TNHSRP 2022 SJMC Final Report

Strengthening the existing Mental Health Programme to reduce suicide rates in rural
Tamil Nadu: an Operational research

Research Team
Dr. G. Nancy Angeline MD DTM&H1
Dr. Jackwin Sam Paul MD2
Dr. Divya Hegde MD3
Dr. Sri Sudha MD4
Dr. Karikalan MPH PhD5
Ms. J. Luciya Nancy MSW6
Dr. Vinod Joseph Abraham MD MPH7
Affiliations
1. Assistant Professor, Department of Community Health, St. John’s Medical College,
Bangalore
2. Assistant Professor, Department of Community Health, Christian Medical College,
Vellore
3. Associate Professor, Department of Psychiatry, St. John’s Medical College Hospital,
Bangalore
4. Associate Professor, Department of Psychiatry, Mental Health Centre, Christian Medical
College, Vellore
5. Scientist and Head, Department of Social and Behavioural Research, ICMR- National
Institute for Research in Tuberculosis, Chennai
6. Research Associate, St. John’s Research Institute, Bangalore
7. Professor, Department of Community Health, Vice Dean UG, Christian Medical College,
Vellore
Table of Contents
Executive Summary............................................................................................................4
Introduction.......................................................................................................................7
Objectives:.......................................................................................................................10
Methods:.........................................................................................................................11
Study Setting:...........................................................................................................................11
Kaniyambadi block.....................................................................................................................................11
Jamunamarathur Block, Jawadhi Hills:.......................................................................................................11
Pallipattu Block:.........................................................................................................................................12
Poonamallee HUD:.....................................................................................................................................12
Ethics Approval:.......................................................................................................................12
Permissions:.............................................................................................................................12
Sampling:.................................................................................................................................13
Study Tools:.............................................................................................................................14
Analysis:...................................................................................................................................15
Results:............................................................................................................................16
Discussion:.......................................................................................................................36
Conclusion:......................................................................................................................41
Recommendations:..........................................................................................................41
ANNEXURES.....................................................................................................................42
Mental Health Literacy Scale....................................................................................................42
PHQ-9......................................................................................................................................56
Suicide risk...............................................................................................................................58
Suicide risk stratification and support Mechanism....................................................................59
WHO-5 Well being index..........................................................................................................61
Topic Guide for Focus Group Discussion/In-Depth Interviews...................................................62
Training Module on Psychological First Aid...............................................................................64
Lecture: Distressing events and how they affect people.............................................................................69
Activity: Listening exercise.......................................................................................................................72
Lecture: Whom should we provide PFA....................................................................................................76
CONFIDENTIALITY AGREEMENT..............................................................................................114
Executive Summary
This study was conducted in Kaniyambadi Block, Vellore District, Jamunamarathur Block,
Thiruvannamalai District, Pallipattu Block, Thiruvallur Health Unit District and Poonamallee
Block of Poonamallee Health Unit District of Tamil Nadu. A total of 117 Community Health
Workers (CHW) were assessed for Mental Health Literacy and trained in Psychological First
Aid. These CHWs screened 571 individuals in Kaniyambadi block and 400 individuals in
Pallipattu Block and 400 individuals in Poonamallee block for depression and suicide
risk. CHWs were observed to be lacking in knowledge of mental illnesses and attitudes that
promote recognition of appropriate help seeking behaviours for mental illnesses. Among the
CHWs, 56% believed that mental illness is not a real illness and 83% believed that people
will mental illness can come out of the illness if they wished to. Among the community
members, 45% could not understand what mental health is and 40% did not know that mental
illness can be treated at their Primary Health Centres. Of the community members screened
by CHWs, 13.18% were positive for depression and 38% were positive for atleast one suicide
risk. The most common suicide risk observed was chronic pain followed by extreme
hopelessness. Being married, higher education, employed status, belonging to minority
religion were observed to be associated with better mental health status. Among the tribal
population in Jamunamarathur Block social determinants of mental health such as literacy,
access to education, livelihoods, social connections were mentioned by community as risk
factors for poor mental health. We recommend the following from our study: Leverage the
current implementation of District Mental Health Programme by appointment of Psychiatrist,
Psychiatry Social Worker and Clinical Psychologist and strengthen the school, workplace
based mental health interventions, DMHP staff should invest their time in training CHWs of
their District in basic Psychological First Aid, PHQ-9/2 Screening, referral and follow-up of
mentally ill patients in their community, facilitation of mental health awareness session in the
community, Promotion of enabling environment in Primary Health Centres by Medical
Officers facilitating the training and follow-up care provided by CHWs and Multisectoral
engagement in addressing inequities and disproportionate impact of mental health on
marginalised and vulnerable population
Introduction
The state of Tamil Nadu has an adequately functional District Mental Health Programme
with universally available Out Patient facilities for psychiatric illnesses and referral
services. In Patient services and basic psychotropic medicines are available in District
Headquarters Hospitals1. The basic training for ASHA workers in Tamil Nadu include a
module on Non-Communicable diseases with inadequate focus on Mental Health 2. As a
part of the Community Based Assessment Checklist, Grass Root level Health Workers
(GLHWs) are trained in administration of Patient Health Questionnaire-2 to screen for
depression3. However, there is significant gap in the primary prevention of depression in
the communities in terms of screening, basic counselling services and knowledge and
attitude among community health workers.
Review of literature
Grassroot level Health Workers (GLHWs) in India:

Each village in India is provided with a trained female Community Health activist ASHA or
Accredited Social Health Activist. ASHA works with all members of the community,
irrespective of age or gender4.
1
Gururaj G, Ramasubramanian C, Girish N, Mathew V and Sunitha S. Tamil Nadu Mental
Health Care Assessment: Review of District Mental Health Programme, 2013. Publication no
106, National Institute of Mental Health and Neuro Sciences, Bangalore, 2014.
2
ASHA, National Health Mission. https://www.nhm.tn.gov.in/en/r-c-h/asha
3
Community Based Assessment Checklist for ASHAs.
http://namayush.gov.in/sites/default/files/doc/Community_based_assessment_checklist_(CB
AC)_form.pdf
4
About Accredited Social Health Activist. National Health Mission.
https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226
The AnganWadi Worker (AWW) through the Integrated Child Development Services and
Scheme elicits community support and participation, she works closely with pre-school
children, pregnant mothers, adolescent girls, lactating mothers and grandmothers of children5.
The Auxiliary Nurse Midwife (ANM) at the health centre and in the community works with
eligible couples, pregnant mothers, lactating mothers. She spends more time with pregnant
mothers as compared to AWWs, starting from registration of pregnancy to delivery,
immunization and next pregnancy till the permanent sterilization phase. This opens up
opportunity to screen and counsel for perinatal depression, intimate partner violence, dowry
harassment and post-partum blues6.
In Tamil Nadu, Village Health Nurses are appointed for every 5000 population in the plains
and 3000 population in tribal areas. They provide health care services for the community,
under National Programmes which cover Reproductive and Child health, tuberculosis,
leprosy, HIV AIDS and non-communicable diseases7. There is sufficient evidence in
literature to prove that, in Low and Middle income countries, when health workers are trained
by professionals to provide mental health interventions, significant improvement in mental
health symptoms can be observed8.
The GLHWs in Tamil Nadu are

1. ASHA workers in tribal areas
2. Village Health Nurse in rural areas
3. Auxiliary Nurse Midwives
4. Anganwadi workers
5. Women Health Volunteers
5
Roles and Responsibilities of Anganwadi Worker. Ministry of Women and Child
Development. https://wcd.nic.in/sites/default/files/Roles%20and%20Responsibilities%20of
%20AWWs.pdf
6
Guidebook for enhancing the performance of Auxiliary Nurse Midwife in Urban areas.
https://nhm.gov.in/images/pdf/NUHM/ANM_Guidebook_under_NUHM.pdf
7
Job responsibilities of the Village Health nurse.
https://www.nhm.tn.gov.in/sites/default/files/documents/jd_vhn.pdf
8
Connolly SM, Vanchu-Orosco M, Warner J, Seidi PA, Edwards J, Boath E, Irgens AC.
Mental health interventions by lay counsellors: a systematic review and meta-analysis. Bull
World Health Organ. 2021 Aug 1;99(8):572-582.
Department of Health, Government of Tamil Nadu has appointed Women Health
Volunteers (WHVs) from Tamil Nadu Women’s Welfare Development Corporation of
the Department of Rural Development to implement the Makkalai Thedi Maruthuvam or
the Door step health scheme. These volunteers are expected to have education of upto 8 th
standard. Under this scheme, registered patients in urban and rural areas will be visited at
their home by the WHVs for screening and drug delivery for hypertension and diabetes,
palliative care therapy, physiotherapy, self-dialysis bag distribution with assistance from
nurses and physiotherapists9.
WHVs in the study areas were allotted 20 houses per day to do RBS, BP screening and
followup and home delivery of drugs prescribed and given by PHC MO, ANM and
pharamacist team. WHVs also spread awareness on oral cancers, cervical cancer
screening and other activities of the PHC to the community. They receive 4500 rs per
month as renumeration.
Psychological First Aid:
It is a humane and supportive response to a fellow human being who is suffering and who
needs support. It involves giving the following care
 Practical care and support

 Assessing needs and concerns
 Listening
 Comforting and help to feel calm
 Connect to information, services and social supports
 Protect from further harm10
Psychosocial support that can be provided by Community Health Workers:
In the WHO MhGAP 2.0 Module, it is recommended that Community Health workers can
provide psychosocial support to individuals by the “Use of Effective Communication
Skills”11. These supportive interventions include
9
https://www.yojanaschemehindi.com/tamil-nadu-makkalai-thedi-maruthuvam-services-application/
10
World Health Organization. 2011. Psychological First Aid: A guide for field workers
11
MhGAP Version 2.0. World Health Organization. For mental, neurological and substance
use disorders in non-specialized health settings.
1. Creating an environment that facilitates open communication
2. Involving the person and showing empathy
3. Listening
4. Being friendly, respectful and non-judgemental at all times
5. Use of good verbal communication skills
6. Responding with sensitivity when people disclose difficult experience
7. Promotion of dignity and respect
Justification / need for the study

1 in 10 people have a mental health disorder, but only 1% of the global health workforce
provides mental health care. Considering the gap in increasing rates of mental health issues in
the country and insufficient mental health professionals per population ratio, it is essential
that task shifting in this regard is executed by training GLHWs on basics of mental health
services. The current District Mental Health Programme addresses only secondary prevention
of mental illnesses and the proposed intervention can be made sustainable and scalable to be
adopted into the National Programme so that from Community Level, primary prevention is
addressed.
Objectives:
 To train community health workers on Psychological First Aid

 To assess the Mental Health Literacy status of community health workers
 To assess the feasibility of training community health workers in screening for
depression and suicide risk
 To assess the prevalence of depression and suicide risk as per the screening done by
community health workers
Methods:
Study Setting:
Kaniyambadi block in Vellore District, Tamil Nadu has a total population of 1,53,062. The
study area has high rates of suicides with hanging and Organo phosphorus consumption as
the common methods. This block is the rural practice area of Community Health Department
of Christian Medical College, Vellore. Post graduate Community Medicine Physicians are the
Resident Medical officers of different areas of this block with Health Aides (GLHW) and
Social Workers assisting them in health care service provision. The CHAD (Community
Health and Development) Hospital administered by the Department of Community Health,
Christian Medical College provides outreach mobile health care services, catering to chronic
mental health conditions, screening and referral to Department of Psychiatry, Christian
Medical College, Vellore. A visiting Psychiatrist also provides OPD care, weekly once at the
CHAD Hospital. The Upgraded Block PHC has a monthly Psychiatrist visiting the PHC for
managing Psychiatric Patients. The Government Medical College, Vellore is also located in
this Aducamparai area of this block having its own Psychiatry Department. Grassroot level
health workers of the Government of Tamil Nadu who work with the community are Village
Health Nurses (VHN), Auxiliary Nurse Midwives (ANM) and Anganwadi workers (AWW).
Jamunamarathur Block, Jawadhi Hills:

Jamunamarathur block in Jawadhi hills has reserve forests and is located in Thiruvannamalai
District, Tamil Nadu.It has a total population of 9861. The CHAD Hospital of CMC Vellore
provides outreach and community health care services in Tribal areas of Jawadhi Hills with
support from Community Health workers. Government of Tamil Nadu staff ASHA workers,
ANMs, AWWs and VHNs also provide services in this area. Psychiatry patients are referred
to Government Medical College, Thiruvannamalai or Vellore (Distance is the same).
Government Hospital Polur had vacant Psychiatry post at the time of the study.
Like other tribal population in India, this population suffers from poor socio-economic status,
illiteracy, inadequate geographical access, political representation and discrimination.
However, the mental health status of this population is expected to be unique because due to
the work of CHAD and the Government of Tamil Nadu, literacy status and access to plains is
improving. This exposes the tribal population to new set of issues – challenges due to
psychological, socio-cultural and economic acculturation, migration related stress, trauma
due to adverse life events, low self-esteem, poor coping skills such as substance use,
inadequate life skills, trauma caused by stigma and discrimination associated with scheduled
tribes.
Pallipattu Block:
Athimanjeerpet PHC area is located in Pallipattu Block, Thiruvallur Health Unit District. It
covers around 30,000 population and it is a border town located close to Chittoor District of
Andhra Pradesh. It is a rural area with most of the population following agriculture
occupation. Psychiatry patients are referred to Thiruvallur Government Hospital.
Poonamallee HUD:
Poonamallee is a suburb area of Chennai City and it is located in Poonamallee Taluk,
Thiruvallur City. It has a total population of 57,224 served by the following PHCs:
Poonamallee Urban PHC, Thirunindravur, Nemam and Thirumalisai. Psychiatry patients are
referred to Government General Hospital Poonamallee.
Ethics Approval:
Institutional Ethics Committee approval from St. John’s National Academy of Health
Sciences was obtained for the first part (IEC Ref. No 12/2022) and second part (IEC Ref No.
295/2022)of the study. Institutional Ethics Committee approval from Christian Medical
College Vellore was obtained (IRB Min No: 14570 dated 27.04.2022). Written informed
consent was obtained from all participants. Directorate of Public Health and Preventive
Medicine Scientific Advisory Committee Approval was obtained.
Permissions:
Permissions were obtained from the following authorities
 Deputy Director of Health Services, Vellore, Thiruvannamalai, Poonamallee and

Thiruvallur
 Project Director, Integrated Child Development Services, Vellore and
Thiruvannamalai
 Project Director, Tamil Nadu Corporation for Development of Women, Thiruvallur
District.
Sampling:
From the DDHS and PD office, complete list of health workers was obtained. By Random
sampling based on the inclusion and exclusion criteria, health workers were selected.
For the Health workers
 Health Aides of Kaniyambadi Block who are employees of the Christian

Medical College, Vellore aged 18 to 55
 Community Health Workers of Jamunamarathur Block who are employees of
Christian Medical College, Vellore aged 18 to 55
 Village Health Nurses, Anganwadi Workers, Auxiliary Nurse Midwives of
Kaniyambadi Block who are employees of the Government of Tamil Nadu
aged 18 to 55
 ASHA workers, Anganwadi Workers, Auxiliary Nurse Midwives of
Jamunamarathur Block who are employees of the Government of Tamil Nadu
aged 18 to 55
 Women Health Volunteers, Village Health Nurses and Auxiliary Nurse
Midwives) of Athimanjeerpet Rural PHC and Poonamallee Urban PHC,
Government of Tamil Nadu with a commitment to service and having no plans
of leaving/retirement from service in the next 5 years
A total of 117 health workers were administered mental health literacy scale and underwent
training in WHO Psychological First Aid.
For the Community members:

 Residents of the PHC areas of the study areas, aged 18 and above
A total of 571 community members from Kaniyambadi, 400 from Athimanjeerpet and 400
from Ponnamallee were screened for depression and suicide risks. Totally 1371 individuals
were screened.
Exclusion Criteria
GLHWs of the Government of Tamil Nadu who are not available for the training due
to long leaves and those who are nearing retirement (Age 55 and above). The reason for not
choosing senior staff is not to discriminate them because of their age. The project is expected
to be scaled up by the Government of Tamil Nadu after 10 months of its execution. At that
time, when a follow-up study is planned to understand the impact of the training and the
services provided by GLHWs, it will be ideal if most trained GLHWs are retained.
Study Tools:
 Socio-demographic variables
 Mental Health literacy scale12 was administered to the health workers
 Patient Health Questionnaire-913 to screen for depression was administered by the
health workers of Kaniyambadi, Athimanjeerpet and Poonamallee Blocks
 Mental Health GAP Questions14 to screen for depression/ Deliberate self harm and
suicide risk was administered by health workers of Kaniyambadi, Athimanjeerpet and
Poonamallee Blocks
 World Health Organization-5 Wellbeing Index15 was administered by health workers
of Athimanjeerpet and Poonamallee Blocks
 Topic guide for Focus Group Discussion and In-depth Interview on mental health,
depression and suicide to be used in Jamunamarathur block
The mental health literacy scale is a 35 item questionnaire with first 15 items scored on a 1-4
scale with items 10,12,15 being reversed. Items 16-35 are scored on a 1-5 scale with items
20-28 being reversed. Total score is produced by summing all items (maximum score 160
and minimum score 35.
12
O'Connor M, Casey L. The Mental Health Literacy Scale (MHLS): A new scale-based
measure of mental health literacy. Psychiatry Res. 2015 Sep 30;229(1-2):511-6.
13
Patient Health Questionnaire-2. https://www.hiv.uw.edu/page/mental-health-screening/phq-
2
14
MhGAP Intervention guide- Version 2.0. World Health Organization.
https://www.who.int/publications/i/item/9789241549790
15
Topp CW, Østergaard SD, Søndergaard S, Bech P. The WHO-5 Well-Being Index: a
systematic review of the literature. Psychother Psychosom. 2015;84(3):167-76.
Patient Health Questionnaire (PHQ-9) is a screening instrument for making criteria based
diagnoses of depression and other mental disorders in primary care settings. It has only 9
questions and has adequate sensitivity and specificity to diagnose and categorise depression
severity.
World Health Organization Mental Health GAP Intervention guide for mental, neurological
and substance use disorders (MNS) in non specialist health settings can be used by doctors,
nurses, health workers, health planners and managers. This guide presents integrated
management of priority MNS conditions using algorithms for clinical decision making. In the
depression and suicide prevention component of the module, 10 risk factors are mentioned as
suicide risk. These factors are taken as a study tool in this study to be used in screening for
suicide risk.
Since women health volunteers are new to the health care system and they have not had
sufficient clinical exposure for now, the World Health Organization Well Being Index-5, a
short measure of current mental well-being was added to their tool kit. This tool is a
wellbeing measure to be used in primary care settings. It has adequate validity in screening
for depression and has good construct validity.
Tribal area had challenges such as ASHA workers with limited literacy, transport difficulties,
difficult terrain and communication challenges to execute training of health workers in
depression screening. Hence qualitative method was chosen to understand mental health
issues among this population.
Analysis:
The quantitative data collected was entered in Microsoft Excel and analysed in STATA. Age
and other continuous variables was analysed as mean and Standard deviation. Sex,
comorbidity status and depression and suicide risk were analysed as percentage. Chi square
test and regression analysis was done to assess any association between the depression status
and socio-demographic variables. Adjusted odds ratio was calculated and p value of <0.05
was considered as significant. 95% confidence interval for the odds ratios was calculated.
Interviewers audio-recorded all interviews and focus group discussions in Jamunamarathur,
which was then transcribed and translated into English for analysis using NVivo 12. The
transcribed interviews were analyzed using an open, focused coding process. We identified
themes to understand socio-economic, cultural and geographical basis of depression in the
tribal population.
Results:
Table 1: Baseline characteristics of GLHWS N=117
Baseline characteristics Mean (SD), N (%)

Age 36.39 (8.3)
Years of experience 7.16 (7.6)
Income 15,132 (14,698)
Designation
Accredited Social Health Activist 16 (13.7%)
Auxiliary Nurse Midwife 3 (2.6%)
Village Health Nurse 22 (18.8%)
Urban Health Nurse 13 (11.1%)
Anganwadi Worker 10 (8.5%)
Women Health Volunteers 19 (16.2%)
Christian Medical College Health Aides 34 (29.1%)
Most of the health workers were in 30-40 years of age group with 7 years of experience. All
the health workers reported receiving training in physical health. All health workers
mentioned that this is the first mental health training they are receiving in their life. In fact,
the definition of mental health itself was heard for the first time in this training. Village
Health Nurses were the most common group covered in our training. In CMC Vellore, there
were two categories of health workers, rural and tribal. The tribal health workers in CMC
were less experienced as compared to rural since the tribal services were initiated only
recently.
Table 2: Mental Health Literacy levels of GLHWs (N=117)
Mean Median Mode Minimum Maximum
Ability to recognise 24.29 25 24 10 32

disorders (1-8)
Knowledge of where to 12.23 12 11 7 16

seek information (9-12)
Knowledge of risk 6.3 6 6 4 8

factors and causes (13-
14)
Knowledge of self 5.7 6 6 3 8

treatment (15-16)
Knowledge of 12.1 12 12 7 15
professional help (17-
19)
Attitudes that promote 17.14 18 19 7 26

recognition of
appropriate help seeking
behaviour (20-25)
Overall Total 105.26 106 102 84 127
All the health workers in our study were administered the mental health literacy scale. This
scale is more suited as a self administered scale. However, health workers with varying
degrees of educational status and experience were assisted in filling up the tool. The
knowledge of mental illnesses domain of the tool had similar answers and it was much easier
to fill that domain. Scores in attitudes that promote recognition of appropriate help seeking
behaviour was much less. This is due to prevailing stigma and inadequate knowledge of
mental health issues.
Table 3: Mean scores of all health workers (N=117)
ASHA AWWs ANMs VHNs UHN WHV HA HA

Tribal
Rural
Ability to recognise 25.5 24.9 21.3 24.1 24.7 21.5 23.4 27.4
disorders (1-8) (1.5) (2.3) (4.04) (3.8) (2.3) (3.6) (2.5) (3.2)
Knowledge of where to 11.25 12 (1.6) 12.3 12.3 11.7 11.4 12.67 14.1
seek information (9-12) (1.5) (1.2) (1.8) (1.8) (1.7) (1.2) (1.2)
Knowledge of risk 5.6 5.6 6.7 6.2 6.3 6.1 6.5 7.6
factors and causes (13- (0.8) (1.6) (0.6) (1.1) (0.9) (0.6) (0.6) (0.7)
14)
Knowledge of self 6.8 5.8 6.3 5.3 5.6 5.2 5.5 5.8
treatment (15-16) (0.5) (0.8) (1.2) (0.9) (0.7) (0.8) (1.1) (0.7)
Knowledge of 13.3 12.3 10.66 11.4 11.7 10.9 12.5 14

professional help (17- (1.4) (1.5) (2.1) (2.2) (2.4) (2.3) (1.2) (1.9)
19)
Attitudes that promote 11.9 18.4 19 (5.6) 17.7 20. 7 19. 35 16.4 15.7
recognition of (3.5) (4.2) (3.2) (1.6) (1.8) (3.2) (2.7)
appropriate help seeking
behaviour (20-25)
Overall score 102.25 106.6 106 102.2 109.5 101.4 105.3 112.7
(8.9) (7.4) (6.2) (10.1) (8.9) (10.8) (7.7) (9.1)
In all domains, CMC rural health aides had the highest scores. This is due to their higher
experience and constant exposure to experts in their outreach clinics. Many Anganwadi
workers have high higher education as compared to other health workers. However, this
doesn’t reflect in their mental health literacy. ASHA workers despite their lower education
had mental health literacy comparable to other workers. VHNs who have adequate
experience and working more closely with community have mental health literacy
comparable to ASHA and women health volunteers. This needs further attention.
N=117
28; 24%
51; 44%
38; 32%
Not willing Unsure Willing
Figure 1: Health workers’ willingness to work with a person having mental illness
Most health workers mentioned that they are not willing to work with a person having mental
illness. This reflects the stigma around mental illness.
N=117
40; 34%
71; 61%
6; 5%
Effective Unsure Not effective

Figure 2: Health Workers' belief on effectiveness of treatment by mental health professional
While most believe in effectiveness of treatment by mental health professions, 34% believe
that mental health treatment is ineffective. There is significant gap in the knowledge of
psychiatry treatment and this needs to be filled.
15; 13%
N=117
5; 4%
97; 83%
Agree Neither Agree nor Disagree Disagree

Figure 3: Health workers' belief that people with mental illness can snap out if they want
Most health workers believed that people with mental illness can become normal if they want
and their wellbeing is in their hands. This reflects lack of mental health knowledge among the
health workers.
N=117
50; 43% 52; 44%
15; 13%
Agree Neither agree nor disagree Disagree

Figure 4: Health workers' perception that mental illness is not a real illness
Almost half of the health workers (44%) believe that mental illness is not a real illness. It is
described as pretence, weakness, some people just decide to be mentally ill.
8
7%
N=117
101
93%
Confident Not confident

Figure 5: Health workers’ confidence in accessing information about mental health
Most health workers are confident about accessing information about mental health due to
their good relationship with medical officers.
After the Mental Health Literacy assessment, all health workers underwent Psychological
First Aid training (Module in Annexure). The total duration of training for Kaniyambadi and
Jamunamarathur was 6 days and Athimanjeerpet and Poonamallee was 2 days due to
logistical constraints.
The training was participatory with principles of adult based learning methods followed. It
also added social determinants of mental health in all the discussion and practical points on
referral mechanisms- Government, Private and NGOs, helplines, short stay homes and
rehabilitation facilities.
In Christian Medical College, the training was supported by Psychiatry Department as well in
better understanding of mental illnesses and establishment of referral mechanisms. In all
trainings, pre and post test assessment was done. This assessment was challenging to
administer to ASHAs and WHVs due to their literacy status and understanding of written
Tamil statements. Except WHVs, all the community health workers showed significant
difference in pre and post test scores.
Table 4: Pre and post test scores of training conducted (N=117)
Participants Mean pre test Mean of Post Mean Paired t test

score test score Difference value and p
value
ASHA 11.47 13.76 2.29 2.69 (0.01)
workers
Anganwadi 17.8 22.3 4.5 4.2 (<0.001)
Workers
ANM 10.5 12.5 2 -7 (0.09)
VHNs 20.07 22.46 2.39 -4 (<0.001)
UHNs 7.5 8.1 0.6 -1.9 (0.06)
Women 5.53 5.94 0.4 1.02 (0.32)
Health
Volunteers
Kaniyambadi 20 22.71 2.71 -3.09 (0.006)
Government
Health
Workers
Jawadhi 11.57 14.61 3.04 -2.97 (0.005)
Government
Health
Workers
Kaniyambadi 17.17 21.52 4.35 -6.7 (<0.001)
CMC Health
Aides
Jawadhi CMC 17.5 24.05 6.55 -2.11 (0.05)
Health
Workers
Feedback from trainings
 VHN shared “today class was good, Positive and negative thoughts class were very
interesting; also trainer teaching very well”.
 Anganwadi worker shared “today training was just awesome, I learnt about positive
skills and negative skills, learnt many techniques for peace of the mind; trainer
training was super, through this training I am getting peace of the mind”.
 Anganwadi W said “I learnt about basic techniques to give PFA and the explanation
through the game was just interesting. Through this training I am seeing my heart in
mirror, really trainer took the class well and I am very grateful to that”.
 Anganwadi W told “today class I learnt about the basic principles, also we were well
taught about positive skills which is good way to encourage the person who need
PFA and Negative skill is not good to listen. Our trainer caring always smile face and
her way of teaching is super, teaching methodology is easy to understand”.
 Anganwadi worker stated that “today classes were interesting, through games I learn
about positive thoughts and negative thoughts game is super. Our trainer talking way
is very impressive, she is very talented person, her way of teaching is much to
appreciate, and her speaking style is too good, excellent and beautiful”.
 VHN shared “today class was wonderful, specifically 3L concept (Look, Listen and
Link) was super, and also I love the games so much it made me very active. Trainer
class was very interesting I love her smile”.
 VHN told “today I learned positivity, whatever the situation comes I taught to be
positive. I love our trainer, I like her teaching method”.
 VHN said “today class was outstanding, well explained by our trainer, I learned
clearly about positive and negative vibes, today game was awesome through the
game I understood well about positivity, also I learnt about negative thought is bad”.
 VHN shared “today class I learnt about how the depression affected person has to
treat and how the person will behave, then also learn about possible way to cure the
disease. I love our trainer classes, she is explaining well with good examples; also
through her talk she made us to believe everything is possible”.
 VHN shared “today class was well explained regarding through the problems how to
get solution. Trainer taught many new things with smiley face, I learned many new
things from her”.
 VHN told “Today training was wonderful, it gives peace of mind, also I learnd 3L
look, listen link concept. Our trainer teaching is awesome; she has given many
examples so it is very easy to understand”.
 ANM Nurse mentioned “today classes were very clear and understandable, also I
understood about positivity and negative attitude through game way method it was
explained well and it was very interesting. Our trainer class is very interesting and
we are listening her class with zeal”.
 VHN shared “today classes went on well, I learnt about positive skills and negative
thoughts in this positive thoughts brings good vibes through games it was explained
clearly. Trainer teaching class very interesting, through examples she is creating zest
to us”.
 VHN told “today class was good and clearly explained about positivity and negativity
through the games. Trainer teaching is very good and clears us I thankful to her so
much”.
 VHN said “today I learnt about which is creating negative situation and how to
convert the situation in to positive mode, also now I am confident to identify the
person with negative thought. Because of our trainer today class went happily, I
loved her teaching method, really super I am giving 5 stars to her”.
 I have never attended any training like this. It was life transforming. I learnt how to
solve problems and how to be patient and loving
 I learnt how to handle everything in a positive manner. I was very stressed when I
came to this training due to personal and workplace reasons. After training I have
become more strong to face any problems.
Part of the training also covered depression and suicide risk screening, suicide risk
stratification and referral. After the training, except in Jamunamarathur all health workers
were given forms to go back to their communities and conduct depression screening. The
given forms contained sociodemographic details, health details, PHQ-9, suicide risk
screening and WHO Wellbeing index (in Athimanjeerpet and Poonamallee only). The
baseline characteristics of the 1371 individuals screened by the health workers are as follows.
Table 5: Baseline characteristics of the study population (N=1371)
Baseline characteristics N (%)

