Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Exploring the Feasibility of Integrating Mental

Health into a Family Planning Program in low-

resource settings

Zahra Sarmad1, Rida Z. Shah2, Fareeha Javaid1, Hasha Siddiqui3, Murk Qazi4, Aneeta Pasha1

1Interactive Research and Development, Karachi, Pakistan

2UCL Institute for Global Health, London, United Kingdom

3Mc Master University, Ontario, Canada

4Mohammad Ali Jinnah University, Karachi, Pakistan

Abstract

Introduction:

Mental health challenges remain a pressing issue, underscored by the glaring

gap between the elevated demand and the scarce resources. Research has highlighted

the effectiveness of integrating mental health services with primary care services,

particularly in low-resource settings.

Purpose:

The objective of this research was to evaluate the perceived implications and

feasibility of integrating basic mental health services into an existing community-based

family planning initiative in Pakistan. By adopting a community-driven and co-produced

methodology, our study not only ensured a deeper resonance with local needs but also

paved the way for a sustainable and transformative uptake of mental health services in

low-resource settings. This co-produced strategy, anchored in mutual collaboration and

shared expertise with the community, promises a more holistic, enduring, and adaptive

integration of essential health services within community frameworks.

Methodology:

This study utilized a qualitative research approa

ch to obtain a

comprehensive understanding of the program's feasibility and potential for expansion.

Interview tools and guides, tailored to the regional language, were developed by the

Research Associate to gather insights from the lady health workers involved in delivering

the intervention, as well as from the clients. Overall, our team conducted 24 interviews, of

which 9 were with the lady health workers and 15 with clients. The interviews were

facilitated by the Research Associate and a Psychologist.

Results:

Utilizing the socio-

ecological model, we thematically analysed factors at

individual, interpersonal, and community levels that support or hinder the integration of

mental health services with existing community-

based programmes. We also examined

the intervention's impact on its users and the healthcare providers.

Our analysis underscores the significant potential of integrating mental health services into

existing community-based health programmes, such as family planning, in low-resource

settings. P

redominant themes highlighted women's willingness to use these services,

influenced by strong relationships and trust in the lady health workers, ease of access to

services, and community support. Identified barriers to integration included prevailing

pove

rty, a preference for direct financial incentives in addition to counselling,

confidentiality concerns in tight-

knit communities, and the lingering stigma surrounding

mental health.

Conclusion

: Our findings highlight the value of community collaboration i

n healthcare,

particularly in low-resource settings. The co-

production approach blends professional

guidance with local insights, fostering community ownership and enhancing program

sustainability. As the first to merge mental health with family planning in Pakistan, our

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

research suggests that future health initiatives can greatly benefit from community-driven

methods, leading to more sustainable and transformative health outcomes..

Keywords

Mental health integration, family planning, women, health workers, socio-ecological

model, co-production, community-based methodology

Address for correspondence:

Zahra Sarmad, Senior Psychologist, 4th Floor, Woodcraft Building, Korangi Creek

Rd, Bhittai Colony Korangi Creek, Karachi, Karachi City, Sindh,

E-mail: zahra.sarmad@ird.global

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0

International License (CC BY-NC 4.0).

©Copyright: Sarmad, 2023

Publisher: Sciendo (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v6i1.176

Submitted for publication: 12

June 2023

Revised: 05 October 2023

Accepted for publication:

09 October 2023

Introduction

Mental health disorders, including anxiety,

depression, and bipolar disorder, contribute

significantly to the global burden of disease,

with heightened risks such as suicide (WHO,

2017). Lower-middle-income countries (LMICs)

face particular challenges due to high rates of

untreated mental illnesses, resulting in a

substantial treatment gap of nearly 90% (Patel

et al., 2018). The World Health Organization

(WHO) has prioritized mental health as part of

global efforts to achieve Sustainable

Development Goal #3, aiming to ensure

healthy lives and well-being for individuals of

all ages by 2030 (United Nations, 2015).

However, LMICs encounter numerous

obstacles, including violence, poverty, and

economic recession, exacerbating the

burden of mental health issues and impeding

progress toward these goals (Kieling et al.,

2011).

