ARTICLE

Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 150-158

Designing Psychosocial Support for COVID-19 Frontline Responders in Pakistan: A Potentially Scalable Self-Help Plus Blueprint for LMICs

Asma Humayun¹, Israr ul Haq², Faisal Rashid Khan³, Sarah Nasir^4
1 Senior Technical Advisor for Mental Health, Mental Health Coordination Unit, Ministry of Planning, Development and Special Initiatives, Government of, Pakistan
² Assistant Professor of Psychiatry, Fazaia Medical College, Islamabad, Pakistan
³ Associate Professor of Psychiatry, ANMCH, Isra University, Islamabad, Pakistan
⁴ MS Clinical Psychology, Meditrina Healthcare, Rawalpindi, Pakistan

Correspondence Address:
Asma Humayun
Senior Technical Advisor for Mental Health, Mental Health Coordination Unit, Ministry of Planning, Development and Special Initiatives, Government of Pakistan
Pakistan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_21_20

As part of its COVID emergency response, the Government of Pakistan’s Ministry of Planning, Development and Special Initiatives has promulgated its first ever Mental Health and Psychosocial Support (MHPSS) initiative. Supported by UNICEF, this initiative will be piloted in Pakistan’s federal capital in coordination with other government ministries. The core feature of this initiative is a web-based integrated system that provides MHPSS interventions at multiple levels, including psychosocial support to frontline responders. For this purpose, we developed a self-help tool, MyCare+, to help users assess and manage their own stress, and to consult a counsellor if needed. It is a comprehensive, evidence-driven, confidential application adapted to local needs and consolidates clinical data for further trend analysis. It is a practical, instructed self-guide for assessment and management of stress-related conditions in the field that is based on existing evidence, thus bridging a gap. Overall, the user feedback was positive for the English and Urdu versions of MyCare+, as they found the content relevant and helpful. More than 90% of users were able to follow the instructions and felt confident to use the tool. This article outlines a blueprint for developing this toolkit, which can be easily translated into regional languages and scaled up for supporting larger populations.

Key implications for practice

• An evidence-driven, resource effective, potentially scalable solution is presented to support the frontline responders in the COVID-19 public health crisis in LMICs.
• A hybrid approach is followed that offers a self-help digital solution, supplemented by person to person contact with mental health professionals.
• The tool is designed to help conduct individual assessments and set personalised treatment goals to support frontline workers.

Keywords: COVID-19, frontline workers, LMIC, MHPSS, public health

Introduction

The Context

Existing Interventions to Support Frontline Workers: Utility and Limitations

Configuring a Framework to Support Pakistan’s Frontline Responders

1. assess their vulnerability to develop mental health conditions
2. assess both the sources and their existing level of stress
3. monitor their symptoms regularly and record their progress
4. manage their stress with the help of a step-by-step guide
5. rule out other mental health conditions and
6. seek advice from a trained counselor, if needed.

1. Content design
   • Content design took 4 to 6 weeks, and involved a project team working through the following stages: (a) defining the project’s objectives; (b) carrying out a preliminary interpretive needs assessment based on media reports, policy statements and publicly available data on health infrastructure in the federal capital; (c) undertaking a comprehensive literature review; (d) drafting a first iteration of the project’s content and; (e) soliciting peer review from a senior technical advisor.
   • The three-stage funnel of the content design allows users to:
   1. create a unique profile and upload their biodata, contact details and a brief clinical history
   2. assess the nature and severity of own stress condition, and track its progress and
   3. manage their condition with the help of a step-by-step guide, which will connect them to a counsellor, if needed.
2. Contextualisation and translation
   • Once the content was drafted in English, it was contextualised through a revision of questions and scripts to enhance local relevance. We took care to avoid unnecessary jargon or lose accuracy. Once finalised, content was translated into Urdu. A literal translation was avoided to strike a delicate, three-way, balance between language fluency, clinical utility and resource fidelity. Multiple rounds of review and revisions were conducted by the team to ensure these goals.
   • The tool was piloted on a group of 20 HCWs. The assessment section was tested online on individual users and the management section was tested in a focused group. Feedback was obtained using a feedback form which assessed clarity of instruction, explanation of technical aspects (symptoms, management techiniques) and self-sufficiency. Incorporating user feedback, the tool was revised to address gaps and further explanations were added to explain terminology where needed.
3. Transformation into a mobile application
   • As the last step, the guide was transformed into the design of a mobile application that would be downloadable from the App Store and the Play Store. This mobile application captures the user’s self-assessment data, stores this information centrally, and presents the user with options to perform weekly updates or to contact the counsellor. The digital user experience was designed for convenience and efficiency. It allows for centralised data storage, analysis and where needed, interventions.