Age 36.2 (14.7)
Religion Hindu 1236 (90.2%)
Muslim 18 (0.3%)
Christian 117 (8.5%)
Gender Male 309 (22.5%)
Female 1062 (77.5%)
Marital Status Married 1028 (75%)
Single 261 (19.03%)
Separated/divorced/widowed 82 (6%)
Caste SC/ST 415 (30.3%)
Others 956 (69.7%)
Education Illiterate 137 (9.9%)
1-5th 123 (8.9%)
5-8th 191 (13.9%)
9-10th 341 (24.8%)
11-12th 306 (22.3%)
College 201 (14.6%)
Post graduation 76 (5.5%)
Per capita monthly Income INR 9360 (18,491)
Age at work 18 years (10.52)
Occupation Unemployed 565 (41.2%)
Unskilled 770 (56.2%)
Semi Skilled 36 (2.6%)
History of physical illness Present 178 (13%)
N= 571
No; 249; 45%
Yes; 309; 55%
Yes No
Figure 6: Knowledge of mental health among Kaniyambadi Population
Nearly half of the population (45%) mentioned that they do not know about mental health.
33; 6%
N= 571
146; 27%
366; 67%
Male Female Both

Figure 7: Knowledge of gender as a risk factor for mental health issues among Kaniyambadi
Population
Most of the study population believe that both sexes are prone for mental health issues.
N= 571
186; 34%
358; 66%
Yes No
Figure 8: Ability of a mentally ill person to lead a normal life among Kaniyambadi
Population
More than half the population believe that a mentally ill person cannot lead a normal life.
This is due to their lack of awareness regarding treatment options available.
N= 571
299; 40%
448; 60%
Yes No
Figure 9: Availability of treatment for mental illnesses among Kaniyambadi Population
Though the Kaniyambadi area has a block PHC with Medical Officer with monthly
Psychiatrist visit and Aducamparai Government Medical College is very close to the block
and presence of Department of Community Health, Christian Medical College Vellore and
the outreach activities, 40% of the community did not know the availability of treatment for
mental illnesses by Psychiatrist.
160
146 149
140
125
120
111
100
80
60
40
20
0
Primary Health Centre Government Medical College Private Hospital Others
Figure 10: Place of treatment availability for mental illnesses among Kaniyambadi
Population
Preference for treatment of mental illnesses was mostly private hospital (especially, Christian
Medical College Vellore), followed by Government Medical College and other places such as
counselling centres.
25; 5%
N= 571
508; 95%
Yes No
Figure 11: Contact with health worker regarding mental health in the last 6 months among
Kaniyambadi Population
Almost all community members mentioned that a community health worker has never
discussed about mental health in the last 6 months with them. This describes the need for this
study and the importance of health workers’ involvement in mental health.
N= 571
103; 26%
293; 74%
Yes No
Figure 12: Privacy provided at health care facility among Kaniyambadi Population
In terms of privacy provided during treatment and care at health facility, most of the study
population mentioned that they have not been provided privacy due to space constraints and
also the large waiting crowd in OPDs.
N= 571
111; 34%
218; 66%
Yes No
Figure 13: Respect provided by the health care provider among Kaniyambadi Population
34% of the study population mentioned that they have not been provided adequate respect by
the health care provider in the treatment settings.
Table 6: WHO Wellbeing scores for Pallipattu and Poonamallee PHCs
WHO Athimanjeerpet Poonamallee

Wellbeing
Index
Poor 108 (27%) 93 (23.3%)
Minimal 81 (20.25%) 101 (25.3%)
wellbeing
Moderate 95 (23.75%) 64 (16%)
Wellbeing
Adequate 116 (29%) 142 (35.5%)
Women Health Volunteers and other Community Health Workers reported that WHO
Wellbeing Index is much easier to administer as compared to PHQ-9 and Suicide Risk
assessment.
39; 3%
96; 7% N= 1371
1236; 90%
No Difficulty Some Difficulty Severe Difficulty
Figure 14: How difficult have these problems (Questions in PHQ-9) have made it difficult for you to do work or take care of
things at home or get along with other people?
Most of the study population, did not have any difficulty at work, home or with people with
regards to their mental health problems as captured in PHQ-9.
Table 7: Depression scores for the study population
Depression scores Kaniyambad Athimanjeerpet Poonamallee Overall

i
Minimal 491 (85.98 %) 333 (83.25%) 366 (91.5%) 1190 (86.79%)
Mild 61 (10.66%) 39 (9.75%) 27 (6.75%) 127 (9.25%)
Moderate 15 (2.62%) 10 (2.5%) 7 (1.75%) 32 (2.33%)
Moderately Severe 3 (0.52%) 12 (3%) 0 15 (1.09%)
Severe 1 (0.17%) 6 (1.5%) 0 7 (0.51%)
Total 571 400 400 1371
Most of the study population in all the study areas do not have depression. Individuals with
mild, moderate, moderately severe and severe depression were listed and shared with PHC
Medical Officer for further follow-up and management. Prevalence of mild depression in our
study was 9.25% and moderate to severe depression was 3.93%. Overall 13.18% of the study
population had depression, as screened by the community health workers.
N= 1371
522; 38%
842; 62%
Present Absent
Figure 15: Presence of atleast one suicide risk factor in the community
As per the MHGAP, 38% of the study population had atleast one suicide risk factor present.
Table 8:Suicide risks present in the study population
S.N Suicide risk Kaniyambad Athimanjeerpe Poonamalle Overall

o i t e
1. Extreme hopelessness and 58 (10.1%) 20 (5%) 5 (1.25%) 83
despair
2. current thoughts/plan/act of 20 (3.49%) 27 (6.75%) 1 (0.25%) 48
self-harm suicide
3. History of self harm/suicide 11 (1.92%) 26 (6.5%) 1 (0.25%) 38
– past month or past year
4. Presence of depression/ 12 (2.09%) 11 (2.75%) 1 (0.25%) 24
child/adolescent mental
health disorders/ substance
use behavioural disorders
psychoses/ epilepsy
5. Chronic pain 40 (6.99%) 42 (10.5%) 6 (1.5%) 88
6. Extreme emotional distress, 21 (3.67%) 28 (7%) 3 (0.75%) 52

extremely agitated, violent,
lacks communication
7. Difficulty in carrying out 17 (2.97%) 22 (5.5%) 5 (1.25%) 44
usual work at
work/school/domestic/socia
l activities
8. Repeated self medication 4 (0.69%) 4 (1%) 1 (0.25%) 9
for emotional distress
9. Repeated help seeking 23 (4.02%) 8 (2%) 2 (0.5%) 33
10. Unexplained physical 3 (0.52%) 6 (1.5%) 2 (0.5%) 11

symptoms
Overall 209/571 194/400 27/400 430/137
1
Total of 430 suicide risks were identified in our study among 1371 individuals.
Table 9: Factors associated with Depression
Independent variables None to Depression UOR AOR

mild Present (95%CI) (95% CI)
depression
Age 36 years 41 years Mean

difference - 1.02 (0.9-
5.36 (p value 1.05)
0.01)
Employment Employed 763 (94.7%) 43 (5.3%) 3.14 (1.3-

2.7 (1.4-5.2)
status 7.2)
Unemployed 554 (98.1%) 11 (1.9%)
Education till
308 (93.9%) 20 (6.1%)
middle school
Education 1.9 (1.11- 1.6 (0.76-
status High school 3.3) 3.3)
and above 891 (96.8%) 29 (3.2%)
education
Employment was observed to be independently associated with depression in our study.

Employment factor can be said as a protective factor against depression.
Table 10: Factors associated with wellbeing
Independent WHO Well being scores UOR (95% AOR (95%

Variables CI) CI)
Inadequate Adequate
Religion Hindu 324 359 (52.6%)

(47.4%) Chi square
16.5 2.1 (1.4-3.3)
Christian 29 (31.5%) 63 (68.5%)
P value
Muslim 0 10 (100%) <0.001
Education Education
till
90 (52.6%) 81 (47.4%)
middle
school
1.6 (1.2-
High 1.6 (1.2-2.3)
2.3)
school
216
and 319 (59.6%)
(40.4%)
above
education
Belonging to minority religion and higher education status was observed to be significantly
associated with better mental well-being.
Table 11: Factors associated with suicide risk
Independent Suicide risk UOR AOR (95%

variables Present Absent (95% CI) CI)
Hindu 487 749 Chi square
(39.4%) (60.6%) 9.4
Christian 30 87 P value
Religion 1.6 (1.1-2.3)
(25.6%) (74.4%) (0.009)
Muslim 5 13
(27.8%) (72.2%)
Unmarried 200 143
(58.3%) (41.7%) 3.06 (2.3-
Marital status 1.7 (1.3-2.2)
Married 322 706 3.9)
(31.3%) (68.7%)
Employment Employed 260 546 1.26 (1.15- 1.6 (1.3-2)
(32.3%) (67.7%) 1.4)
Unemploye 262 303
d (46.4%) (53.6%)
Upto middle 156 172
school (47.6%) (52.4%) 1.3 (1.2-
Education 1.7 (1.3-2.2)
High school 319 601 1.5)
and above (34.7%) (65.3%)
Higher education, employed status, minority religion, currently married are significantly
associated with lesser suicide risk.
Table 12: Conceptual framework of mental health among tribals in Jawadhi hills
tion
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Causes of poor mental health among tribal population:
Results from IDIs and FGDs
• Illiteracy
This was mentioned by most of the participants as a cause for poor mental health due to lack
of knowledge and access to resources.
• Stigma and discrimination
People are illiterate in the hill area and don’t have work. When they send their children to
the plains for studies, it is a hardship for them because they discriminate against them and
say that their parents are illiterate. They are facing financial trouble.
• Lack of livelihood and poverty
We don’t have work, those who have land can cultivate and earn but we can’t.
If rains are not there, there is no farming
It is not that easy to get government seats. Most often we get cheated and pay more for
education or employment
Those who have work don’t have problems but those who don’t go to work have problems in
their home. People start consuming alcohol when they don’t have work and quarrel in their
family that is also a problem. The alcohol habit spoils the whole family.
• Families being separated for occupation/education
When my daughter and son-in-law go to Tirupur for a job, I have to take care of their girl
child. Sometimes the child suffers fever because their parents left her alone which is also a
problem.
Discussion:
In our study, we trained 117 Community Health Workers (CHWs) on Psychological First
Aid, Depression and suicide risk screening. From the feasibility point of view, training
community health workers on Psychological First Aid by a skilled professional is feasible
and the feedback from health workers reveals that community health workers themselves
benefited from the contents of the training. During the trainings, it was observed that CHWs
perceived their work as very stressful due to the emotional labour involved in the interactions
with the community, hard physical labour, inability to attain work life balance, pressure and
harassment from superiors, inter personal conflicts between colleagues and pressure to do
technical work such as data entry and upload of data without adequate training or equipment.
Also, the questioning process in review meetings with superiors also is harassing in nature,
causing work related stress for them. ASHA workers shared that when a maternal death or
vaccine related complication happens in the community, it is very stressful for them since all
the community members will join together and question them for the problems in the health
care system and issues with vaccines. Women Health Volunteers shared that completing 20
houses per day with meagre renumeration and poor support from the community for them
was causing work related stress. Anganwadi workers were well educated as compared to their
other CHW Peers, however the stress faced by them was higher due to many meetings, data
entry work and aspiration for better job opportunities and the preparation required for them.
The workers in tribal area also mentioned travel associated with the occupation as an
additional stressor in terms of the costs and time involved.
The training on Psychological First Aid included listening skills, empathy and non-
judgemental attitude. This particularly helped the CHWs to build and continue excellent
relationships with their community members. Many CHWs mentioned that they understood
their own mental health status after this training and could connect with their family members
in a better way in terms of strengthening marital relationships and parenting connections with
children.
In our study, all CHWs were administered the Mental Health Literacy scale. This scale is
easy to self administer. However very difficult to administer by the interviewer when the
participants such as ASHA worker and Women Health Volunteers have limited literacy.
Also, the questions and answers on ability to recognise disorders domain are framed in such a
way that answers are the same for all the questions. In second or third question, the
participant will realise that all the questions in this domain have the same answer. In the
questions on attitude towards mental health, it was observed that CHWs have stigma towards
mental illnesses, comparable to general population. 24% of the CHWs are unwilling to work
with another person with mental illnesses and 32% were not sure if they would work with
these individuals. This reflects the unacceptability towards individuals with mental illness. In
India, generally the stigma towards mentally ill individuals are high 16, if the CHWs are also
stigmatising mentally ill individuals, this would further worsen the health outcomes of the
patients.
Most of the CHWs (83%) believed that mentally ill people can snap out if they want. This
reflects gross inadequacy of knowledge of mental health and mental illnesses. In the Attitudes
that promote recognition of appropriate help seeking behaviour domain, most CHWs had
inadequate scores, this reflects their lack of knowledge and skills to obtain help for mentally
ill and distressed individuals. In the spectrum of mental health, it should be understood that
only the seriously mentally ill are identified by the CHWs as those requiring medical
treatment and others are considered as one type or abnormal character or hyper emotional
types who are capable of snaping out of the situation if they wanted. The knowledge of other
services in Psychiatry such as rehabilitation, counselling, therapy and follow-up services
were grossly inadequate. When counselling was mentioned, most could related to it through
marriage counselling during divorce and not for any other reasons.
Venkatesh BT, Andrews T, Mayya SS, Singh MM, Parsekar SS. Perception of stigma toward
16
mental illness in South India. J Family Med Prim Care. 2015 Jul-Sep;4(3):449-53
Also, under the District Mental Health Programme 17 Psychiatrist post is vacant in one of the
study districts and Psychiatry social worker and clinical psychologist is also vacant. Even
though under the DMHP, Life skills education, suicide prevention, workplace stress
management and counselling services should be provided, none of the CHWs in the study
areas have been a part of any of these activities.
With regards to the screening for depression and suicide risk component of the training, the
rural and urban health workers understood the interviewing skills and techniques easily.
However in tribal area, due to their educational status, it was challenging to make them
understand the suicide risk stratification and screening process. So only CHWs in rural and
urban areas completed the depression and suicide risk screening process. In that, the women
health volunteers struggled to complete interviews due to their lack of previous experience in
interviewing and rapport building with the community. Women Health Volunteers shared that
WHO Wellbeing index was an easier questionnaire to administer to administer as compared
to PHQ-9 and suicide risk screening. Hence the study team recommends that WHO
Wellbeing Index for scalable CHW based mental health screening interventions. Also PHQ-2
can supplement WHO Wellbeing to rapidly identify those in high risk for depression.
The suicide risk checklist from MhGAP can complement the depression assessment in
providing more care and referral to those in high risk categories such as repeated help seeking
and emotional distress.
As per the National Mental Health Survey (NMHS), Life time prevalence of depressive
disorders is 5.3% and current prevalence of depression is 2.7% 18. Prevalence of mild
depression in our study was 9.25% and moderate to severe depression was 3.93%. Overall
13.18% of the study population had depression, as screened by the community health
workers. In our study the prevalence is higher as compared to the NMHS where a set of 10
instruments, including Mini International Neuro Psychiatric Interview tool was used and
training period was a total of 8 weeks.
17
National Mental Health Programme.
https://main.mohfw.gov.in/sites/default/files/9903463892NMHP%20detail_0_2.pdf
18
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, Mehta RY, Ram D, Shibukumar
TM, Kokane A, Lenin Singh RK, Chavan BS, Sharma P, Ramasubramanian C, Dalal PK, Saha PK ,
Deuri SP, Giri AK, Kavishvar AB, Sinha VK, Thavody J, Chatterji R, Akoijam BS, Das S, Kashyap
A, Ragavan VS, Singh SK, Misra R and NMHS collaborators group. National Mental Health Survey
of India, 2015-16: Mental Health Systems. Bengaluru, National Institute of Mental Health and Neuro
Sciences, NIMHANS Publication No. 130, 2016.
There is sufficient evidence that psychoeducation by lay health counsellors, addressing
interpersonal difficulties, sharing emotional symptoms and personal difficulties, alleviation of
symptoms by breathing exercises with collaborative care intervention can lead to
improvement in recovery from Common Mental Disorders among patients in Government
Health Care settings19. Lay counsellor driver brief psychological interventions have also
proven to be efficient in addressing severe depression 20. In this regard, CHWs should be
considered as a valuable resource in providing cost effective psychological first aid at the
community and at the Primary Health Centres for patients in emotional distress. However,
caution should be exercised in settings where high levels of work related harassment, work
stress, inadequate renumeration and social support is present, listening to patients’ stories can
add to the emotional labour, cause vicarious trauma and further worsen the mental health of
health care workers21. This factor should be considered in implementation of the Training on
Mental, Neurological and Substance Use (MNS) disorders care for ASHA at Ayushman
Bharat Health and Wellness Centres across the Nation 22. Also, in this study the mental health
status of CHWs was not assessed. Previous studies have shown that CHWs themselves suffer
from mental health issues23 , 24 .
In our study, prevalence of atleast one suicide risk is 38% and chronic pain and extreme
hopelessness were 2 common suicide risk factor responses. Other studies have mentioned
known psychiatric illness, Personality disorders, physical illness, Parental deprivation,
19
Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, De Silva MJ, Bhat B, Araya
R, King M, Simon G, Verdeli H, Kirkwood BR. Effectiveness of an intervention led by lay health
counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster
randomised controlled trial. Lancet. 2010 Dec 18;376(9758):2086-95.
20
Chowdhary N, Anand A, Dimidjian S, Shinde S, Weobong B, Balaji M, Hollon SD, Rahman A,
Wilson GT, Verdeli H, Araya R, King M, Jordans MJ, Fairburn C, Kirkwood B, Patel V. The Healthy
Activity Program lay counsellor delivered treatment for severe depression in India: systematic
development and randomised evaluation. Br J Psychiatry. 2016 Apr;208(4):381-8
21
Kennedy S, Booth R. Vicarious trauma in nursing professionals: A concept analysis. Nurs Forum.
2022 Sep;57(5):893-897.
22
Training Manual for Community Health Workers, Vishram (Vidarbha Stress and Health Program),
Sangath. Taskforce for Mental Health Care as part of Comprehensive Primary Health Care MoHFW.
https://nhsrcindia.org/sites/default/files/2021-12/MNS%20Care%20Training%20Manual%20for
%20ASHA.pdf
23
Kapanee ARM, Meena KS, Nattala P, Sudhir PM. Mental health orientation among ASHAs: A
study from Karnataka State, India. J Family Med Prim Care. 2021 Oct;10(10):3748-3752.
24
Hoang, NA., Van Hoang, N., Quach, HL. et al. Assessing the mental effects of COVID-19-related
work on depression among community health workers in Vietnam. Hum Resour Health 20, 64 (2022)
bereavement, family history of suicide as risk factors25 26. The MhGAP suicide risk questions
were perceived to be simple to administer by all CHWs except Women Health Volunteers.
104 medical help line and 1098 and 1091 child and women help lines were also shared with
CHWs to address issues of suicidal attempts, medical help, children and women in distress.
Many CHWs mentioned that it is the first time, they are hearing about these helplines. The
complete list of People with depression and suicide risks were shared with PHC Medical
Officers and CMC Vellore Department of Community Health for follow-up and care.
In our study, the factors which were significantly associated with mental health status were
employment, education, marital status and belonging to minority religion. Socio-economic
factors such as education and employment can have two way relationship with mental health
with poor mental health status affecting education and employment opportunities and lack of
27
education and employment worsening mental health . Religion is a multidimensional
complexity and the combination of the belief, practices, social networks can altogether act to
impact mental health28. Marital status has consistently shown a positive relationship with
mental health status29.
In our study, social determinants of mental health, political and environmental factors are
reported by Scheduled tribes population of Jawadhi hills as factors impacting mental health.
Suicide, alcohol use, extreme poverty, debts, hopelessness and coping issues are some
identified mental health issues among scheduled tribes 30. Effect of mental illness in this
31
population impacts their education, marriage, financial crisis and violence . Lifetime
25
Radhakrishnan R, Andrade C. Suicide: An Indian perspective. Indian J Psychiatry. 2012
Oct;54(4):304-19
26
Vijayakumar L. Indian research on suicide. Indian J Psychiatry. 2010 Jan;52(Suppl 1):S291-6.
27
Gariépy G, Danna SM, Hawke L, Henderson J, Iyer SN. The mental health of young people who are
not in education, employment, or training: a systematic review and meta-analysis. Soc Psychiatry
Psychiatr Epidemiol. 2022 Jun;57(6):1107-1121
28
Behere PB, Das A, Yadav R, Behere AP. Religion and mental health. Indian J Psychiatry. 2013
Jan;55(Suppl 2):S187-94
29
Vaingankar, J.A., Abdin, E., Chong, S. et al. The association of mental disorders with perceived
social support, and the role of marital status: results from a national cross-sectional survey. Arch
Public Health 78, 108 (2020)
30
Devarapalli SVSK, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in
India. Indian J Psychiatry. 2020 Nov-Dec;62(6):617-630
31
Subudhi C, Biswal R, Pathak A. Multidimensional impact of mental illness on tribal families in
India. Taiwan J Psychiatry 2022;36:82-7
discrimination is associated with increased risk of major depression 32. From our study, we
recommend employment, education opportunities at the geographical proximity to the tribal
population. Perceived discrimination causes activation of chronic heightened stress response
and with lack of social support and stigma salience can result in reduction in self control and
engagement in risk activities impacting mental health33.
Conclusion:
In conclusion, our research has proven that Community Health Workers (CHWs)- ASHAs,
Women Health Volunteers, Anganwadi Workers, Auxiliary Nurse Midwives, Village/Urban
Health Nurses can be trained in Psychological First Aid to promote mental health of the
community members. In the baseline, all CHWs have inadequate knowledge regarding
identification and referral of mental illnesses. PHQ-9 and suicide risk screening can be used
for depression screening by Auxiliary Nurse Midwives, Village/Urban Health Nurses and
Anganwadi Workers and not ASHA workers and Women Health Volunteers. For the ASHA
Workers and Women Health Volunteers, WHO Wellbeing Index and PHQ-2 can be advised.
Any mental health training among CHWs should be accompanied by improving working
conditions of CHWs by addressing workplace harassment, work related stress and improving
social support.
Social determinants of mental health needs to be addressed in tribal community, before
strengthening the health care access and capacity building of CHWs.
Recommendations:
Health Systems Recommendations:
1. Leverage the current implementation of District Mental Health Programme by appointment