Co-production, a burgeoning approach in

global health research, refers to the

collaborative and participatory process

wherein service users and stakeholders work

alongside professionals to design, implement,

and evaluate services, ensuring a tailored and

contextually relevant fit (Bovaird & Loeffler,

2012). This method champions the principle

that those who are affected by health

services, particularly in resource-limited

settings, have a vital role to play in shaping

those services (Osborne et al., 2016). Research

consistently underscores the transformative

potential of co-production in enhancing the

sustainability, efficiency, and quality of health

service delivery. For instance, a study in

Uganda demonstrated that through co-

production, community health initiatives

achieved higher user satisfaction, increased

community trust, and a stronger sense of

ownership, leading to the longevity of health

interventions (Nabatchi et al., 2017). Another

exploration in Kenya revealed that co-

produced health initiatives addressed

community-specific needs more adeptly,

fostering resilience and adaptability in the

face of local challenges (Heaton et al., 2016).

Such evidence strongly indicates that

harnessing the power of co-production can

be instrumental in magnifying the impact and

reach of health services in settings with

constrained resources.

Community-based interventions have

been widely recognized as effective

strategies for delivering mental health services

to underserved populations, offering

enhanced accessibility, flexibility, and

sustainability compared to formal healthcare

settings (Hobfoll et al., 2017). Additionally,

these programs promote social and

economic inclusion, which is crucial for LMICs

(Patel et al., 2018).

As an LMIC, Pakistan is faced with extreme

income inequality. This creates an

environment conducive to social disparities

experienced by the population, mainly within

the housing, education, and health sectors.

Despite the high prevalence of mental health

disorders in Pakistan, it is one of the most

neglected fields in the health sector.

Approximately 10-16% of the total population

suffers from mild to moderate psychological

illnesses (Hussain et al, 2018). Most

psychological services offered in the private

sector are not affordable for the masses,

especially in the lower and middle-income

groups.

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Additionally, these conditions are made

worse for women due to the patriarchal

structures existing within Pakistani society;

factors such as domestic abuse, child

marriages, lack of decision-making power,

economic dependence, lack of reproductive

rights etc. can adversely affect women’s

mental health (Ali, 2012). A study conducted

with pregnant women in Karachi revealed

that 70% of the total participants experienced

symptoms of depression and anxiety due to

factors such as fear of stillbirth, abortion,

miscarriage, role in decision-making, and

domestic violence. (Ali et al., 2018)

Efforts have been made in Pakistan to

integrate mental health services with

community-based programs. For example, a

study in Karachi trained nurses to deliver

mental health interventions to households and

nursing homes, positively impacting

participants' mental health and quality of life

(Ali et al., 2015). Similarly, in rural Punjab,

integrating a cognitive-behavioral therapy

(CBT)-based intervention into a community

primary health worker model demonstrated

improvements in maternal depression, infant

health, and perceived social support

(Rahman et al., 2008)

In 2014, IRD Pakistan implemented a lay

counseling model for mental health, training

community members as counselors to provide

first-line counseling therapy for mild to

moderate anxiety and depression (IRD

Pakistan, 2014). This program aimed to bridge

the prevalent treatment resource gap in

LMICs and has provided free counseling

services to thousands of individuals (ibid).

In this pioneering research, we employed a

co-produced and community-centric

approach to mental health service delivery.

Instead of in conventional clinical settings,

services were rendered directly within

communities. Lady health workers, originally

engaged in providing family planning services

to women in rural Sanghar, received training in

basic mental health counseling. These trained

professionals then ventured into the

community to offer counseling sessions to their

clientele. The feasibility and impact of this

innovative approach were assessed using

qualitative research methods.

Purpose

This qualitative exploratory study aimed to

understand the feasibility of integrating

mental health into an already existing family

planning program. Another important goal

was to examine the reception and perceived

impact of mental health integration within an

already existing service. This study is a stepping

stone toward scaling up the services in primary

care.

