title: The effectiveness of Technology-assisted Cascade Training and Supervision of community health workers in delivering the Thinking Healthy Program for perinatal depression in a post-conflict area of Pakistan - study protocol for a randomized controlled trial.
abstract: BACKGROUND
  Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women's health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision.
  
  
  METHODS
  This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status.
  
  
  CONCLUSIONS
  Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP.
  
  
  BACKGROUND
  Registered with ClinicalTrials.gov as GCC-THP-TACTS-2015, Identifier: NCT02644902 .
authors.affiliation: Human Development Research Foundation and Health Services Academy, Islamabad, Pakistan. shamsazafar@gmail.com.
authors.forename: Shamsa
authors.initials: S
authors.lastname: Zafar
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Siham
authors.initials: S
authors.lastname: Sikander
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Syed Usman
authors.initials: SU
authors.lastname: Hamdani
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Najia
authors.initials: N
authors.lastname: Atif
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Parveen
authors.initials: P
authors.lastname: Akhtar
authors.affiliation: Human Development Research Foundation, Islamabad, Pakistan.
authors.forename: Huma
authors.initials: H
authors.lastname: Nazir
authors.affiliation: Duke University, Islamabad, Pakistan.
authors.forename: Joanna
authors.initials: J
authors.lastname: Maselko
authors.affiliation: Institute of Psychology, Health and Society, University of Liverpool, Manchester, UK.
authors.forename: Atif
authors.initials: A
authors.lastname: Rahman
mesh_terms: D000068337:Armed Conflicts; D002985:Clinical Protocols; D003150:Community Health Workers / Q000193:education*; D003156:Community Mental Health Services / Q000379:methods*; D003194:Computer-Assisted Instruction / Q000295:instrumentation; D034201:Computers, Handheld; D003695:Delivery of Health Care; D019052:Depression, Postpartum / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D003906:Developing Countries; D005260:Female; D006801:Humans; D007318:Inservice Training; D008603:Mental Health; D010154:Pakistan; D018743:Perinatal Care / Q000379:methods*; D011247:Pregnancy; D011569:Psychiatric Status Rating Scales; D012107:Research Design; D016037:Single-Blind Method; D013997:Time Factors; D016896:Treatment Outcome
keywords: Community health workers; Conflict settings; Low and middle income countries; Perinatal depression; Psychosocial intervention; Technology-assisted Cascade Training and Supervision; Thinking Healthy Program