of Psychiatrist, Psychiatry Social Worker and Clinical Psychologist and strengthen the
school, workplace based mental health interventions.
32
Rashmi, R., Srivastava, S., Muhammad, T. et al. Indigenous population and major depressive
disorder in later life: a study based on the data from Longitudinal Ageing Study in India. BMC Public
Health 22, 2258 (2022).
33
Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol
Bull. 2009 Jul;135(4):531-54. doi: 10.1037/a0016059
2. DMHP staff should invest their time in training CHWs of their District in basic
Psychological First Aid, PHQ-9/2 Screening, referral and follow-up of mentally ill patients in
their community, facilitation of mental health awareness session in the community
3. Promotion of enabling environment in Primary Health Centres by Medical Officers
facilitating the training and follow-up care provided by CHWs
4. Multisectoral engagement in addressing inequities and disproportionate impact of mental
health on marginalised and vulnerable population
ANNEXURES
Mental Health Literacy Scale
1. Name of the Health Worker:

2. Age:
3. Education:
4. Years of experience:
5. Area of work: Kaniyambadi/Jawadhi
6. Name of Designation:
7. Employer: CMC Vellore/TN Government
8. Nature of work: Permanent/Contract/Casual
9. Monthly income:
10. Renumeration if any:
11. Mental Health Literacy Scale
The purpose of these questions is to gain an understanding of your knowledge of various

aspects to do with mental health. When responding, we are interested in your degree of
knowledge. Therefore when choosing your response, consider that:
Very unlikely = I am certain that it is NOT likely

Unlikely = I think it is unlikely but am not certain
Likely = I think it is likely but am not certain
Very Likely = I am certain that it IS very likely
1. If someone became extremely nervous or anxious in one or more situations with other
people (e.g., a party) or performance situations (e.g., presenting at a meeting) in
which they were afraid of being evaluated by others and that they would act in a way
that was humiliating or feel embarrassed, then to what extent do you think it is likely
they have Social Phobia
Very unlikely Unlikely Likely Very Likely
2. If someone experienced excessive worry about a number of events or activities where

this level of concern was not warranted, had difficulty controlling this worry and had
physical symptoms such as having tense muscles and feeling fatigued then to what
extent do you think it is likely they have Generalised Anxiety Disorder
3. If someone experienced a low mood for two or more weeks, had a loss of pleasure or
interest in their normal activities and experienced changes in their appetite and sleep
then to what extent do you think it is likely they have Major Depressive Disorder
4. To what extent do you think it is likely that Personality Disorders are a category of
mental illness
5. To what extent do you think it is likely that Dysthymia (no interest in life or other
activities) is a disorder
6. To what extent do you think it is likely that the diagnosis of Agoraphobia includes
anxiety about situations where escape may be difficult or embarrassing
7. To what extent do you think it is likely that the diagnosis of Bipolar Disorder includes
experiencing periods of elevated (i.e., high) and periods of depressed (i.e., low) mood
8. To what extent do you think it is likely that the diagnosis of Drug Dependence
includes physical and psychological tolerance of the drug (i.e., require more of the
drug to get the same effect)
9. To what extent do you think it is likely that in general, women are MORE likely to
experience a mental illness of any kind compared to men
10. To what extent do you think it is likely that in general, men are MORE likely to
experience an anxiety disorder compared to women
When choosing your response, consider that:
 Very Unhelpful = I am certain that it is NOT helpful
 Unhelpful = I think it is unhelpful but am not certain
 Helpful = I think it is helpful but am not certain
 Very Helpful = I am certain that it IS very helpful
11. To what extent do you think it would be helpful for someone to improve their quality
of sleep if they were having difficulties managing their emotions (e.g., becoming very
anxious or depressed)
Very Unhelpful Unhelpful Helpful Very Helpful
12. To what extent do you think it would be helpful for someone to avoid all activities or
situations that made them feel anxious if they were having difficulties managing their
emotions
Very Unhelpful Unhelpful Helpful Very Helpful

When choosing your response, consider that:
 Very unlikely = I am certain that it is NOT likely
 Unlikely = I think it is unlikely but am not certain
 Likely = I think it is likely but am not certain
 Very Likely = I am certain that it IS very likely
13. To what extent do you think it is likely that Cognitive Behaviour Therapy (CBT)
(mental health treatment by talking) is a therapy based on challenging negative
thoughts and increasing helpful behaviours
14. Mental health professionals are bound by confidentiality; however there are certain
conditions under which this does not apply.
To what extent do you think it is likely that the following is a condition that would
allow a mental health professional to break confidentiality:
If you are at immediate risk of harm to yourself or others

15. if your problem is not life-threatening and they want to assist others to better support
you
Please indicate to what extent you agree with the following statements:
 Strongly disagree
 Disagree
 Neither agree or disagree
 Agree
 Strongly agree
16. I am confident that I know where to seek information about mental illness
Strongly Disagree Neither agree agree Strongly agree

disagree or disagree
17. I am confident using the computer or telephone to seek information about mental
illness

18. I am confident attending face to face appointments to seek information about mental
illness (e.g., seeing the GP)

19. I am confident I have access to resources (e.g., GP, internet, friends) that I can use to
seek information about mental illness

20. People with a mental illness could snap out if it if they wanted

21. A mental illness is a sign of personal weakness

22. A mental illness is not a real medical illness

23. People with a mental illness are dangerous

24. It is best to avoid people with a mental illness so that you don't develop this problem

25. If I had a mental illness I would not tell anyone

26. Seeing a mental health professional means you are not strong enough to manage your
own difficulties

27. If I had a mental illness, I would not seek help from a mental health professional

28. I believe treatment for a mental illness, provided by a mental health professional,
would not be effective

Please indicate to what extent you agree with the following statements:
 Definitely unwilling
 Probably unwilling
 Neither unwilling or willing
 Probably willing
 Definitely willing
29. How willing would you be to move next door to someone with a mental illness?
Definitely Probably Neither Probably Definitely

unwilling unwilling unwilling or willing willing
willing
30. How willing would you be to spend an evening socialising with someone with a
mental illness?

willing
31. How willing would you be to make friends with someone with a mental illness?
willing
32. How willing would you be to have someone with a mental illness start working
closely with you on a job?

willing
33. How willing would you be to have someone with a mental illness marry into your
family?

willing
34. How willing would you be to vote for a politician if you knew they had suffered a
mental illness?

willing
35. How willing would you be to employ someone if you knew they had a mental illness?

willing
Title of the study: SUPREA- Suicide PREvention by ASHA/Anganwadi
workers/ANM/Health Aides: an Operational Research to Strengthen the District Mental
Health Programme to Prevent Suicides in rural Tamil Nadu
Name of the GLHW:

Study ID No of GHLW:
Section I: Basic information of the informant
Study ID No.
Age
Religion 1 Hindu
2 Christian
3 Muslim
4 Others
Name of the village
Sex 1 Male
2 Female
Date of birth
Marital Status 1 Single
2 Married
3 Separated/Divorced
4 Widowed
Number of family members
Family history of mental illness 1 Yes
2 No
Total monthly family income
Name of caste
Caste category 1 BC
2 OBC
3 MBC
4 SC/ST
5 Others
Section II: Education and occupation

1. Have you ever attended school? 1 Yes
2 No
2. Are you currently studying? 1 Yes
2 No
3. What grade you are currently studying in?
1 5-8th
2 9-10th
3 11th-12th
4 College
5 Post
graduation
4. What is your highest educational
attainment? 1 1-5th
2 5-8th
3 9-10th
4 11th-12th
5 College
6 Post
graduation
5. The school/ college that you attend/ have
attended is for both boys and girls or only 1 Both boys and
for girls? girls
2 Only for
girls/boys
6. Have you ever worked for pay? 1 Yes
2 No
7. How old were you when you started
working?
8. Where do you work?
1 Government
sector
2 Private sector
3 Self-employed
4 Unemployed
5 Housewife
6 Others
9. What kind of work do you do?
1 Agriculture
2 Non-agriculture
3 Others
10. Name of the occupation
Section III: For Females: Child birth

1. Are you currently pregnant? 1 Yes
2 No
2. If you have delivered recently (past 1 year), mention
the delivery date
3. Did you experience any serious health issues during 1 Yes
pregnancy or child birth? 2 No
4. If you have delivered recently, what is the sex of the 1 Male
child 2 Female
Section IV: Physical Health