Methodology

Study design

Utilizing a qualitative research approach,

semi-structured interview guides were

prepared and translated to Sindhi, the local

language, by the Research Associate. Insights

were sought from two pivotal groups: lady

health workers and service users. A purposive

sampling technique was employed for this

study. A total of 24 comprehensive interviews

were undertaken, encompassing 9 from key

informants and 15 from clients. Prior to the

interviews, all participants granted their

informed consent. Conducted exclusively in

Sindhi to ensure comfort and accuracy, the

sessions were audio-recorded, subsequently

transcribed verbatim, and then meticulously

translated into English. The interviews took

place in May 2021, and were conducted by

the Research Associate and Psychologist.

Study Participants

The study protocol was reviewed and

approved by IRD_IRB_2020_02_013. Written

informed consent was obtained from

participants. Participants included a randomly

selected sample of 15 women from a

population of 297 women who had received

the mental health intervention. Additionally,

the 9 lady health workers that delivered the

intervention were also included in the study

sample for this research. A compensation of

500 PKR was also provided to both clients and

lady health workers who agreed to be a part

of the qualitative interview in order to cover

transport.

The Intervention

The mental health intervention included

initial screening for depression and anxiety

using the Patient Health Questionnaire - 4

(PHQ-4) which was administered by lady

health workers. These 9 health workers were

trained and supervised by a psychologist.

Clients who were symptomatic for depression

and anxiety or self-reported the need for

counselling, were enrolled for 3 to 6 sessions.

Baseline and end line screening tools included

the Patient Health Questionnaire-9 (PHQ-9)

and the Generalized Anxiety Disorder

questionnaire-7 (GAD-7). All tools were

translated to Sindhi. Each counselling session

lasted 30-40 minutes. To monitor quality,

weekly supervision and operational discussion

with each Lady health worker were

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conducted by the Psychologist and Research

Associate.

Questionnaire design and outcome

measures

To assess the perceived impact, facilitators,

and barriers of the mental health intervention,

two separate interview guides were designed

for clients and lady health workers. The key

informant interviews with lady health workers

included open ended questions about their

experience within the community as a lady

health worker, community response to

contraceptives and mental health services,

barriers in accessing and providing mental

health services. They were also asked about

the impact of mental health services on their

personal lives in addition to the clients’ lives.

Similarly, the client interviews also included

questions about their experience and

perceptions of lady health workers. To assess

the impact of mental health intervention, the

clients were asked about benefits and

changes they perceived in their individual

lives, interpersonal skills, symptom alleviation

etc. Moreover, they were also asked about

any perceived barriers or facilitators to the

mental health intervention.

Analysis

The study results were structured using the

socio-ecological framework (SEM) mapped

onto individual, interpersonal and community

level factors. This framework is used in this

study because it helps us understand how

different factors at each level interact with

each other to shape the experiences and

perceptions of the service consumers and

providers. The socioecological framework has

been utilized widely for health promotion,

violence prevention, feasibility and effective

implementation studies. (Kilanowski, 2017,

Bamuya et al., 2021). Individuals operate in a

multi-layered system. The success or failure of

a program consequently relates to the system

it is operating in. SEM is suitable for this study as

it informs about the possible facilitators and

barriers of mental health integration at all

levels an individual operates in. The interviews

were recorded in the local language and

later transcribed into English. Each interview

was assessed, and themes were identified

through the selective coding process. Codes

from all the interviews, including clients and

lady health workers, were categorized into

broader themes according to the SEM model.

Results

The primary purpose of this study was to

understand the response to mental health

integration and its feasibility. The results have

been divided according to various themes in

the SEM model.

Figure 1: Identified themes mapped onto

the Socio-ecological Model. This includes

themes identified by the service users (clients)

and service providers (Lady Health Workers).

Levels

Themes

Individual

. Positive perception of MH

services

a. Positive perception of MWs

b. Financial distress due to lack of

resources

c. Fear of peoples’ judgment

Interpersonal

a. Familial relationship with MWs

b. Fear of breach

c. Permission Issues

Community

. Communal support for mental

health

Community needs and

expectations around support provided

Table 1: Breakdown of themes and

subthemes using Socioecological Model

Facilitators

Individual Level.

There were several individual-level factors

that were identified that helped in facilitating

the mental health intervention with the

community.

Marvi Workers are Trustworthy and Reliant.