Introducing MyCare+: An Integrated Self-Help Tool



There are three sections in MyCare+: a personal profile, assessment tools and management tools.

Section I: Personal Profile

Users choose a language of their preference and register with their national ID number to create a personal account. They submit brief personal details (name, age, gender, marital status, number of children, education, profession, contact, etc.), including some of the vulnerability factors described for mental health impact of the outbreak on HCWs (Kisely et al., 2020). To protect the identity and personal information of the users, they will be allocated an ID number. This number will be used for any interaction that follows.

This is followed by a brief clinical history to assess their vulnerability to developing a mental health condition. The screening questions are designed to assess their predisposition (hereditary risk or pre-existing mental conditions) and environmental challenges (life events, social support, etc.):
1. Do you have a previous history of a mental disorder, such as depression?
2. Do you have a tendency to excessively worry?
3. Do you often struggle to cope with stress?
4. Do you have a family history of a mental disorder?
5. Do you use alcohol or other substances of abuse in excess?
6. Do you suffer from any medical condition?
7. Do you have social support (close family, trusted friends)?
8. Have you experienced a significant life event in the recent past such as loss of a loved one?


For the last item, we developed a template (based on Holmes and Rahe, 1967) where users can record their life events on a timeline.

Section II: Assessment

This section is a self-assessment tool for their stress condition and includes the following:
1. Identify sources of stress
   • Based on a qualitative analysis of the experiences of HCWs (Liu et al., 2020) and anecdotal evidence of the causes of stress for frontline responders in Pakistani media, we developed a table to identify the sources of stress for the users (please see [Table 1] below).

     Table 1 Sources of Stress Click here to view

2. Assess nature of stress symptoms
   • The assessment of stress symptoms in our guide is based on the stress module in the mhGAP Humanitarian Intervention Guide (mhGAP-HIG; WHO & UNHCR, 2015). This assessment comprises presence of a potentially traumatic stressful life situation, onset of symptoms within a month of this situation, a list of symptoms related to preoccupation and difficulty in adapting to the stressful situation. Using standardised interview scales, we developed assessment questions to identify these symptoms (please see [Table 2]). These questions were supplemented by additional examples (in italics) for further clarification (based on user feedback).

     Table 2 Stress Assessment Questionnaire Showing the Symptom Checklist and Questions Designed for Self-Assessment Click here to view

   • Column A (symptoms) will not appear on the app. The user will go through the 12 questions in column B, one by one. If the user wishes to understand the questions through examples, further questions (in italics) can be accessed. The user would be able to go back and forth to modify responses. Once the responses are submitted, the app will add the total score of ‘Yes’ counts. These responses will be automatically sent to our system. The mhGAP-HIG does not comment on a quantitative assessment of these symptoms. In order to guide users, the project team decided that the presence of some symptoms and considerable difficulty with daily functioning would indicate moderate levels of stress, which should be monitored.
3. Monitor progress
   • To monitor progress quantitatively, we developed a progress monitoring questionnaire. For this, we used the Adjustment Disorder-New Module 20 Self-Report Questionnaire (ADNM 20) which is cognisant with the symptom presentations in our stress assessment questionnaire. The ADNM-20 is a standardised tool with recommended cut-offs (47.5 out of a maximum score of 80). This indicates that a score of 48 or more indicates high risk for adjustment disorder (Lorenz et al., 2016). Monitoring their symptoms will help the users rule out normal stress reactions where the symptoms might be transient and resolve spontaneously. Our application is also designed to send reminder prompts to the users for recording their weekly progress.
   • For the ADNM-20, the International Test Commission Guidelines for Translating and Adapting Tests were used to guide the translation process (International Test Commission, 2017). The forward translation was completed by four clinical psychologists, and the back translation by four different clinical psychologists with sound clinical, language, and testing skills. Details of the translation process of the scale are beyond the purview of this article.
4. Exclude other disorders
   • The last part of the self-assessment is designed to help users exclude other mental health conditions which are common at times of stressful events (WHO & UNHCR, 2015). These conditions include grief, depression, PTSD and harmful use of substances. During the pandemic, there is evidence of high prevalence of these conditions in HCW (Rossi et al., 2020).


