# A digital adaptation of the WHO’s Self-Help Plus psychological intervention to alleviate stress among community health workers: a mixed-methods evaluation of the SAMBHAV program in rural India

## TL;DR

A digital version of a WHO psychological intervention was tested in rural India to reduce stress among community health workers, showing promising results in improving their mental health.

## Contribution

The study adapts and evaluates a digital version of the WHO’s SH+ intervention for community health workers in a low-resource setting.

## Key findings

- Psychological distress levels significantly decreased among participants after 12 weeks of the intervention.
- The digital intervention was found to be acceptable and usable, though some interface challenges were noted.
- Qualitative feedback indicated that the program was practical and effective in reducing stress for community health workers.

## Abstract

Psychological distress and risk of burnout among community health workers (CHWs) in low- and middle-income countries represent a serious global public health concern and threat to efficient health system functioning and resilience. This mixed methods study aimed to test the acceptability, feasibility and preliminary effectiveness of a digital adaptation of the WHO’s evidence-based Self-Help Plus (SH+) psychological intervention among CHWs, called Accredited Social Health Activists (ASHAs), in rural India. A total of 40 ASHAs, all women, were recruited from Sehore district, Madhya Pradesh, from October 2022 to March 2023. The intervention, a culturally adapted, digitized version of the WHO’s evidence-based SH+ intervention, called SAMBHAV, was delivered via smartphone app. Psychological distress was measured using the Kessler-10 at baseline, 6- and 12-week follow up. The System Usability Scale and Client Satisfaction Questionnaire-8 were used to assess usability and satisfaction with the digital intervention, respectively. Focus group discussions were used to assess acceptability. From baseline to 12-week follow-up, psychological distress levels significantly reduced (mean decrease of 2.5 points, P = .043), indicating improved psychological health and psychological distress management capacity. The intervention demonstrated favorable acceptability (mean = 20.45) and usability (mean = 69.31), though challenges related to user interface and app navigation were identified. Qualitative feedback supported these findings, with ASHAs describing the intervention as practical, easy to learn, and effective in reducing their psychological distress while empowering them to assist others in managing tension. These findings highlight that the WHO’s SH+ intervention can be adapted for different low resource contexts and tailored to meet the needs of specific target groups, specifically for alleviating psychological distress among frontline CHWs. Future research is needed to determine the benefits of scalable brief digital self-help interventions in promoting the well-being of frontline health workers and its resulting impacts on service delivery and health system functioning.