MENDIS.app (Mental Distress Application) is an audio-based survey web-app, using mental health screening as a test case to evaluate the broader use of audio-based surveys.
Despite progress in some countries, people with mental illness often face severe human rights violations, discrimination and stigma. Many mental illnesses can be treated effectively at relatively low cost, but the gap between people who need care and those who have access to it remains wide. Coverage with effective treatments remains extremely low.
Community-based organisations (CBOs) and NGOs are often the only health care providers for marginalised populations. Unfortunately, they often lack resources and expertise in mental health matters. However, they can play an important role in raising awareness of and recognising mental health problems. There is a great need for open digital solutions to help these organisations identify mental health issues among populations that are often illiterate. This is why the development of MENDIS, an audio-based mental health survey web-app was started.
MENDIS is was built on the "Augmented Audio" (AUMA) framework. AUMA is a lightweight, open source software framework that allows developers to produce interactive audio-based learning content or surveys.
The MENDIS survey is based on the WHO’s ten question “Self Response Questionnaire”, or SRQ-10 for short. MENDIS.app was piloted in Pakistan, in collaboration with a local partner NGO, Aurat Raaj. Part of this pilot trial was an evaluation of the user experience, the experience of the NGO using the app and the impact on beneficiaries.
This evaluation highlighted the potential of the survey framework, specifically in the context of mental health support:
- In the pilot, the survey framework had huge potential to improve beneficiary support. This is as the interactive elements of the survey tool made users actively engage with its content also after the survey’s completion, creating reflective spaces for learning. The information gathered in the survey could also be used to ensure that highly specific and context sensitive information is delivered to the user.
- The pilot highlighted that NGOs can similarly benefit from the survey framework, as it allowed them to target support for individual beneficiaries remotely. Additionally, aggregating the data collected through the survey framework to a population level has the potential to produce robust evidence on the prevalence of issues in target populations, which could enable NGOs to develop support strategies and unlock the funding necessary to deliver them.
- However, piloting the survey framework also highlighted the need for a close integration of the software into existing support structures and work “on the ground”. In the first instance, users need to be sufficiently digitally literate, understand the survey tool, and trust it enough to share (sensitive) information with it; in our pilot, having local charity partners explain the survey and its purpose was a highly effective way to accomplish this. In the second case, there are clear limits on what the provision of information can achieve by itself, if users are not at the same time provided the material support and help they need to act on this information.
- The pilot revealed the need for developing mental health support in women in rural Pakistan, the location of the pilot intervention.
Further assistance for health community workers
Health community workers are key in offering support in the current model and escalating issues/making referrals. However, the app could have supported them better, especially since in-depth mental health knowledge cannot always be presupposed. This can be achieved with the following additions to the current framework: (1) adding questions on causes and (2) improving feedback in WhatsApp messages. The participants enumerated several aspects that they felt influenced their mental health. In order for health community workers to better classify the results of individuals and subsequently assist the women in overcoming their difficulties it would certainly be of assistance to understand the causes of the mental health issues. Potential response options are: (1) financial issues, (2) domestic issues, (3) health burdens, (4) family responsibilities, and (5) other. Furthermore, the feedback provided to health community workers via WhatsApp messages should be improved. Currently, only the total score is provided within the message. This does not allow health community workers insights into the questions that were responded to with "yes". Thus, the feedback should be enhanced with information on the relevant topics for individual participants.
Delivering effective mental health support with the assistance of local partners
To deliver effective mental health support, the current survey app alone is insufficient. Instead it requires additional content produced by local partners and their networks. Particularly, the support of mental health professionals will be key to providing profound mental health support to health community workers and beneficiaries. The necessary support can be divided into several facettes.
Firstly, the topic itself might need a primer in certain communities. The test sample consisted of women, who were already comfortable speaking about rather sensitive topics. This may not always be the case, given that mental health is a highly sensitive topic in many cultures. Listening parties, as conducted by Aurat Raj on diverse topics (currently menstruation and related topics such as pregnancy, nutrition, climate change), or videos could function as the necessary primer. For this reason, audio and/or video content should be developed and provided to local partners in the respective languages.
Secondly, additional information should be provided to local partners in order to enhance the general knowledge about mental health within the community. Ideas on the format of such information include: (1) the organisation of listening parties on mental health, (2) the creation of podcasts, (3) encouraging people to engage in small daily activities that have a positive impact on mental health (e.g. meditation activities, peer discussions, exercises, yoga).
Thirdly, cooperations between mental health start-ups/NGOs as mental health professionals and health community workers should be promoted (as planned between Aurat Raj and ReliveNow). Such cooperations can support the sharing of knowledge (through mental health start-ups/NGOs) on the one side and access to the target audience (through health community workers) on the other side.
Comprehensive package of information and tools
In order to provide the support and information detailed above a comprehensive package of information and tools is needed for effective implementation and mental health support. This offer could support different groups, allowing them to pick and mix the relevant support offers matching their specific needs. Such a package acknowledges and allows different forms of trust bases, prior knowledge on mental health as well as different stages of digital literacy. The comprehensive package should include: (1) information on mental health (e.g. audio and video files), (2) the app, (3) information on the app for health community workers, (4) instructions for the use of the app for beneficiaries, (5) etc.
Possible Intervention Design based on Pilot Results - Theory of Change
Based on the insights gained during the pilot trial, we consider that a possible intervention around the AUMA SRQ10 Survey could take the following form.