The diagnostic approach of the mhGAP-HIG was used to develop self-reported questionnaires to rule out these conditions. The questionnaires were developed using relevant standardised interview scales (see [Table 1] and [Table 2] as an example). Our challenge was to ensure that even nonclinical frontline responders could assess their symptoms. Finally, we translated these questionnaires into Urdu to increase their utility and cultural relevance.{Table 2}

If users suspect another mental health condition, the application will help them connect to the counsellors for a detailed objective assessment. At this point the counsellors will either offer treatment for ‘other mental health conditions’ or refer the users appropriately.

Section III: Management Tools

We used evidence-based resources developed specifically in response to COVID-19 to formulate our stress management tools (WHO & UNHCR, 2015, WHO, 2020; IASC & WHO, 2020). Management strategies were designed at multiple levels, ranging from preventive techniques, practising stress management techniques and finally consulting a counsellor for supervised management or referral to a psychiatrist, if needed. The counsellor can access their saved data promptly for a one-one intervention.

The preventive strategies include self-care measures such as exercising; consuming a balanced diet; staying connected with others; adherence to a routine; doing relaxation exercises, etc. We have also incorporated a daily monitoring chart to encourage action and self-monitoring (WHO, 2020). All users are encouraged to incorporate these measures in routine.

Users are then facilitated to strengthen their coping mechanisms through the following steps:
• Step 1: Identify your sources of stress.
• Step 2: What can you do about these?
• Step 3: Who is the person you can talk to about what you are going through?
• Step 4: What helped you when you were stressed in the past?


The specific treatment strategies included a slow breathing technique (IASC & WHO, 2020); a progressive muscle relaxation technique (IASC & WHO, 2020); a grounding technique (WHO, 2020); a problem solving technique (WHO, 2020) when feeling overwhelmed with problems; sleep hygiene and medication advice for insomnia (WHO & UNHCR, 2015); and guidelines for addressing dissociative symptoms (WHO & UNHCR, 2015). These techniques were presented using simple language and a user-friendly format and clear instructions. We also described indications and a brief rationale about each technique.

To help users choose specific stress management techniques, brief indications were also defined for each intervention. These are linked to the nature of their symptoms and are described in [Table 3].

Table 3 Link Between Nature of Stress Symptoms and Management Techniques Click here to view



From the user feedback in focused group discussion, some areas were not very clearly understood. For example, there were questions about the nature of dissociative symptoms and the grounding technique.

A sample example was also added to explain the technique of problem solving. To enhance clinical utility of management techniques, all users who score above the cut-off for a stress condition (in [Table 2]) are advised to connect with a counsellor for supervised interventions.

Data to be recorded on the web portal for further research

The following indicators will be consolidated for comparative analysis and saved on a web portal for ongoing needs assessment:
1. What is the number and demographics of frontline workers who register?
2. How many were at risk for mental health conditions (including those with pre-existing mental disorders)?
3. What are the main sources of stress for the frontline workers?
4. What is the nature of their stress symptoms?
5. What is the course of their stress condition?
6. How many referred themselves to the counsellors?
7. Which management strategies were used?
8. How many developed other mental disorders? Which ones?


Strengths and Weaknesses of Our Approach

Like other LMICs, the pandemic has caused severe disruption in mental healthcare in Pakistan as well, where we were already struggling with limited and fragmented mental health services. There is neither a precedence to develop a digital mental health intervention nor to provide psychosocial support to frontline workers in any previous crisis in the country. As per recommendations by the Lancet Commission (Patel et al., 2018), our challenge was to design a digital, resource-effective strategy, which could (1) assess needs, (2) strengthen mental health resources, (3) sustain with a long-term impact and (4) be scaled up in other provinces. We used two recommended strategies for global mental health in the context of COVID-19: task shifting to manage stress in frontline workers and offering a digital solution for this initiative (Kola 2020) − both with a view to develop a scalable intervention.