The clients reported that they were able to

trust and rely upon the lady health workers

because of their experiences of coming to

their homes to provide family planning

options.

“We were tension free about everything.

We said that we trust baji. She came to us for

the first time to inject us, and since that day I

have shared every problem with her.” (P11)

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The clients usually referred to the lady

health workers as “baji” (sister) and reported

that they felt comfortable in sharing their

personal issues with these lady health workers

because they were supportive and

maintained confidentiality:

“No, no we would trust no one other than

sister…whatever problem we face we consult

her and she solves it for us. She guides us time

and again, we are indebted to her.” (K011)

Marvi Workers are a source of guidance

and knowledge. The lady health workers were

a source of guidance for these women

because they provided guidance about

family planning and additional domestic

issues,

“We are poor and are barred from going

anywhere and also stuck in food scarcity.

They've helped us by hearing our problems

and providing solutions to them.” (P4)

Clients reported that the lady health

workers were helpful and were always readily

available for guidance. According to the

results, the clients were satisfied with the

degree of information and guidance

provided by these workers:

“They come to us timely. They give us

strength. They brought a change. They give us

contraceptive pills. Now we are thankful for

them.” (P13)

Interpersonal Level.

An interpersonal level factor was identified

by the clients as a facilitator for this mental

health intervention.

Availability and Readiness of Lady health

workers. Clients found ease of access to lady

health workers as they belonged to the same

community. At the same time, the willingness

of lady health workers to make extra efforts to

provide support to the clients helped in not just

building trust and relationships, but also

comforted the clients.

“Whenever I feel worried, my children

come here and tell her about me. She comes

and consoles me and tells me that I should not

be worried about everything. Everything will

be fine.” (P2).

Community level.

Communal Support for Mental health.

Despite the challenges of permission from the

family, there is a general community support

for mental health intervention. This sense of

community seems to facilitate mental health

integration.

“Yes our entire village knows about

it…...they help us in attending more sessions.”

(P2)

Suggested Support Mode. The clients

mentioned a preference for community-

based services rather than hospital-based

mental health sessions. The reason behind it

seems to be the easy accessibility of services

and overcoming the permission issues by

family members.

“Home-based is far better…..Because, our

guardians will not allow us to go to the

hospital…..Yes, as soon as husband goes for

work, marvi workers should come here for

sessions.” (P1)

Barriers

Individual level.

In addition to facilitators, participants also

recognised certain factors as barriers for the

mental health intervention and provided

suggestions.

Financial Distress due to Lack of Resources.

Financial distress was a frequently reported

problem by the clients. Mental health was

secondary to them as their basic survival

needs were not met. They mentioned how the

lack of basic necessities such as food, money,

housing caused emotional distress but it would

get them all consumed and they would not

get mental health help,

“Sister, there is a worrisome situation at

home. Poverty, illness, day to day affairs and

sometimes there is nothing to eat. Sometimes,

we eat one meal and wait for another. These

are our daily worries. Poor people face such

types of tensions. If there is something to eat

for today, then we start worrying about

tomorrow.” (A0418)

This theme was also present in lady health

workers interviews as an expectation from the

clients. Lady health workers reflected on their

experiences with the clients and reported that

clients expect compensation in the form of

money, jobs, basic resources with the mental

health intervention:

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“They see it (counseling) as hoping to get

some kind of (monetary) help….. That's

because previously organizations often came

to them and gave them monetary funds so

they can't help but hope for the same from

us.” (LHW 01)

Some clients were also skeptical of the

benefits from the mental health intervention

because they didn’t think only talk therapy

could help their issues:

“Some of them said what benefit would

come to them by talking, unless I was giving

them something” - (LHW-05)

Increased Workload. Lady health workers

reported an increase in workload due to the

mental health intervention alongside family

planning sessions. Data management was

particularly an issue because they had to

maintain forms and registers which required

extra time. As a suggestion, LHW said that

there should be limited sessions in one month

to make the work more manageable:

“So, due to this we were not getting time for

paperwork as we had to maintain registers

which you gave us. In this context our

workload had increased.” (LHW F09)

Interpersonal level.

A few barriers were mentioned by the lady

health workers and clients that hindered the

uptake of mental health services.