1. Do you suffer from any non-communicable health 1 Yes
conditions? (probe for diabetes, hypertension, heart 2 No
diseases)
2. When was it diagnosed?
3. Are you one regular medication? 1 Yes
2 No
4. For any general health issue which health provider
would you prefer? 1 Government
2 Private
5. Give reason for this preference.
6. Do you use any of these
1 Chewable
tobacco
2 smoking
3 alcohol
4 drugs
Section V: Mental Health

1. Have you heard about any mental health conditions? 1 Yes
2 No
2. What is the reason for getting mental illness?  Genetic
 Familial issues
 Substance abuse
 Environmental
toxins
 Black magic
 Others
1 Genetic
2 Familial
issues
3 Substance use
4 Environmental
toxins
5 Black magic
6 others
3. Who do you think is at risk of getting mental illness?
1 Men
2 women
3 Both
equally
4. Do you think people with mental illness can lead a 1 Yes
normal life? (for example can they work, marry etc) 2 No
5. Is there any treatment available for mental illness? 1 Yes
2 No
6. Where can one get mental health services?
1 Primary
Health
centre
2 District
hospital
3 Private
4 Others
7. Have you ever availed any mental health services 1 Yes
anytime in your life time? 2 No
8. Did you have any contact with the ASHA/ANM in 1 Yes
regard to mental health problem in the last 6 months? 2 No
9. Did you go to SC/PHC/private clinic for any of these 1 Yes
problems? 2 No
10. Was there privacy/confidentiality during consultation 1 Yes
with doctor? 2 No
11. Was the health provider respectful? 1 Yes
2 No
12. On an average how much time does it take to reach a
health center from your home? 1 < ½
hour
2 ½
hour-
1
hour
3 1-2
hours
4 >2
hours
PHQ-9
Over the last two weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things 0 Not at all

1 Several days
2 More than
half the days
3 Nearly
everyday
2. Feeling down, depressed or hopeless 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
3. Trouble falling or staying asleep or sleeping too much 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
4. Feeling tired or having little energy 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
5. Poor appetite or overeating 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
6. Feeling bad about yourself or that you are a failure or have let 0 Not at all
yourself or your family down 1 Several days
2 More than
half the days
3 Nearly
everyday
7. Trouble concentrating on things, such as reading newspaper 0 Not at all
or watching television 1 Several days
2 More than
half the days
3 Nearly
everyday
8. Moving or speaking so slowly that other people could have 0 Not at all
noticed? Or the opposite – being so fidgety or restless that you 1 Several days
have been moving around or a lot more than usual 2 More than
half the days
3 Nearly
everyday
9. Thoughts that you would be better off dead or of hurting 0 Not at all
yourself in some way 1 Several days
2 More than
half the days
3 Nearly
everyday
10. If you checked off any problems, how difficult have these
problems made it for you to do your work, take care of 1 Not difficult
things at home, or get along with other people? at all
2 Somewhat
difficult
3 Very
difficult
Suicide risk
Questions
1. Extreme hopelessness and despair 1 Yes
2 No
2. current thoughts/plan/act of self-harm suicide 1 Yes
2 No
3. History of self harm/suicide – past month or past year 1 Yes
2 No
4. Presence of depression/ child/adolescent mental health disorders/ 1 Yes
substance use behavioural disorders psychoses/ epilepsy 2 No
5. Chronic pain 1 Yes
2 No
6. Extreme emotional distress, extremely agitated, violent, lacks 1 Yes
communication 2 No
7. Difficulty in carrying out usual work at work/school/domestic/social 1 Yes
activities 2 No
8. Repeated self medication for emotional distress 1 Yes
2 No
9. Repeated help seeking 1 Yes
2 No
10. Unexplained physical symptoms 1 Yes
2 No
Suicide risk stratification and support Mechanism

After administration of MhGAP Questions on Deliberate Self Harm/suicide risk, the patient
will be stratified and treated according to these categories as mentioned in MhGAP
Stratification Criteria Management
Medical Serious act of self- Evidence of self-injury and/or Immediate referral

harm signs/symptoms requiring through 108
urgent medical treatment Emergency transport
services to emergency
services of
Government Medical
College, Vellore or
CHAD Hospital,
Bagayam, Vellore for
medical care. Further
follow-up in outreach
services of CHAD
Hospital
Imminent risk of self History of thoughts or plan of Immediate referral to
harm/suicide self-harm in the past month or Emergency services of
act of self-harm in the past Mental Health Centre,
year Department of
Psychiatry, Christian
In a person who is now
Medical College,
Vellore or emergency
distressed or lacks
services of
communication
Government Medical
College, Vellore.
Further follow-up in
outreach services of
CHAD Hospital
Risk of self harm/suicide Patient with known Referral and follow-up
conditions in Psychiatry OPD of
CHAD Hospital or
Depression
Mental Health Centre
or Government
Child & adolescent mental
Medical College,
Disorders due to substance Vellore. Further
use follow-up in outreach
services of CHAD
Behavioral disorders
Hospital
Psychoses
Epilepsy
Depression Screened Positive for Referral and follow-up

Depression in PHQ-9 in Psychiatry OPD of
CHAD Hospital or
or Government
Medical College,
Vellore. Further
services of CHAD
Hospital
WHO-5 Well being index

Over the last All of Most of More Less Some of At no
2 weeks the the time than half than half the time time
time the time the time
I have felt 5 4 3 2 1 0
cheerful in
good spirits
I have felt 5 4 3 2 1 0
calm and
relaxed.
I have felt 5 4 3 2 1 0
active and
vigorous
I woke up 5 4 3 2 1 0
feeling fresh
and rested
My daily life 5 4 3 2 1 0
has been
filled with
things that
interest me
If the patient answers 0 or 1 for any of the questions, refer to PHC
Topic Guide for Focus Group Discussion/In-Depth Interviews

Instructions to the interviewer:
 Introduce yourself and ask all participants to introduce themselves
 Be an active listener and demonstrate empathy to participants
 You might be the first person who is speaking about mental health to your study
participants. Be kind
 Avoid leading questions
 Remain neutral. Don’t react emotionally to their comments
 Arrange for snacks and hot beverages
 Select a venue with good privacy
Instructions to the participants:
 Please read/listen to PIS being read carefully
 Please read/listen to consent form being read carefully before consenting to
participate
 Remember, there is no right or wrong answer, only different opinion.
 Since the entire discussion is audio-recorded, it is best if one person speaks at a time.
 You may refuse to answer any question or withdraw from the study at any point.
 Please share your thoughts during the discussion. Even if you don’t agree with others
point there is no need to argue.
 You must listen patiently.
 We request your full participation. I will guide the discussion while you talk to each
other.
PIS and consent:

 Printed PIS forms should be given to all participants
 PIS should be read to all participants by the interviewer before administration of
consent
 Sign two consent forms- one to participants, one for the interviewer
 Parental consent forms and assent forms to be signed by all participants aged 18 years
and less
TOPIC GUIDE:
Introduction:
1. What is your opinion on general health issues in your community/village? (probe -for
COVID-19, non-communicable diseases)
2. How do the health services available in your area relate to the desired quality?
Mental illness:
3. What is your general understanding about mental illness?

4. How do the mental health services available in your area relate to the desired quality?
5. What is your thinking about the utilization of mental health services? (probe- If it is
good then why? If it is not so good then why?)
6. What according to you are some of the barriers for utilizing mental health services ?
(probe- availability/acceptability/confidentiality/ privacy/ inconvenient timing/ staff
behavior/ lack of awareness/stigma/taboo/ workload of health providers)
7. How can we improve the quality of mental health services? (probe- availability of
mental health clinics/ doctors/ medicine/ materials etc)
8. What is your suggestion to enable more patients to obtain the mental health services
they need?
9. What do you think is more relevant for patients with mental disorders?
Depression/Suicide:
1. Among your community members how common is depression/suicide/ or any mental

illness?
2. How common is alcohol and tobacco use?
3. Why do people develop depression?
4. Are people in hills more prone for depression? Why?
5. Can you describe about the challenges faced by people in hills who move to plains for
studies or career?
6. How do these challenges affect their mental health?
7. Any other thoughts that you would like to share with us?
Training Module on Psychological First Aid
Aim of the module
Train Grassroot Level Health Workers on provision of humane, supportive response to a

fellow human being who is suffering and who may need support
Important Information
 This training is provided as a part of the Project funded by Tamil Nadu Health System
Reform Program
 This training requires you to attend 6 days of training
 Each session will be conducted once in two weeks
 The venue and dates will be confirmed only after discussion with you and your
Medical Officer
 Attending this training does not mean that you will have to work extra days
 This training will enable you to provide humane, supportive response to a fellow
human being who is suffering and needs support
 We expect you to be punctual and sincere during these trainings.
 No one in this training should be discriminated based on their work designation, place
of work, age, external appearance, gender, caste, colour or language
 It is important to actively participate in discussions, games and activities for
successful completion of this training
 In any discussion, only one person can speak at a time. Others can wait and patiently
listen.
 While trainees are free to discuss any issues-personal or training related queries with
the trainers, they are discouraged to share their core personal problems with fellow
trainees personally or in the public discussions
 Introduce and sign confidentiality agreement. (appendix 1), Participants keep a copy.
3 Modules of this training
1. Helping a person responsibly

2. Providing Psychological first aid
3. Stress Management, Depression and common mental health problems
Ground rules of this training during these 4 modules
Let us brain storm the rules which have to followed by all of us during this training.
Anyone can volunteer!
Example:
Cell phones to be in silent mode
No talking when another person is talking
Asking questions freely without worrying about other’s opinions
Be punctual to all trainings
Be in touch with each other
Become friends after completing the 8 trainings
Let us get to know each other: Icebreaking game

Each person in the training hall, including the trainer introduces themselves to everybody by
sharing their name.
Then, randomly two membered teams are formed. Each person in this 2 membered team
should talk to each other and understand the other person in the team in terms of points not
covered in introduction such as birthday, anniversary, views on life, likes, dislikes, hobbies,
dreams etc.
Once all the team members have understood about their teammates, then each person should
come forward and introduce their team mate in terms of the above mentioned items.
Module I: Helping a Person Responsibly
Aim of Module 1
 What are the sufferings humans undergo and why?
 What is Psychological First Aid
 Ethics of helping a person
Day 1 of training: Schedule

Time Session
10:00-10:30 Introduction to the training – aim and instructions
10:30-11:00 4 modules and ground rules
11:00-11:30 Coffee break
11:30-12:00 Icebreaking game
12:00-12:30 Pretest and module overview
12:30-01:00 Group discussion on healthy mind and body
01:00-01:45 Lunch Break
01:45-02:15 Distressing events, vulnerable population, taking care of self
02:15-02:45 What is Psychological First Aid?
02:45 – 03:00 Demonstration of Psychological First Aid
03:30-04:00 Listening exercise
04:00-04:30 Summary and Oral feedback
Pre-test Evaluation
1. A person does not have mental illness. Can we call him as a mentally healthy person?
 Yes
 No
2. Physical health and mental health are connected. If your physical health fails, mental
health also can fail
 Yes
 No
3. Psychological First Aid can be given by Psychiatrists only
 Yes
 No
4. Psychological First Aid can be given only in hospitals
 Yes
 No
5. When talking to individuals who are suffering, privacy is very important
 Yes
 No
6. A community health worker should take decision for the patient since they don’t
know anything
 Yes
 No
7. In Psychological First Aid, we need to ask the entire history for the patient who is
suffering
 True
 False
8. For the same distressing event, each human will react differently due to the difference
in ability to cope with difficulties
 True
 False
9. Which is very helpful for suffering individuals: Listening or advising?
 Listening
 Advising
10. When a family is undergoing distress, women and children need more support.
 True
 False
Group Discussion: Healthy Body and Mind
1. What does it mean to have a healthy body and healthy mind?

2. Which is more important? Healthy body or healthy mind?
3. List some of the problems we face in life that may cause us to suffer in our mind
4. What happens if some one decides to share their problems in life and sufferings of
mind to others in family/community/workplace?
5. Brainstorm: how do we know when someone is suffering in mind
Answers for group discussion
 Healthy body means no physical ailments and the person can be productive in life.
(WHO Definition: Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity) Healthy mind means absent of
mental illnesses and the ability to face stressors of life (WHO Definition: Mental
health is a state of well-being in which an individual realizes his or her own abilities,
can cope with the normal stresses of life, can work productively and is able to make a
contribution to his or her community)
 Both physical and mental health are equally important and both are interconnected. A
person with poor physical health can develop mental health issues
 Worrying is often called stress and overwhelming sadness causing mental illness is
known as depression. Stress and depression can cause physical symptoms,
mental/psychological symptoms, and changes in behavior (e.g: Physical symptoms;-
headache, sleeplessness, poor appetite, stomach problems. Psychological symptoms;-
feeling sad, worthless and helpless, overwhelmed, anxious or worried all the time.
Behavioral symptoms;- hiding away, using alcohol and drugs, shouting, violence,
anger at self or others. Etc
 People often don’t talk about the problems they face or ask for help because they
worry about gossip, feel shame and they fear that people will think they are weak; this
is know as “Stigma” and it stops people from asking for help.
 However talking through a problem with someone you trust and who listens to you
can really help you to look after your mind health.
Lecture: Distressing events and how they affect people
When faced with problems in life, everyone is affected in some way. There are a wide range
of reactions and feelings each person can have. Some people may have mild reactions,
whereas others may have more severe reactions. How someone reacts to a problem in life
depends on the following
 the nature and severity of the event(s) they experience;

 their experience with previous distressing events;
 the support they have in their life from others;
 their physical health;
 their personal and family history of mental health problems;
 their cultural background and traditions;
 their age (for example, children of different age groups react differently).
Vulnerable People- Those who are at risk for severe reactions to problems in life:
1. Children, including adolescents.

2. People with health conditions or disabilities.
3. People at risk of discrimination (Poverty, Women, minorities in community)
Lecture: Why should we take care of ourselves?
 Taking care of yourself gives you the tolerating capacity to face stress
 In fact when you take care of yourself, you are also taking care of others indirectly
because you are building a “stronger” you which makes you a better person
How do we take care of ourselves- Brainstorm?
The following are some self-care tips

 Know what causes stress for you and avoid them or learn to face them
*when you have a difficult situation, always talk it over with another health worker so that you
done take the worry home with you*
 Get good rest and sleep
 Doing routine work
 Spending time with children
 Planning the next day the previous night itself
 Re-planning the day when we wake up
 Exercise everyday
 Listening to music
 Spending time for oneself like going to a beauty parlour
 Finding out favourite hobby and doing it
 Try gardening
 Talk with friends, family
 Taking control of the situation
 Accept what you cannot change
 Have nutritious food
Summary:
Taking good care of ourselves makes us have better capacity to face stress and be ready to
provide support to others.
Group activity: Lets be selfish!
We often think only about our family and people around us and forget about ourselves and our
desires. Now each of us can individually sit and write down our dreams and desires (forget
family, work, financial situations, responsibilities) for life such as a solo vacation, wanting to
learn music etc. Without any shame each of us will come to the stage and share with others
what dreams we have. We can also present what we are going to do to achieve these dreams
and hopes, considering all the responsibilities we have in life.
Lecture : What is PFA?
Psychological first aid (PFA) is a humane, supportive response to a fellow human being who
is suffering and who may need support. PFA involves the following themes:
 providing practical care and support, which does not intrude;

 assessing needs and concerns;
 helping people to address basic needs of human life
 listening to people, but not pressuring them to talk;
 comforting people and helping them to feel calm;
 helping people connect to information, mental health services and social
supports;
 protecting people from further harm.
Demonstration of PFA:
ASHA Worker: Hello. Good morning.

