Abstract
BACKGROUND: Majority evidence on task-sharing of psychological treatments for depression is focused on randomized controlled trials with project staff-delivered treatment. Ours is a scaling up of a brief evidence-based psychological treatment, Healthy Activity Program (HAP) by non-specialist providers (NSPs) -Accredited Social Health Activists (ASHAs) in rural India. Objectives included testing the acceptability, feasibility and effectiveness of ASHA-delivered HAP, and to examine implementation outcomes using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. METHODS: ASHA were recruited in three rural districts in Madhya Pradesh, India. During the study duration, 1001 ASHA completed training using the EMPOWER approach (digital curricula and supervision protocols); 458 ASHA went on to deliver the HAP to adults with depression screened opportunistically using the Patient Health Questionnaire-8 (PHQ-8). This paper describes the delivery of the HAP over a one-year period (24–07-2022 till 30–06-2023). The primary outcomes were treatment completion, patient and ASHA satisfaction, and change in depression symptom scores on treatment completion; whether treatment effects were sustained at long-term (i.e., 9 month) among a consecutively recruited follow-up sample (10% of the total participants (n = 246)); additionally, we applied the RE-AIM framework to analyse the implementation process and outcomes. RESULTS: 94.3%(1001/1061) of the non-specialist providers (NSPs) completed the full training. 12.1% of the patients (2208/18195) 2208 patients were screened positive for depression and all 100%(2208) agreed to receive the treatment. A total of 13,008 sessions were delivered with a 97.82%(2160/2208) completion rate. We found substantial reduction in depressive symptom severity from baseline to immediate post-treatment [Cohen’s d = 2.52; 95% CI: 2.44, 2.61], which was sustained at 9-month follow-up [Cohen’s d = .96, 95% CI: 0.81, 1.11]. Patients with severe symptoms tended to remain symptomatic and stayed in treatment longer. Both ASHA and patients reported high levels of satisfaction. Reach, adoption and implementation fidelity were high, as mapped through RE-AIM, which also revealed multilevel facilitators and barriers to scale-up. CONCLUSIONS: The scaling up of a brief evidence-based psychological treatment by existing frontline workers through digital platforms for training and supervision is associated with high levels of satisfaction, treatment completion and remission rates. The application of the RE-AIM helped in systematically documenting implementation learnings to inform future scale-up. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12875-025-02943-6.