Fear of Breach. One of the main reasons for

initial resistance towards counseling was that

women thought their confidentiality would be

breached by the LHW. While discussing why

more women do not choose to take

counseling despite the community having so

many fundamental life issues, a LHW said that:

“Sister, they did not want to share anything.

They had a fear that people would come to

know about their problems and mock them.”

(LHW 05).

Familial Issues /Restrictions. Familial issues

was a common barrier in both lady health

workers and clients interviews as both of these

groups faces restrictions and lack of

permission restrictions from family members

especially husbands. Other familial issues

included their children and other

responsibilities at home.

“Men said their women shouldn't go

anywhere, to anyone but should remain

home.” (LHW 01)

This finding corroborates with client

interviews as well where the restriction from

family decreased their mental health service

uptake,

“Because husbands of such women don’t

allow their wives to attend sessions at home,”

(S0323)

Learned Helplessness. This theme was not

commonly reported, however, it gives

important information about barriers on an

interpersonal level. Lady health workers

suggested a lack of initiative and a sense of

learned helplessness in the community

members that hinders their ability to seek

mental health assistance,

“They are always hoping to extract money

from here and there. Never do they think of

earning money by labor. Always thinking of

getting it from an institution and then letting us

do the work.” (LHW 01)

Community level.

Social Stigma. Social stigma was a

common but less frequently reported factor as

a community level barrier to mental health

services. People seeking mental health

support were perceived differently by some

community members. It prevented them to

seek help initially,

“Baji at the initial stage they said to us that

we are not mental to attend these sessions”

(LHW 03)

Clients also shared that some community

members either consider it useless or make fun

of the mental health services,

“Each neighbor has its own way of thinking.

Some people are laughing at it and some

consider it right. And some are saying that if

they are asking from you then they are making

a joke out of it.” (P13)

Poverty. A hindrance pointed out by lady

health workers and clients was poverty. The

clients seemed to have an expectation of

material support with counseling to overcome

their financial challenges. This poverty seems

to be one hindrance for them in seeking

support.

“Yes their lives did change for the better

but there was one problem that even we

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couldn’t consult and that was poverty they

always used to tell us that we are only anxious

due to poverty”. (LHW 06)

They shared how they feel helpless due to

poverty and lack of basic resources,

“I have tension for my children and home.

My father is disabled and I am nervous about

his treatment as well. I am equally tense for my

daughters as well. Sometimes we have one

meal a day and worry for the next”.(P7)

Fear and apprehension about community

response. Another important but less

frequently reported barrier in the view of lady

health workers was their fear of how this

intervention is going to be received by the

community. The lady health workers were

apprehensive about people trusting them with

their mental health.

“Whether or not the villagers would listen to

us, will treat us well or not. Whether they will

say that why are we doing all this. We were

bothered by these things.”(LHW, 01)

Impact

Individual level.

The mental health intervention had a

positive impact on both clients and lady

health workers.

Improved sense of self-sufficiency.

Reportedly, after the mental health

intervention, clients were able to establish

lifestyles that are more self-sufficient and

contributed more effectively to household

expenses.

“She told us about methods of survival. She

told me that if I continue sewing my life can

turn the other way round. I can lead my life in

a better way. I get wages and from that I buy

flour and that is how we are surviving.”(P10)

Clients also reported that these sessions

helped them initiate small businesses that

further improved their financial situation,

“Yes lady health worker gave us a session

that we should start a little business so that our

kid’s expenses of pens and copies should be

met easily…[so] I started a shop using only 500

Rs, so that all the expenses of copies and pens

could be paid by the shop.” (P9)

Lady health workers also emphasized the

role of education in self-reliance because the

clients were able to utilize their time more

effectively and develop skills that can help

them achieve long term independence. One

LHW suggested that basic skills like

mathematics can help these women operate

their businesses effectively.

Additionally, due to the intervention lady

reported that they were able to provide

guidance about finance management,

mental health, domestic issues which further

impacted the clients’ ability to make better

decisions:

“One lady took a loan from the bank and

was worried about how she would return it so I

advised her that … it would be wise to buy a

goat. Client bought the goat and she (goat)

got pregnant. After the birth, the client sold

the goat and kept the offspring. She thanked

us a lot” (LHW 1)

Improved Knowledge about Mental Health.