Woman of the house: Hello akka. May I talk to you for few minutes. I feel so upset from
morning. Please come inside my house
ASHA: OK. How are you? How is everything at home? Can we sit in a private place in your
home?
Woman: Yes akka. Please come inside the kitchen. We can sit down in this mat. No one is
there in home.
ASHA and woman comfortably sit down.
Woman: Akka my husband fought with me today. Since then I am feeling very down. I don’t
want to do anything and have lunch also.
ASHA (leans forward, maintains eye contact): ok… I see that you are very upset. Are you
comfortable telling me what happened?
Woman: He finds fault with everything. He says I am not cooking well and not keeping the
house clean.
ASHA: ok.. why do you think he does that?
Woman: Most of the days he is ok only. But some days when he drinks with friends he wakes
up with a headache in the morning and scolds me.
ASHA: I understand your problem. How can I help you?
Woman: You listen to me akka. That’s enough
ASHA: Ok. I have sufficient time. You can talk with me.
Conclusion:
What did you observe?
This ASHA worker ensured privacy before talking to the woman who was upset about
something.
She gave respect to the woman by looking at her in eye and leaning forward
She is trying to understand the woman’s needs and concerns by asking questions about her
situation
She did not force the woman to talk
She is not judgemental about anything
She is kind to the woman by saying I understand
She is helpful by asking how can I help you
She provides comfort by allotting time for her
Activity: Listening exercise
Each participant is paired with another.

Each is given 15 minutes to listen to each other talk about themselves, their work or any other
non-sensitive topic.
Conclusion:
Listening without interruption is a skill which needs experience and training. We should
listen to people but not pressurising them to talk.
Share your experience of listening/getting listened to.
Summary of the day:
When faced with problems in life, everyone is affected in some way. Each person reacts in a
different way, some minor and some major based on various factors.
Psychological first aid (PFA) describes a humane, supportive response to a fellow human
being who is suffering and who may need support. PFA involves the following themes:

 helping people to address basic needs
 helping people connect to information, services and social supports
 protecting people from further harm
Oral feedback:
Participants are asked to share their view about the training and the experience.
I Module
Helping a Person Responsibly
Day 2 of training: Schedule

Time Session
10:00-10:30 Summary of Day-1 learning
10:30-11:00 What is not PFA, where and when to give PFA
11:30-12:30 Demonstration of PFA and Psychological debriefing
12:30-01:00 Safety, Dignity and rights of individuals
01:45-02:15 Ethics of PFA
02:15-02:45 Activity: Listing information, services and social supports for mental
health in our area
02:45 – 03:00 Activity on Psychological First Aid- active listening, confidentiality
03:30-04:00 Summary of Module 1
04:00-04:30 Post test and Feedback
Summary of Day-1:
When faced with problems in life, everyone is affected in some way. Each reacts in a

Lecture: What is not PFA
 It is not something that only professionals such as Psychologists or psychiatrists

can do.
 It is not equal to professional counselling given by Psychologists or psychiatrists
in hospitals or counselling centers
 PFA does not involve a detailed discussion of the event that caused the distress
like in a police station or court
 It is not asking someone to analyse what happened to them or to put time and
events in order like in a police station
 Although PFA involves being available to listen to people’s stories, it is not about
pressuring people to tell you their feelings and reactions to an event.
Demonstration of what is PFA and what is not PFA:
PFA:
AWW: Hello. How are you?
Woman: I am not OK akka. There are lots of issues going on in my home. Do you have time?
AWW: Yes. I have time.
Woman: Can I sit down and talk here (Anganwadi)
AWW: OK.
Woman: I am feeling very low nowadays. I have no interest in doing any work.
AWW: I can understand… (leans forwards and looks in her eye)
Woman: I cant sleep or eat properly. So many thoughts about family issues, in laws, children
AWW: OK.it must be really difficult. how is your health?
Woman: yes akka. I think a lot and losing sleep. Now I don’t have any energy to do work. no
one to take me to hospital
AWW: since your health is much affected, I can help you to go to hospital. These are OPD
timings of doctor. You can tell my name and go to the PHC
Woman: OK Akka. Thank you for listening to me.
Conclusion:
AWW does not intrude. She is allowing the woman to talk
She connects the woman to health service

She makes the woman feel comfortable
Not PFA:
Woman: Hello akka
AWW: Hello. I heard that you were fighting with your mother in law last night. What
happened?
Woman: She only scolded me for silly reasons
AWW: shouldn’t you keep quiet when a senior person in the husband’s family side is talking
to you. When exactly did the problem the problem start? What were you talking?
Woman: she is not understanding me akka.
AWW: As married women, we only have to adjust. Don’t expect others to adjust for you.
Conclusion:
The AWW is forcing the woman to talk about a family problem.
She is asking detailed questions about the event
She is asking the woman to analyse why it happened.
She is advising the woman on what to do
Lecture: How does PFA help people
 feeling safe, connected to others, calm and hopeful;

 having access to social, physical and emotional support; and
 feeling able to help themselves, as individuals and communities.
Lecture: Whom should we provide PFA?
 PFA is for distressed people

 For both children and adults.
 Some people can refuse to talk. Do not force help on people who do not want it, but
make yourself easily available to those who may want support.
 Anyone who needs advanced support should be referred to the doctor. Know your
limits and get help
Important information on referral:
1. Referral: People in these situations need medical or other help as a priority to save
life.
 people with physical health problems requiring medical care

 people who are so upset that they cannot care for themselves or their children
 people who may hurt themselves
 people who may hurt others
2. When to provide PFA:
You can provide PFA when you first have contact with very distressed people.
3. Where to provide PFA?
Community settings with good privacy is essential for confidentiality and to respect the
person’s dignity.
Lecture: Very important points while respecting people

Safety
Dignity Rights
Safety
Make sure, to the best of your ability, that the adults and children you help are safe and
protect them from physical or psychological harm. (talking without privacy can put an
individual at risk of harm)
Avoid putting people at further risk of harm as a result of your actions (in cases of domestic
violence, if family members come to know that the woman has shared details with you, she
might be at risk of more harm)
Dignity
Treat people with respect and according to their religious, cultural and social norms.
Rights
Help people to claim their rights and access available support.
Act only in the best interest of any person you encounter
Make sure people can access help fairly and without discrimination of age, gender or
background
Lecture: Ethics of PFA

DO’s
Be honest and trustworthy.
» Respect people’s right to make their own decisions.
» Be aware of and set aside your own biases and prejudices.
» Many people might refuse help now. Gently tell them that they can access help in the
future.
» Respect privacy and keep the person’s story confidential
» Behave appropriately by considering the person’s culture, age and gender
Don’ts
Don’t exploit your relationship as a helper.
Don’t ask the person for any money or favour for helping them.
Don’t make false promises or give false information.
Don’t exaggerate your skills.
Don’t force help on people
Don’t be intrusive or pushy.
Don’t pressure people to tell you their story.
Don’t share the person’s story with others.
Don’t judge the person for their actions or feelings.
Point to note: Very important skills for a health worker
Listening
No judging Confidentiality
Activity: Creation of list of mental health services in our area
Health workers are given a sheet with the following categories. They can also add items
which are not in the list. Each one of them presents their list after compilation.
Suggestions:
Police: 100
Women’s help line: 1091
Child line: 1098
Depression and suicide prevention: 104
Emergency services of Government Medical College Vellore, Thiruvannamalai, Mental
Health Center of CMC Bagayam, CHAD Hospital Bagayam, CMC Hospital
Christian Counselling Centre Vellore
Hospital Contact Rehabilitation Counselling Social NGO Help-
based details of services services work related lines
services hospital services services
details
Activity on Psychological First Aid- active listening, confidentiality, non-judgemental

attitude
Each participant is paired with another participant randomly and given 15 minutes to listen to
each other following the principles of
Listening
Confidentiality
Non judgemental attitude
The experience can be shared with others.
Summary of Module 1:
providing practical care and support, which does not intrude;
assessing needs and concerns;
helping people to address basic needs
listening to people, but not pressuring them to talk;
comforting people and helping them to feel calm;
helping people connect to information, services and social supports
protecting people from further harm
Respect the
safety
dignity
rights of the person
Listen with no judgement, confidentiality and respect the person’s right to make their own
decisions.
Post test Evaluation
Home work: Apply listening with no judgment and confidentiality in work and family life
and share experience in the next module
Feedback of Module 1 Training

Your inputs are valuable for us trainers to improvise our teaching skills and make this project
a big success.
Your responses will be anonymous and data will be analyzed in a grouped manner.
Kindly score the first 5 questions using the following scoring
5= excellent 4= good 3= average 2= poor 1= very poor
Day -1 Day-2
1. Knowledge and
content
2. Activities
3. Method of teaching
Written feedback and comments to improve sessions:
Module 2: Providing Psychological first aid

Aim of module 2:
This module trains you in
 Good communication skills
 Action principles of PFA
 Strengthening coping skills
Schedule for day 1

Time Session
10:00-10:30 Summary of Module 1, Pre-test
10:30-10:45 Experience sharing of applying listening with no judgement and
confidentiality
10:45 – 11:00 Introduction to Module 2
11:15-12:15 Good Communication skills
12:15-01:00 Empathy – Musical chairs game, Discussion on Do’s and Don’t’s of
communication
01:00-01:45 Lunch
01:45-02:45 Non verbal Communication game
02:45-03:45 Non verbal Communication activity
04:00-04:30 Summary and Oral feedback
Revision of Module 1:
psychological first aid (PFA) describes a humane, supportive response to a fellow human

Respect the
1. safety
2. dignity
3. rights of the person
decisions.
Pre-test Evaluation:
1. A health worker should be calm while communicating with a patient in distress
 True
 False
2. A health worker must advise and talk much to be respected by the community
 True
 False
3. Non verbal communication is equally important as verbal communication
 True
 False
1. While talking to a patient, it is important to find a quiet place to talk to
minimize distraction
 True
 False
2. To be trusted by the community, even if you don’t know a fact, you should
act as if you know
 True
 False
3. To reassure a person, we need to share our own personal struggles
 True
 False
4. Eye contact while talking helps strengthening the communication
 True
 False
5. Singing is a positive coping skill
 True
 False
6. Not talking to anyone in family is a positive coping skill
 True
 False
7. For religious people, religion can give a sense of hope in life
 True
 False
Experience sharing of active listening:

All participants are invited to share their experience of active listening at work and family life
and how it had changed their life.
Introduction to Module 2:
In this module, we learn about about how to provide PFA to individuals
 Good communication skills
 PFA Action principles
 Teaching coping skills
Lecture: Good Communication Skills
 People who have mental health issues may be very upset, anxious or confused.
 Some people may blame themselves for things that have happened to them
 Being calm and showing understanding can help people in distress feel more safe
and secure, understood, respected and cared for appropriately.
 Someone who has been through a distressing event may want to tell you their story.
 Listening to someone’s story can be a great support.
 However, it is important not to pressure anyone to tell you what they have been
through.
 Some people may not want to speak about what has happened or their circumstances.
 However, they may value it if you stay with them quietly, let them know you are there
if they want to talk, or offer practical support like a glass of water.
 Don’t talk too much; allow for silence.
 Keeping silent for a while may give the person space and encourage them to share
with you if they wish.
Information: Non Verbal Communication
 To communicate well, be aware of both your words and body language, such as facial
expressions, eye contact, gestures, and the way you sit or stand in relation to the other
person.
 Speak and behave in ways that take into account the person’s culture, age, gender,
customs and religion.
To Do:
 Try to find a quiet place to talk, and minimize outside distractions. This is very
important for cases of domestic violence, child and adolescent cases
 » Respect privacy and keep the person’s story confidential. Never share with
your friends, family or other community members. You can share with ANM or
Medical Officer for help.
 » Stay near the person but keep an appropriate distance from males
 » Let them know you are listening; for example, nod your head or say
“hmmmm....”. This helps individuals to open up.
 » Be patient and calm. Don’t become emotional listening to their stories.
 » Provide factual information, if you have it. Be honest about what you know and
don’t know. “I don’t know, but I will try to find out about that for you.”
 » Give information in a way the person can understand – keep it simple.
 » Acknowledge how they are feeling and any losses or important events they tell
you about, such as loss of their home or death of a loved one. “I’m so sorry. I can
imagine this is very sad for you.”
 » Acknowledge the person’s strengths and how they have helped themselves.
Don’t do:
 » Don’t pressure someone to tell their story.

 » Don’t interrupt or rush someone’s story (for example, don’t look at your watch or
speak too rapidly).
 » Don’t touch the person if you’re not sure it is appropriate to do so.
 » Don’t judge what they have or haven’t done, or how they are feeling. Don’t say:
“You shouldn’t feel that way,” or “You should feel lucky you survived.”
 » Don’t make up things you don’t know.
 » Don’t use terms that are too technical.
 » Don’t tell them someone else’s story.
 » Don’t talk about your own troubles.
 » Don’t give false promises or false reassurances.
 » Don’t think and act as if you must solve all the person’s problems for them.
 » Don’t take away the person’s strength and sense of being able to care for
themselves.
 » Don’t talk about people in negative terms (for example, don’t call them “crazy” or
“mad”).
Discussion:
As a health worker, if we follow the Do’s what will be the response from community?
And what will be the response if we practise the don’t’s?
Activity: Empathy
Musical Chair game:
Chairs are arranged for musical chair game. All participants are requested to stand outside the
chair and play usual musical chair game. In the next step, the participants are asked to remove
their chappals. Now the trainer asks participants to swap places and wear the chappal of
another person and play the game. Participants struggle with running wearing another
person’s chappal.
Conclusion:
It is very difficult to put ourselves in another person’s situation and understand their
difficulty. But it can be done with practice.
Information: Definition of Empathy
Empathy is the ability put yourself into the position of another person and understand the
their feelings, emotions and events from his/her perspective.
Conclusion: Important attributes of a community health worker
Active Listening
Confidentiality Empathy
No Judging
Communication game:
One of the important features of effective communication is keeping messages short, sensible
and simple.
We are going to play a game which will reinforce the importance of short and simple
messages.
 5 volunteers will be asked to wait outside the training hall
 Once volunteer reads the follOwing to the remaining group members:
Dear all, My mother is turning 60 next Friday i.e., 15 th of May this year 2022. I have never
celebrated her birthday in a grand manner. Now that she has turned 60 I wish to organise a
party for her. I have ordered cake and flowers. I will be cooking biriyani, rotis, halwa and
chicken curry. The party will be conducted in my home which is at 101, Double road,
College bus stop, Vellore. You can easily come by bus also. The party will be during evening,
since it will be easy for you to come. It starts at 6 pm. You are invited for this party. Please
pray for my mother’s good health
 After reading out the script, the trainer calls no. 1+2 volunteer from the 5 who are
waiting outside the door and gives the script to the 1 volunteer to read privately
 After the volunteer has read and is sure of understanding the content, he/she returns
the script to the trainer and recites what he/she understood to the audience
 The audience is instructed not to comment or correct the volunteer reciting the script
 After the 1st volunteer has completed his recital, the next volunteer is asked to come in
and the same procedure is repeated for all 5 volunteers.
Key learning points:

Everyone reads something different based on their own personal and life experience.
Communication process can fail when lengthy and complex messages due to difficulty in
understanding.
**Keep your messages sensible and short
Activity 2 on Non verbal communication:

Second batch of 5 volunteers is called
The rules and steps are the same as above. Only the script is changed:
You are cordially invited for my mother’s 60th birthday organised by me on 15.05.2022
(Friday) 6 PM onwards at my home.
Address: 101, double road, college bus stop, Vellore
Cake will be cut and dinner will be served for all.
Summary:
Clear, sensible and short messages are better understood by everybody.
A Health Worker should be able to communicate in simple language, sensibly and give short
messages.
Non Verbal Communication: Activity
Activity:
* In this activity there will be a prize for the best story/contribution by all.
Instructions:
 Trainees are divided into 2 groups of 7-8 members each
 Each group is assigned a director, assistant director, lead actor, lead actress and
supporting actors
 Each group is instructed to write a brief story and direct a 10 minute silent skit which
has to be acted out without any talking. They have 15 mintes to prepare.
 When the first group acts, the second group has to take notes of the scenes, emotions
and story, share what they understood from the skit and compare with the original
story.
 The second group does their performance before receiving feedback from the group.
Slide:
 Nonverbal messages conveys the internal feelings of people which often are difficult
to communicate orally
 The Health workers’ non verbal component of communication (body language, facial
expression, head nodding, clothing, seating etc.) has 55% impact on the patients.
Trainer connects to real life by asking participants to give examples.
Summary of Day 1:
 Empathy is the ability put yourself into the position of another person and understand
the their feelings, emotions and events from his/her perspective.
 Communication process can fail when lengthy and complex messages due to
difficulty in understanding.
 **Keep your messages sensible and short
Oral feedback about today’s sessions and learnings:
Schedule for Day 2
Time Session
10:00-10:30 Summary of Module-2 Day-1 learning
10:30-11:30 Basic action principles of PFA
11:45-01:00 Application of Look-Listen-Link
01:45-02:15 Summary of Coping skills
02:15-03:00 Demonstration of provision of PFA and coping skills teaching
04:00-04:30 Post test and Feedback
Summary of Module -2 Day 1 learnings
Information: Basic action principles of PFA:
Look
 Check for safety of the individual

 Check for people with obvious urgent basic needs.
 Check for people with serious distress reactions.
Listen
 Approach people who may need support.