To achieve this, we applied evidence-based resources to develop a practical, instructed self-guide for the assessment and management of stress-related conditions in the field, thus bridging a gap. (IASC & WHO, 2020; WHO & UNHCR, 2015, WHO, 2018, (2020)). We were aware that many of our frontline responders (nonclinical) may not be literate in English or in medical terms. Therefore, the relevant guidelines and resources needed the content to be adapted to local context (healthcare and cultural) and translated into the national language (Urdu) without compromising scientific accuracy or clinical utility.

Overall user feedback was positive for the English and Urdu versions of MyCare+ and users found the content relevant and helpful. More than 90% of users were able to follow the instructions and felt confident to use the tool. They found it much easier to follow the translated, Urdu version of the breathing exercise, the progressive muscle relaxation and problem-solving techniques, even when they were literate in English. Some participants reported difficulty in the conceptual understanding of the grounding technique. Some users suggested that clinical examples should be added to the management of dissociative symptoms. In our view supervision by the counsellors, however limited, will be essential to help frontline workers manage their stress. The developed content can now be easily translated into regional languages and offers scope to cover large populations. Also, the application has the potential to be updated as a rapidly developing body of information is emerging.

Duan (2020) suggested that interventions should be based on a comprehensive assessment of risk factors leading to psychological issues, for example, pre-existing mental disorders, bereavement and socioeconomic challenges. It is also known that the risk factors to identify those who are more vulnerable might vary between different countries (Jahanshahi et al., 2020). Keeping this in view, we developed a template for individual risk assessment in the first section. MyCare+ is also customised to individual users to help them assess needs at an individual level, and create personalised treatment plans with the help of a counsellor. We aim to build a user-friendly app designed to help individuals make swift clinical decisions (Torous et al., 2019). The tool helps maintain user anonymity and ensures protection of their data, an established need for web-based interventions (Kerst et al., 2020; Torous et al., 2019).

The main limitation of our intervention is that we are relying on the frontline workers to access our digital support through the use of their smartphones or computers. There might be a considerable proportion of workers who do not have these devices or access to the internet. Therefore, it would be extremely important to complement this intervention with a trained mental health workforce in the community to refer cases (Tier 1 of our project).

Even if frontline workers have access to our tool, there are at least four more foreseeable barriers for which we have little knowledge: (1) to overcome stigma and access psychological support, (2) to find time and space to utilise this support, (3) to engage with digital technology and (4) to fully comprehend management interventions. We know from other experiences that at least the medical staff did not prioritise psychosocial support and were reluctant to participate in psychological interventions (Chen, 2020). The acceptance and willingness to use an e-mental health intervention could be improved through the education and training of frontline responders (Kerst et al., 2020). It is also known that interventions for psychosocial support for frontline workers are better accepted when these are integrated into their routine duties (Wind et al., 2020).

During implementation of our intervention, we might have to find ways to engage the frontline workers through education, offering incentives and by integrating this support into their routine practices. Our intervention does not directly address basic needs of the frontline responders, but we hope to collaborate with relevant stakeholders to influence protocols and policies for protecting mental health conditions during the emergency response.




Conclusion



The present public health crisis has thrown up a gamut of mental health challenges, many of which have to do with mental health, for those operating on the frontlines. However, in many LMICs including Pakistan, the resources to provide psychosocial care for them are insufficient and inaccessible. The digital intervention to support frontline responders outlined above is an evidence-based, scalable, resource-efficient, practical step-by-step guide that has been adapted to local needs. The blueprint offers several lessons for MHPSS in public health emergencies.

Acknowledgements

We are very grateful to Dr. M. Asif, Chief Health, Ministry of Planning, Development and Special Initiatives, Government of Pakistan; Muqadissa Mehreen, Child Protection Specialist, UNICEF Pakistan; and Ayesha Chaudhry, MD Techhivesolutions.com for their valuable support towards this initiative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.







 

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Tables


  [Table 1], [Table 2], [Table 3]