Participants reported that initially there was a

lack of awareness about mental health and

this often led to confusion and fear about the

process. Lady health workers also

experienced this in the form of resistance

towards counseling sessions:

“In the beginning they were very scared.

The kind of questions they had in their minds

were “what is this, what is being explained,

what if we tell them about our secrets and

they share it with others”. (LHW 06)

However, once the sessions started and

were being delivered by the lady health

workers, there was a marked improvement in

the clients’ knowledge and acceptability of

mental health:

“At first, we didn't care much about it.

Later, they taught us about it (mental health)

and now we understand and are aware of its

importance.” (P4)

Lay health workers also reported an

improvement in their own knowledge and

perception about mental health and

counseling:

“First we had only heard about these things

but when we were in the training we learned a

lot about what mental health is. Problems can

happen, depression can happen. Tension and

depression is a part of every woman's life

therefore we do these (counseling) sessions.”

(LHW 06)

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Alleviation of Symptoms. The mental health

intervention aided in alleviating symptoms of

depression and anxiety through the

counseling sessions. Clients reported that by

discussing their grievances with the lady

health workers, their stress levels reduced and

they were able to maintain a healthier

lifestyle,

“It (counseling) helped us in life. Especially

with mental health. We have started helping

ourselves and we do not get depressed very

often.” (P3)

Moreover, the lady health workers

themselves reported that they observed a

marked reduction in the clients’ stress levels

due to the mental health intervention:

“..When at first I used to visit them I didn’t

see any kind of happiness on their faces and

they were not sharing their problems and

worries... But now as I meet with them, they

talk about their problems, I feel from their eyes

that they are now relaxed from every worry.”

(LHW 09)

Lady health workers also observed an

improvement in the clients’ physical health

due to the mental health sessions:

“Due to depression, anxiety they suffered

from low blood pressure.. but now everything's

fixed, they say. Earlier their faces or bodies

used to be weak ,but after consultation

they're taking care of themselves and are now

in much better health.” (LHW 06)

Improved Work Satisfaction. Lady health

workers reported that their work satisfaction

improved due to the mental health

intervention:

“We felt good that because of us someone

else's life was better and with it our lives have

improved as well. We are doing much by

going out, for others and for ourselves. We

liked that I am capable enough to be a Marvi

worker and a counselor. So, it has benefited us

a lot.” (LHW-05)

In addition to work satisfaction, being a

part of the mental health intervention

improved the lady health workers sense of self

because they started receiving the

community’s respect and gratitude.

Monetary Benefit. The intervention became

a source of extra income for the lady health

workers and opened new avenues of earning

livelihood.

Interpersonal level.

Family-esque relationship with lady health

workers due to mental health sessions. The

mental health sessions according to clients

have played a great part in forming family-like

relationships with lady health workers.

“We just followed her, whatever she said.

Yes they've guided us a lot. We are very

thankful and pray for them. since they have

started working here for our betterment. We

praise them a lot.” (P2)

Similar responses were found in LHW

interviews,

“Now our relationship with our client is

getting better. Previously the woman who

used to only talk about contraception now

shares her life with us and with that we also get

happy that there is a connection of trust

building”. (LHW 06)

Improved response of clients towards FP

due to mental health. Lady health workers

found the impact of mental health

intervention on improvement in clients’

attitudes regarding family planning as well,

“First, we used to go to them at least ten

times a day but now they themselves come to

us along with their other family members as

well.” (LHW 09)

Suggestions.

Further Community-Based Program. Lady

health workers and clients considered mental

health integration to be helpful and wanted

this program to go further. They wanted it to

be community-based rather than in the

hospital due to accessibility and permission

issues.