 Ask about people’s needs and concerns.
 Listen to people, and help them to feel calm.
Link
 Help people address basic needs and access services.

 Help people cope with problems.
 Give information regarding medical services available.
 Connect people with loved ones and social support.
Lecture: Application of Look-Listen-Link:

Listening properly to people you are helping is essential to understand their situation
and needs, to help them to feel calm, and to be able to offer appropriate help. Learn to
listen with your:
Eyes: Giving the person your undivided attention
Ears: Truly hearing their concerns
Heart: With caring and showing respect
Remove person from immediate danger such as violence, self-harm, if it is safe to do

so
If the person is very distressed, try to make sure they are not alone
Find out what is most important to them at this moment, and help them work out what
their priorities are.
Tips: How to keep a person calm?
People in distress can be very anxious or upset. They might look very confused or
overwhelmed and have some physical reaction such as shaking or trembling, difficulty in
breathing or heart pounding. The following are some techniques to feel calm
 Keep your tone of voice calm and soft

 Maintain eye contact while talking with them
 Remind that you are there to help them and remind that they are safe, after checking
for safety
 Ask them to feel their feel on floor
 Tap their fingers or hands on lap
 Notice some non-distressing things in environment such as sky, birds,water
 Concentrate on their own breathing
Link:
 Help people address basic needs such as food, water, sanitation and access health
services
 Give information about health care services
 Connect people with loved ones and social support
 Teach positive coping skills
 Give more attention to women, children, discriminated individuals
Lecture: Coping skills
People will have too many worries and fears. Help them to consider their most urgent needs
and how to prioritise and address them. Focus on what needs to be addressed now and what
can wait later. Being able to manage fewer issues will give a person a greater sense of control
in their situation
 Help people identify immediate support in life such as family and

friends
 Give practical suggestions such as guidance on disability pension,
ration card, construction of toilet etc
 Ask the person to consider how they coped with difficult situation in
the past and build their confidence of ability to cope with current
situation
 Ask what helps them to feel better.
 Encourage positive coping strategies
 Avoid negative coping strategies
Encourage positive coping strategies
 Get enough rest.

 Eat as regularly as possible and drink water.
 Talk and spend time with family and friends.
 Discuss problems with someone you trust.
 Do activities that help you relax (walk, sing, pray, play with children).
 Do physical exercise.
 Find safe ways to help others and get involved in community activities.
 Be aware of and respect the person’s religion. Religion can give meaning to life and
sense of hope.
Avoid negative coping strategies:
 Don’t take drugs, smoke or drink alcohol

 Don’t sleep all day.
 Don’t work all the time without any rest or relaxation.
 Don’t isolate yourself from friends and loved ones.
 Don’t neglect basic personal hygiene.
 Don’t be violent.
Demonstration:
Each participant is paired with another. Each pair is given an imaginary scenario as follows:
domestic violence, death in family, diagnosis of chronic illness, disability issues, loans in
family, child with developmental delay in family, pregnancy complication, abortion,
infertility. One of the participant acts as patient and the other acts as health worker providing
PFA and teaching coping skills. Each pair comes to the stage to demonstrate their skills.
Summary of Module 2:
 Keep your messages sensible and short
expression, head nodding, clothing, seating etc.) has 55% impact on the patients
Basic action principles of PFA

Look

Listen

Link

 Connect people with loved ones and social support.
Post test evaluation:
Feedback of the training

Your inputs are valuable for us trainers to improvise our teaching skills and make this
project a big success.
Day -1 Day-2
1. Knowledge and
content
2. Activities
 Written feedback and comments to improve sessions:
Module 3: Stress Management, Depression and common mental health problems
Aim of Module 3:
 Understand stress and learn simple stress management techniques

 2 simple problem solving skills for life
 Understand about depression and common mental health problems
 Learn about depression and suicide risk screening
 Referral system for patients with depression and suicide risk
Day 1 of Module 3:
Time Session
10:00-10:30 Summary of Module-1&2
10:30-10:45 Introduction to Module 3
10:45-11:00 Pretest
11:45-12:15 Group discussion on stress management, taking care of self
12:15-01:00 What is Depression and what are the common mental health problems
in community?
01:45-02:15 Brain storming game – JAM
02:15-03:00 Positive attitude –discussion
03:30-04:00 Fun stress management activities
04:00-04:30 Summary of Day-1

Respect the
1. safety
2. dignity
decisions.
Look

Listen

Link

Connect people with loved ones and social support

Introduction to Module 3:
In this module you will learn about
 Stress
 Depression
 Common mental health disorders
 Screening for depression
 Simple stress management techniques
 2 problem solving skills useful for life
Pre-test Evaluation:
1. The same stress factor can cause different reactions in different people
 True
 False
2. Drinking is a bad habit. It is not a mental health issue

 True
 False
2. By concentrating on breathing, we can reduce effects of stress
 True
 False
3. Taking care of our mind and body is a selfish act
 True
 False
4. Accepting what cannot be changed is a good attitude
 True
 False
5. Those who are positive about life have a good mental health
 True
 False
6. A person with known mental illness is at risk of committing suicide
 True
 False
7. Those who have already attempted suicide will not attempt again
 True
 False
8. If a person has no interest in doing routine activities for the past 2 weeks are more, he
has become lazy
 True
 False
9. Once a person gets treatment from Psychiatrist, he should not be followed up at

outreach clinics.
 True
 False
Introduction to Stress:
Life can be stressful! Some people manage the stress well and others do not. To stay well, we
all need to learn to manage stress in our lives. There are are many ways to do this some are
healthy and others are not.
Group Activity
How do you release the stress in your life?
In groups of 3 list all the ways you can think of to release stress in your life. Put a tick next to
the positive or healthy ways of relieving stress and a cross next to the negative or unhealthy
ways.
e.g: (+) Talking with friends, listening to music, watching a movie, dancing, singing,
laughing, playing games, eating a meal with family and friends, exercise, yoga, mediation,
practicing religion or spiritual activity. etc.
(-) Drinking alcohol, taking drugs, smoking, overeating, underrating. Risky activity like
dangerous driving.
Summary
These are all common ways to reduce stress and most of the time we don’t realise we are
reducing our stress, we just do it! However we should all make a conscious effort to find
time in our lives for activities that reduce stress and begin to recognise in ourselves when our
stress is becoming too much.
Introduction to depression:
When stress gets too much, we can go on to suffer from depression or even have suicidal
thoughts. All of us have cried, had low mood, had moments where we didn’t want to do any
work and we may have faced situations in life where we have had thoughts of committing
suicide. In this session we will learn about a disease of the mind called “Depression”. The
WHO say that depression is the leading cause of illness and disability worldwide with over 300
million people living with depression. One of the biggest problems we face is our failure to
recognise depression and help people who are feeling low.
As health workers, we need to know about this disease in detail, since many people often
complain low mood, suicidal thoughts and their family members might complain that they are
not working at home or outside properly.
Group discussion:
We are going to watch a video then discuss what we saw.
(Consider Black dog, WHO video https://www.youtube.com/watch?v=XiCrniLQGYc&t=62s)
Discuss signs and symptoms of depression.
Information
Slide:
Signs and symptoms of depression and suicidal thoughts:
 Looking dull and depressed due to depressed mood
 No interest or enjoyment in anything
 Less energy to do regular work
 Disturbed sleep and hunger
 Looking tensed
 Feeling guilty, helpless and hopeless
 Low self worth (inferiority complex)
 Lack of concentration at work
 Excess body pain and other body problems
 Not able to come for work
 Previous history of suicide attempt
 Now having thoughts of committing suicide
 Sudden change of mood, seeming to recover or setting affairs in order, this can mean
they have decided to commit suicide.
Common Mental illnesses:

What mental illnesses have you heard of? Brainstorm
Trainer lists on the board, as the conditions below are explained she/he returns to the list and
points out those that correspond. (it is extremely important that the trainer knows these
conditions and can answer questions without adding to the stigma and misunderstanding, they
need to connect the conditions participants come up with to the conditions below that they
will describe.)
* Trainer connects conditions from the brainstormed list made to the illnesses listed below
using both colloquial name and medical name)
1. Anxiety
When we are faced with a stressful situation, all of us will have some nervousness, fear and
tension. This feeling is called “anxiety”. Anxiety disorder is a mental disease in which the
affected person has too much anxiety and fear which will affect his ability to function
normally at work, school, home and public.
Symptoms of anxiety disorder: (These symptoms will be affecting the patient’s normal lives,
they may be unable to leave their home, work or enjoy life, they may be unable to eat and
sleep)
 Excess worries for minor matters
 Physical symptoms such as tiredness, body pain
 Developing panic attacks – sudden increase in heart beat, sweating, trembling,
breathing difficulty, chest pain, fear, fainting
 Excessive fear for certain things like darkness, spiders, heights
 Fear of going out of house
 Fear of being in public places and avoiding social events
 Fear of losing the person we love
Management (how do we help a person with anxiety)
 Listen to them to understand their problems
 Referral to psychiatry doctor for starting tablets and therapy
 Stress management techniques
 Talk to friends and family to provide good support to patient
2. Substance (Alcohol, Tobacco, Drugs) use disorder

People use these substances for many reasons, to take to stop them from remembering, to
reduce stress and numb them to bad experiences, If a person uses alcohol/tobacco/drugs in
such a way that it causes health problems or if the person could not do his routine family
work or other works due to substance use then we consider the person to suffer from
addiction or substance use disorder
3.Schizophrenia (broken mind):
Symptoms:
Hearing or seeing or feeling things which are not there in reality, such as voices of strangers
in a room which nobody else hears
Strongly believing in something which is not true (thinking that the relatives are trying to kill
him or parents are trying to poison him in his food, when actually they are all trying to help
him)
Abnormal behaviour such as not taking care of self- not combing hair, not dressed properly,
laughing or talking to self (responding to the voices )
4. Mania (Grand thoughts):

Symptoms:
Thinking very high of one self (like telling that I was a king, I have rich relatives, I am
related to some actor/politician) when it is not the truth
Thinking that someone is trying to kill them
Suspicious about the people around them
5. Bipolar Disorder (mania in one pole- depression in another pole):
Suffering from mania at times and depression at times
High risk for committing suicide during depressive episodes
6. Stress related disease:
Having multiple symptoms like body pain, headache, weakness, fainting due to stress but all
blood tests and doctor checkups will be normal
7. Obsessive compulsive disorder (repeated thoughts and behaviours):
Having excessive thoughts and behaviours which will be repeated again and again
Causes: Mental illness can be caused by a variety of genetic and environmental factors,
It is more common in people who have a blood relative who has a mental illness, certain
genes can increase your risk of getting it and life situation, e.g stress, abuse or neglect as a
child etc can trigger it. Exposure to some environmental toxins, drugs and alcohol before
birth Can also be the cause. Depression can be caused by problems with the brains chemistry.
Treatment and care:

All of these mental illnesses require diagnosis and treatment from a psychiatrist or senior
psychologist. Early diagnosis and treatment is the key to recovery. People can get better but
the longer the condition continues the harder it is to treat. The person will need support from
their family and friends. They can easily be shunned and face stigma. As a health worker if
you hear of such cases in your community, encourage the person to get treatment and support
the family.
Brain storming Game: JAM

Using sticky notes with problems in life name, trainer chooses a problem (one with multiple
solutions) the participants are asked to come one by one to the stage. Each participant will be
given a problem by the trainers and given 60 seconds to brainstorm all possible positive
solutions for that particular problem. After 60 seconds the participant tells the solutions that
he/she has thought of. Each possible positive solution gets one point and the person with
maximum points is given the award of best problem solver
Example for the trainer, possible positive solutions (help participants to come up with these,
don’t just read them out)
Problem: diagnosed to have cancer
Accept the diagnosis
Contact all relatives, old friends meet them and have the best moments with them
Get the best possible treatment with the money that you have
Show all the love and affection you have you’re your immediate family members
Start writing a diary of memories
Start meeting other people with cancer and know their experiences
Train yourself to be a motivator and give motivational speech to others
Start an online blog
Start a you tube channel of your daily treatments and activities
Spread awareness about what are the causes of cancer such as tobacco, alcohol
Try your level best to keep going for work and not missing routine activities
Take many photographs and videos
Give gifts to everyone
Make a bucket list of what to do and keep ticking them off
Ask your immediate family members their wish list and try to fulfil them
Settle all financial and other responsibilities
Explore spirituality and divine healing
Practice meditation and do some stress relaxation exercises
Conclusion:
One problem can have many solutions. Be creative and brainstorm solutions.
Information:
Experiencing problems is normal. Everyone experiences them.
Symptoms such as anger, sadness, other negative feelings appear or get aggravated by the
problems. Address the problems and the symptoms will reduce.
Adopting a positive coping strategy such as spirituality, growing pets, developing hobbies etc
is very important
Positive thinking: An important problem solving skill
Discuss the following points:
A person who sees the negative aspects of situations often faces more problems
A person who takes things positively prevents and solves problems easily
Group Activity
Stress Management Technique: Deep breathing:
Deep breathing is using abdomen rather than the chest when breathing.
This voluntary slow deep breathing relaxes the heart, lungs and brain, reduces effects of
stress, delays anger and other negative emotions.
Activity:
The trainer plays relaxing music in the background and instructs the participants in a
soothing voice to either
Sit with arms, shoulder and legs relaxed in chairs or on the floor (lotus position)
to close the eyes
“Start breathing in and breathing out slowly. Think of your lungs a pot which has to be filled
with water. Instead of water, I will instruct you to fill air. Breathe in slowly till the air
reaches the bottom of lungs. Do this slowly. As you are breathing in, your diaphragm
relaxes, abdominal muscles relax and your heart rate slows down. Now breathe out slowly.
As you keep breathing in and out your body will receive more oxygen. Can you feel the rise
and fall of abdominal and chest muscles. Keep doing this whenever you are feeling stressed”
At the end of this exercise, ask the participants about the experience. They should have felt
relaxed physically and mentally.
Summary
It is very important to learn this simple stress reduction technique, practice it on yourself then
on your family and friends so that you are ready to show a patient if they need to learn this
technique to help them to relax.
Summary of Day 1 of Module 3:

