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Using technology to scale-up training and supervision of community health workers in the psychosocial management of perinatal depression: a non-inferiority, randomized controlled trial

  • Atif Rahman (a1), Parveen Akhtar (a2), Syed Usman Hamdani (a2), Najia Atif (a2), Huma Nazir (a2), Iftikhar Uddin (a3), Anum Nisar (a2), Zille Huma (a2), Joanna Maselko (a2) (a4), Siham Sikander (a2) (a5) and Shamsa Zafar (a2) (a6)...



The Thinking Healthy Programme (THP) is an evidence-based psychological intervention endorsed by the World Health Organization, tailored for non-specialist health workers in low- and middle-income countries. However, training and supervision of large numbers of health workers is a major challenge for the scale-up of THP. We developed a ‘Technology-Assisted Cascaded Training and Supervision system’ (TACTS) for THP consisting of a training application and cascaded supervision delivered from a distance.


A single-blind, non-inferiority, randomized controlled trial was conducted in District Swat, a post-conflict area of North Pakistan. Eighty community health workers (called Lady Health Workers or LHWs) were randomly assigned to either TACTS or conventional face-to-face training and supervision by a specialist. Competence of LHWs in delivering THP post-training was assessed by independent observers rating a therapeutic session using a standardized measure, the ‘Enhancing Assessment of Common Therapeutic factors’ (ENACT), immediately post-training and after 3 months. ENACT uses a Likert scale to score an observed interaction on 18 dimensions, with a total score of 54, and a higher score indicating greater competence.


Results indicated no significant differences between health workers trained using TACTS and supervised from distance v. those trained and supervised by a specialist face-to-face (mean ENACT score M  =  24.97, s.d.  =  5.95 v. M =  27.27, s.d.  =  5.60, p  =  0.079, 95% CI 4.87–0.27) and at 3 months follow-up assessment (M  =  44.48, s.d.  =  3.97 v. M =  43.63, s.d.  =  6.34, p  =  0.53, CI −1.88 to 3.59).


TACTS can provide a promising tool for training and supervision of front-line workers in areas where there is a shortage of specialist trainers and supervisors.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited

Corresponding author

*Address for correspondence: Atif Rahman, Professor of Psychiatry, Department of Psychological Sciences, University of Liverpool, Block B, Waterhouse Building, 1–5 Dover Street, Liverpool L69 3BX, UK. (Email:


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Siham Sikander and Shamsa Zafar are joint last authors.



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Using technology to scale-up training and supervision of community health workers in the psychosocial management of perinatal depression: a non-inferiority, randomized controlled trial

  • Atif Rahman (a1), Parveen Akhtar (a2), Syed Usman Hamdani (a2), Najia Atif (a2), Huma Nazir (a2), Iftikhar Uddin (a3), Anum Nisar (a2), Zille Huma (a2), Joanna Maselko (a2) (a4), Siham Sikander (a2) (a5) and Shamsa Zafar (a2) (a6)...


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