“There must be continuous sessions on

health and education as they give us

knowledge.” (P5 )

“Yes ma'am this was a good thing,

because the main problem was money

because these women whatever happens

wouldn't spend money and go to hospitals. “

(LHW-05)

Monetary Support. Both lady health workers

and clients pointed out the impoverished

state of being in the community. They

expected and suggested monetary support

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along with counselling to overcome this

challenge,

“Sister, we don't have a water tap. We

don't have a school for a year, where our

children can study. They're roaming freely and

we don't have any religious academy. We

lack roads, we're sick here. Recently, rain

poured and our roads deteriorated…..After

that, you should help us tackle poverty.” (P2)

Lady health workers also mentioned the

expectation of the community for monetary

support that also prevented them from

seeking mental health support as their basic

needs were not met,

“We were visiting them for

consultation…after the consultation, their

husband would ask them about what they

were asked and how they responded and if

they are going to help us with our poverty / will

they give us anything”. (LHW, 06)

Discussion

Exploring the perceptions of service users

and service providers helped us understand

the feasibility and impact of introducing a

mental health intervention in a community-

based family planning program. The

dissemination of the mental health

intervention through lady health workers was

well-received amongst the community. It

reduced the amount of effort required to build

trust and a working relationship between a

health worker and client. One of the major

reasons for this seems to be the positive

impact in the women’s’ lives and their families.

Improvement in their physical and mental

health along with better solutions for their

financial issues were found to have been

motivating for them to continue the

intervention. In addition to that, the lady

health workers were readily available and

went an extra mile to be helpful. It was further

supported by the communal support for the

mental health integration, which shows that

within a collectivist culture, community

support is integral for mental health

interventions with individuals. Community

based services are often successful because

of these existing networks of support that offer

an environment of trust for the clients (Ali et al.,

2018). This relationship of trust is specifically

important for women because they are often

restricted by male family members from

seeking help from external resources or male

health workers. Furthermore, spreading

awareness about mental health through lady

health workers was also easier because the

community already considered them a source

of knowledge regarding sensitive matters such

as family planning. Therefore, integrating

mental health information into this program

increased the acceptability of mental health.

The most significant barriers came out to be

on an interpersonal level where most women

had difficulty seeking permission to attain

mental health intervention. Gender inequality

is found to be related to increased mental

health burden for women. It comes from a

financial distress and low education levels

(Collier et al, 2020). When someone’s basic

survival needs are unmet, all the other needs

become secondary. Poverty made it difficult

for women to prioritize their mental health

needs that led to a difficulty for some women

to avail the intervention. The women who

received this intervention also suggested that

this intervention will be more helpful if coupled

with financial incentives to alleviate financial

distress. Thus, a psychosocial intervention

seems to be an answer for an impoverished

community

The mental health intervention helped the

clients to be more self-sufficient, and

improved their sense of self. This improvement

contributed to greater initiatives to improve

their finances and increase their family

income. This signifies the impact of mental

health intervention on a larger scale and helps

reduce the major stressor of poverty in the first

place. This can be beneficial while introducing

a psychosocial support model whereby these

women can be further empowered through

financial interventions that can help them

create sources of income to support

themselves and their families.

The intervention was also helpful in

increasing the mental health knowledge of

women who received the intervention and

the lady health workers as well. This improved

awareness and seems to have a positive

impact on attitudes towards mental health.

The most reported improvement was seen in

the symptoms of psychological and physical

symptoms of mental health problems that the

clients experienced. The symptom reduction

has been found as a result of community

mental health intervention in previous studies

as well (Anne et al., 2012).

The mental health integration not only

benefited the clients but also had a positive

impact on lady health workers work

satisfaction. Previous studies also point

towards improved sense of efficacy in

healthcare providers with mental health

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training to be better able to provide help to

people with mental health problems (Jenkins,

2010). They felt more connected with their

work and felt a sense of satisfaction in it by

helping others. This also had a positive impact

on their relationship with clients who started

seeing them as family members and were

more inclined towards mental health

interventions.

Another interesting finding was a

perceived improvement in attitude related to

family planning and better uptake. Poor

mental health was associated with low

contraceptive and family planning measures

uptake (Catalao, 2020). This reflects how an

improvement in mental health can have a

positive impact on contraceptive outcomes

as well and further studies can be conducted

to investigate the impact of mental health on

family planning uptake in lower middle-

income communities.

