scores were comparable except for the item 3, (b) “Does the family has access to services such as telephone/transport/education/medical care/benefits.” HHW scored higher which probably may be due to preoccupation by PCs regarding more medical inquisitiveness in the groups led by the psychiatrist and PSW and more “identification” shown with the lay person (HHW); hence, PCs probably were more vocal about the basic needs.

Overall, it may be interpreted that the FPP did not bring about any significant change in the level of knowledge that the PCs had about their affected member's illness and how it had affected their functioning as a family. This is contrary to intervention-based literature on FP where it was delivered through psychiatrists and reported from other parts of India in the past.^{[16],[17],[18],[21],[29],[30]} It is difficult to identify reasons for the contrary findings, but chronicity of illness and long duration of caregiving may have led onto potential adaptation of the PCs to the illness of their patients with SMI. In addition, the PCs were receiving inputs from our FIS for a long time, wherein the multidisciplinary team tended to impart psychoeducation (even if unstructured, yet potentially overlapping) on a regular basis and that may have confounded (and impeded) the effectiveness of the FPP. Nevertheless, this aspect will need further evaluation on an ongoing basis as and when new PCs are recruited and provided service through the FIS.

Limitations

Despite being a service evaluation, there were numerous aspects which still needed addressing. These could have gone a long way in strengthening the robustness of our results and conclusions so drawn. First and foremost, a research trial with a proper intervention-based design would have been superior to a “service evaluation;” though understandably in terms of generic issues of “research versus service evaluation.”^[13] Nevertheless, the small sample limits generalizability; there is a lack of longitudinal perspective (due to it being cross-sectional); the assessments were nonblinded with potential for positive bias as the PCs were previously known to the professionals (psychiatrists and PSWs). It also needs to be acknowledged that FPP in our FIS was delivered over less number of sessions than that advocated in “the manual.”^[12]

Strengths

Nevertheless, this study had its own strengths that make the findings hard to ignore, i.e., it was the first of its kind to be reported from a general hospital-based psychiatric rehabilitation setting. The HHWs were extremely motivated and involved, enhancement and monitoring of which have been identified as an essential prerequisite for successful implementation of the “scaling-up” approach and “task-sharing” strategy.^[9] As was mandated with demonstrating appropriate implementation of “task sharing”^[9] and use of “the manual,”^[12] supervision was provided with due care. Delivery of FPP was done using the most popular and widely used FP in India, by which comparability with previous literature was enhanced.^{[12],[16],[17],[18]} Finally, nearly all previous researches on FP have tried to show its effectiveness but delivery by only one set of mental health professionals;^{[16],[17],[18]} however, our study has compared two different sets of different professionals (medical and nonmedical).

Conclusions

The WHO and the Expert Policy Group of the Ministry of Health in India have recommended the use of nonspecialist health workers to deliver community-based psychosocial interventions to scale up services in LAMICs.^[11],[31] Our finding of effective delivery of “FPP” to caregivers of PWS by “trained HHW” adds to the evidence base of use of “lay workers,” “task-sharing strategy,” and “scaling-up approach,” as previously demonstrated in the community-based COPSI trial.

The caveat of FPP not being an effective intervention needs to be appreciated; notwithstanding, the confounders so potentially recognized. Finally, as highlighted earlier, assessment and monitoring of such evidence-based and locally relevant services are essential to ensure wider dissemination and generalizability.^[9]

Hence, the future should focus on further strengthening the range of service (by utilizing HHWs), development of effective interventions (by demonstrating FPP being effective), and addressing the lacunae as identified in this “service evaluation framework.” By this, we shall be able to empower the families, carers, and volunteers through “task sharing,” provide choice for interventions, and avoid reducing choice by replacing the proper provision of professional services on which people also rely.^[9]

In the Indian context, this “service evaluation” is conceptually akin to “one small step for man, one giant leap for mankind” (Neil Armstrong, July 20, 1969) as it is an important addition to the meager evidence existing on use of “lay workers” for “psychosocial interventions” using the “task-sharing strategy.”

Acknowledgments

We would like to thank Mrs. Seema and Mrs. Sunaina for their immense contribution and seminal component as HHWs, Mr. Kuldeep (PSW) for his help and involvement in the imparting of psychoeducation, and Mrs. Rosy Arora for her help in data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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