We should all make a conscious effort to find time in our lives for activities that reduce stress
and begin to recognise in ourselves when our stress is becoming too much.
Deep breathing is a simple stress management technique
Looking dull and depressed due to depressed mood
No interest or enjoyment in anything
Less energy to do regular work
Disturbed sleep and hunger
Looking tensed
Feeling guilty, helpless and hopeless
Low self worth (inferiority complex)
Lack of concentration at work
Excess body pain and other body problems
Not able to come for work
Previous history of suicide attempt
Now having thoughts of committing suicide
Sudden change of mood, seeming to recover or setting affairs in order, this can mean they
have decided to commit suicide.
Brain storming and positive attitude are 2 simple problem solving skills in life
Other common mental illnesses are
Anxiety
Substance use disorder
Mania
Bipolar disorder
Obsessive compulsive disorder
Phobia
Stress disorders
Oral Feedback of Day-1:
Day 2 of Module 3 Schedule
Time Session
10:00-10:30 Summary of Day-1
10:30-10:45 Depression screening- PHQ-9
10:45-11:00 MHGAP questions on suicide risk
11:45-01:00 Suicide risk stratification and support mechanism
02:15-03:00 Summary of PFA training
03:30-04:00 Post test
04:00-04:30 Feedback
Summary of Day -1
Looking dull and depressed due to depressed mood
No interest or enjoyment in anything
Less energy to do regular work
Disturbed sleep and hunger
Looking tensed
Feeling guilty, helpless and hopeless
Low self worth (inferiority complex)
Lack of concentration at work
Excess body pain and other body problems
Not able to come for work
Previous history of suicide attempt
Now having thoughts of committing suicide
Sudden change of mood, seeming to recover or setting affairs in order, this can mean they
have decided to commit suicide.
Anxiety
Substance use disorder
Mania
Bipolar disorder
Obsessive compulsive disorder
Phobia
Stress disorders
Depression screening in community:
PHQ-9
Over the last two weeks, how often have you been bothered by any of the following problems?
11. Little interest or pleasure in doing things 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
12. Feeling down, depressed or hopeless 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
13. Trouble falling or staying asleep or sleeping too much 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
14. Feeling tired or having little energy 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
15. Poor appetite or overeating 0 Not at all
1 Several days
2 More than
half the days
3 Nearly
everyday
16. Feeling bad about yourself or that you are a failure or have let 0 Not at all
yourself or your family down 1 Several days
2 More than
half the days
3 Nearly
everyday
17. Trouble concentrating on things, such as reading newspaper 0 Not at all
or watching television 1 Several days
2 More than
half the days
3 Nearly
everyday
18. Moving or speaking so slowly that other people could have 0 Not at all
noticed? Or the opposite – being so fidgety or restless that you 1 Several days
have been moving around or a lot more than usual 2 More than
half the days
3 Nearly
everyday
19. Thoughts that you would be better off dead or of hurting 0 Not at all
yourself in some way 1 Several days
2 More than
half the days
3 Nearly
everyday
20. If you checked off any problems, how difficult have these
problems made it for you to do your work, take care of 0 Not difficult
things at home, or get along with other people? at all
1 Somewhat
difficult
2 Very
difficult
If the total score for the first 9 of these questions adds to 5, the patient needs to be referred to
a psychiatrist for further evaluation. If in the above 9th question, a person responds option
2,3,4 then he needs referral to Psychiatrist for further evaluation.
Suicide risk assessment:
If a patient says yes for any of the following questions, he is at risk of suicide or self harm.
He needs to be referred to Psychiatrist. Those who have current thoughts/plans/act of self
harm or suicide need immediate referral to Emergency/Psychiatry OPD.
Questions
11. Extreme hopelessness and despair 1 Yes
2 No
12. current thoughts/plan/act of self-harm suicide 1 Yes
2 No
13. History of self harm/suicide – past month or past year 1 Yes
2 No
14. Presence of depression/ child/adolescent mental health disorders/ 1 Yes
substance use behavioural disorders psychoses/ epilepsy 2 No
15. Chronic pain 1 Yes
2 No
16. Extreme emotional distress, extremely agitated, violent, lacks 1 Yes
communication 2 No
17. Difficulty in carrying out usual work at work/school/domestic/social 1 Yes
activities 2 No
18. Repeated self medication for emotional distress 1 Yes
2 No
19. Repeated help seeking 1 Yes
2 No
20. Unexplained physical symptoms 1 Yes
2 No
Suicide risk stratification and support Mechanism
After administration of MhGAP Questions on Deliberate Self Harm/suicide risk, the patient
will be stratified and treated according to these categories as mentioned in MhGAP
Stratification Criteria Management
Medical Serious act of self- Evidence of self-injury and/or Immediate referral

harm signs/symptoms requiring through 108
urgent medical treatment Emergency transport
services to emergency
services of
Government Medical
College, Vellore or
CHAD Hospital,
Bagayam, Vellore for
medical care. Further
services of CHAD
Hospital
Imminent risk of self History of thoughts or plan of Immediate referral to
harm/suicide self-harm in the past month or Emergency services of
act of self-harm in the past Mental Health Centre,
year Department of
Psychiatry, Christian
In a person who is now
Medical College,
Vellore or emergency
distressed or lacks
services of
communication
Government Medical
College, Vellore.
Further follow-up in
outreach services of
CHAD Hospital
Risk of self harm/suicide Patient with known Referral and follow-up
conditions in Psychiatry OPD of
CHAD Hospital or
Depression
or Government
Child & adolescent mental
Medical College,
Disorders due to substance Vellore. Further
use follow-up in outreach
services of CHAD
Behavioral disorders
Hospital
Psychoses
Epilepsy
Depression Screened Positive for Referral and follow-up

Depression in PHQ-9 in Psychiatry OPD of
CHAD Hospital or
or Government
Medical College,
Vellore. Further
services of CHAD
Hospital
Summary of Day 2:
If anyone has symptoms of depression or at risk of suicide, they should be referred to

Psychiatrist for evaluation and treatment
Summary of all 4 modules:


Respect the
1. safety
2. dignity
decisions.
Look

Listen

Link

Connect people with loved ones and social support
 Looking dull and depressed due to depressed mood
 No interest or enjoyment in anything
 Less energy to do regular work
 Disturbed sleep and hunger
 Looking tensed
 Feeling guilty, helpless and hopeless
 Low self worth (inferiority complex)
 Lack of concentration at work
 Excess body pain and other body problems
 Not able to come for work
 Previous history of suicide attempt
 Now having thoughts of committing suicide
 Sudden change of mood, seeming to recover or setting affairs in order, this can mean
they have decided to commit suicide.
 Anxiety
 Substance use disorder
 Mania
 Bipolar disorder
 Obsessive compulsive disorder
 Phobia
 Stress disorders
If anyone has symptoms of depression or at risk of suicide, they should be referred to

Psychiatrist for evaluation and treatment
Post test evaluation:

Feedback:
Your inputs are valuable for us trainers to improvise our teaching skills and make this
project a big success.
Day -1 Day-2
1. Knowledge and
content
2. Activities
 Written feedback and comments to improve sessions:

 Oral feedback about the entire training
ANNEXURE 1:
CONFIDENTIALITY AGREEMENT
This agreement is made by …………………………… who is a participant of the

“SUPREA” project training which is organised by Christian Medical College, St. John’s
Medical College, Bangalore and Government of Tamil Nadu.
During the course of this training, certain confidential private information regarding the
personal lives of other people will be discussed. You will also be taught the importance of
empathy and privacy, maintenance of confidentiality. Since the training involves teaching
about mental health, some of your fellow trainees also might disclose about their personal
lives unhesitatingly.
Once the training is completed, you will be providing emotional care, support and listen to
many of your community members in your village, many of the stories will be of sensitive
information.
By signing this agreement, you agree to respect those who share such information and keep
these personal details, in strict confidence and not disclose to public domain, any person, be
it your medical officer or your close family member such as spouse.
Participant signature: Date:
Witness:
Study title: Feasibility of training Village Health Nurses, Auxiliary Nurse Midwives and
Women Health Volunteers of Government of Tamil Nadu on screening for Depression
Pre and post test assessment for health workers:
1. A health worker need not explain to the patient that information shared with her will
kept confidential. This is because the community knows her well
 Yes.
 No
2. Patients don’t know many things. As a health worker, we need to take decisions for
them
 Yes
 No
3. Open ended questions allow patients to share more details with us.
 Yes
 No
4. Since the healthworker is from the same community, she need not address a younger
individual with respect
 Yes
 No
5. Do you have knowledge about mental illness?
 Yes
 No
6. Do you know what it means by being mentally healthy?
 Yes
 No
7. While administering questions regarding mental health, it does not matter if family
members are around
 Yes
 No
8. Using simple questions, we can screen individuals for certain mental illnesses
 Yes
 No
9. If a person is not happy in the past 2 weeks, he needs to sent to PHC medical officer
for further evaluation and treatment
 Yes
 No
10. If a person has interest in doing routine activities or those activities which interest him
in the past 2 weeks, he should be termed as lazy and advised to be more active
 Yes
 No
11. Sleep problems can denote mental illness
 Yes
 No
12. If a person has excessive or no appetite in the past 2 weeks, he should be advised
healthy diet.
 Yes
 No
Key:
1. A health worker need not explain to the patient that information shared with her will
kept confidential. This is because the community knows her well
 Yes.
 No. Even though everyone in the village knows her, it is very important
during patient interactions for mental health issues to express and assure that
all information shared with her will be kept confidential.
2. Patients don’t know many things. As a health worker, we need to take decisions for
them
 Yes
 No. All patients, including mentally ill patients should be involved in the
treatment process. Their consent should be obtained after explaining about
treatment and course of illness.
3. Open ended questions allow patients to share more details with us.
 Yes. These questions will make individuals to share more details and sensitive
information also.
 No
4. Since the healthworker is from the same community, she need not address a younger
individual with respect
 Yes
 No. All individuals including children should be treated with respect and
dignity. This increases trust and respect of the patient for you.
5. While administering questions regarding mental health, it does not matter if family
members are around
 Yes
 No. Most adults and adolescents prefer to discuss about their condition in
privacy due to stigma around mental illnesses.
6. Using simple questions, we can screen individuals for certain mental illnesses
 Yes. The disease depression can be screened by easily administered questions.
 No
7. If a person is not happy in the past 2 weeks, he needs to sent to PHC medical officer
for further evaluation and treatment
 Yes. Lack of happiness in the past 2 weeks can denote depression.
 No
8. If a person has interest in doing routine activities or those activities which interest him
in the past 2 weeks, he should be termed as lazy and advised to be more active
 Yes
 No. This can denote depression. He needs referral to PHC Medical Officer
9. Sleep problems can denote mental illness
 Yes
 No
10. If a person has excessive or no appetite in the past 2 weeks, he should be advised
healthy diet.
 Yes
 No. This can denote depression. He needs referral to PHC Medical Officer
Figure 16: Certificate provided for trained CHWs

Figure 17: IEC Approval St. John's Medical College
Figure 18: IEC Approval Part II of the study
Table 13: AWWs and ASHA workers of Jamunamarathur listing common determinants of
mental health
Table 14: VHNs of Kaniyambadi discussing on coping skills
Table 15: Psychiatrist Dr. Srisudha on seriously ill Psychiatry Patients and how to refer
them
Table 16: Women Health Volunteer and UHNs of Poonamallee discussing common mental
illnesses in the community
Table 17: Dr. Jackwin Paul teaching health workers on home visits to mentally ill patients
and follow up
Table 18: Christian Medical College, Jamunamarathur Batch

Table 19: Christian Medical College Vellore Batch
Table 20: Woman Health Volunteer in Athimanjeerpet asking doubts on mental illnesses and
its causes
Table 21: Dr. Senthil DDHS Poonamallee interacting with our project staff and health
workers on mental health
Table 22: Jamunamarathur Batch

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Strengthening the existing Mental Health Programme to reduce suicide rates in rural

Tamil Nadu: an Operational research

Grassroot level Health Workers (GLHWs) in India:

The GLHWs in Tamil Nadu are

Psychological First Aid:

 Practical care and support

Psychosocial support that can be provided by Community Health Workers:

2. Involving the person and showing empathy

4. Being friendly, respectful and non-judgemental at all times

5. Use of good verbal communication skills

6. Responding with sensitivity when people disclose difficult experience

7. Promotion of dignity and respect

Justification / need for the study

 To train community health workers on Psychological First Aid

Jamunamarathur Block, Jawadhi Hills:

Permissions were obtained from the following authorities

 Deputy Director of Health Services, Vellore, Thiruvannamalai, Poonamallee and

For the Health workers

 Health Aides of Kaniyambadi Block who are employees of the Christian

For the Community members:

Table 1: Baseline characteristics of GLHWS N=117

Baseline characteristics Mean (SD), N (%)

Mean Median Mode Minimum Maximum

Ability to recognise 24.29 25 24 10 32

Knowledge of where to 12.23 12 11 7 16

Knowledge of risk 6.3 6 6 4 8

Knowledge of self 5.7 6 6 3 8

Attitudes that promote 17.14 18 19 7 26

Overall Total 105.26 106 102 84 127

ASHA AWWs ANMs VHNs UHN WHV HA HA

Knowledge of 13.3 12.3 10.66 11.4 11.7 10.9 12.5 14

Not willing Unsure Willing

Effective Unsure Not effective

Agree Neither Agree nor Disagree Disagree

50; 43% 52; 44%

Agree Neither agree nor disagree Disagree

Confident Not confident

Participants Mean pre test Mean of Post Mean Paired t test

Feedback from trainings

Table 5: Baseline characteristics of the study population (N=1371)

Baseline characteristics N (%)

No; 249; 45%

Yes; 309; 55%

Figure 6: Knowledge of mental health among Kaniyambadi Population

Male Female Both

WHO Athimanjeerpet Poonamallee

No Difficulty Some Difficulty Severe Difficulty

Depression scores Kaniyambad Athimanjeerpet Poonamallee Overall

S.N Suicide risk Kaniyambad Athimanjeerpe Poonamalle Overall

6. Extreme emotional distress, 21 (3.67%) 28 (7%) 3 (0.75%) 52

10. Unexplained physical 3 (0.52%) 6 (1.5%) 2 (0.5%) 11

Independent variables None to Depression UOR AOR

Age 36 years 41 years Mean

Employment Employed 763 (94.7%) 43 (5.3%) 3.14 (1.3-

Employment was observed to be independently associated with depression in our study.

Independent WHO Well being scores UOR (95% AOR (95%

Religion Hindu 324 359 (52.6%)

Independent Suicide risk UOR AOR (95%

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skil adequ Stigma