To improve the feasibility and

implementation of mental health intervention,

suggestions were provided by the clients and

lady health workers. Finances and mental

health are closely interrelated. Studies have

found that people in debt and financial

difficulties have more mental health problems

and poorer recovery. Financial difficulties and

a lack of basic resources seem to have

contributed to the mental health problems of

the community under study immensely. The

clients and lady health workers suggested

some monetary or basic resource assistance

along with mental health intervention for

better outcomes. This is expected to result in

better mental health outcomes. Moreover,

the intervention was provided on a

home/community-based level and was found

effective due to accessibility and ease. Thus,

continuation of service on the community

level rather than in hospital settings was

recommended by both lady health workers

and clients. This mode of delivery is reliable

and sustainable in other studies as well.

Integration of mental health in family

planning is supported by multiple factors

including the ease of access and

communication with the health workers, trust

and being a community service. The need of

upskilling health workers being the frontline

psychosocial support provider has been

identified by the World Health Organization to

bridge the need and resource gap. However,

the current curriculum of lady health workers is

missing the mental health curriculum. A

commentary on Pakistani context also

suggests upskilling lady health workers and

bridge the existing mental health gap

(Rabbani, 2023).

Limitations of the Study

A key limitation of the study was that

husbands of LHWs and clients were not

interviewed. In the cultural context of

Pakistan, decision-making power for women

often lies with the husband. So, in the future

studies it is pivotal to understand their

perception of mental health services to ensure

more effective integration.

Conclusions

This pioneering study marks a significant

advancement in Pakistan's public health

research, offering a first-of-its-kind integration

of mental health services into an established

family planning initiative using a co-produced,

community-centred approach. The

transformative and sustainable impact

observed reaffirms the pivotal role of co-

production in ensuring the efficacy and

relevancy of health service delivery,

particularly in resource-constrained settings

(Bovaird & Loeffler, 2012; Osborne et al., 2016).

Such a collaborative method, as our study

underscores, can bridge persistent treatment

gaps, offering a template for diverse health

conditions beyond just mental health.

A salient finding of our research is the

accentuated comfort and acceptability of

community-based sessions over traditional

clinical environments. These community

sessions provided an ambiance of trust and

relatability, fostering improved mental health

outcomes and catalysing enhanced service

uptake (Ali et al., 2018). The community’s

implicit trust in the lady health workers, already

recognized as repositories of knowledge on

sensitive matters, facilitated seamless

integration and acceptance of mental health

education.

Furthermore, our program ignited a wave

of empowerment among women,

emblematic of the transformative potential of

community-focused interventions. Women,

traditionally bound by societal constraints,

found an avenue to candidly discuss their

challenges, take charge of their mental

health, and proactively forge sustainable

solutions to elevate their circumstances. This

empowerment extends beyond the individual,

as evidenced by the broader community

effects on family planning and the improved

attitudes towards it (Catalao, 2020).

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The inclusion of financial support with

mental health services in the form of a

psychosocial intervention is an avenue

warranting future exploration, given the

profound linkage between financial distress

and mental well-being (Collier et al, 2020).

Encouragingly, the community-driven model,

underscored by our findings, showcases the

potential of delivering vital services at the

doorstep, furthering the goals of accessibility

and effectiveness.

The World Health Organization’s emphasis

on upskilling frontline health workers finds

validation in our study’s results. The glaring

omission of a mental health curriculum in

current training, as highlighted by Rabbani

(2023), underscores a crucial opportunity for

systemic enhancements.

Our study, while groundbreaking, does

come with its limitations, most notably the

absence of insights from male family

members, a critical stakeholder in the cultural

fabric of Pakistan's decision-making processes.

Yet, this very gap also provides direction for

subsequent research endeavors, emphasizing

the importance of holistic perspectives in

understanding health intervention impacts.

In conclusion, this research represents a

pivotal moment in public health initiatives

within Pakistan, elucidating the transformative

potential of co-produced, community-centric

health programs.

List of Abbreviations

Lady Health Workers- LHWs

Patient- P

Socioecological Model - SEM

Lowe Middle Income Countries -LMICs

Conflict of interest

The authors declare that they have no

conflicts of interest.

Acknowledgements

We are deeply grateful to all the study

participants who agreed to be a part of it and

made it happen.

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