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Abstract This study uses a randomized controlled trial to study the take-up of mental health services in the context of a "sender" who has private information about an available mental health service, and a "recipient" who may be in need and with whom the sender may share the information. The study is conducted with a sample of Syrian refugees living in Jordan. In this setting there is a large mental health burden, with roughly 50% of the adult population having symptoms aligned with clinical depression (Stillman et al. 2022). Senders are invited to share with their friends mental health awareness information advertising a free counseling helpline. The sender's choice to share is observed by the researcher, as is the recipient's decision of whether to take-up the helpline. I consider first what constrains sharing of information, and second how message recipients are impacted, both in their probability of using the helpline as well as their perceptions about their own fit for the service relative to the reputational costs of using it. Amendment 8/22/23 This amendment adds a new, longer-term primary outcome (recipient's desire to be contacted directly by the helpline), and adds a new randomized intervention (when the recipient is directly contacted by the helpline). Citations Stillman, Sarah, Rozo, Sandra V, Tamim, Abdulrazzak, Palmer, I Bailey, Smith, Emma and Miguel, Edward, (2022), The Syrian refugee life study: first glance, Oxford Review of Economic Policy, 38, issue 3, p. 625-653. This study uses a randomized controlled trial to study the take-up of mental health services in the context of a "sender" who has private information about an available mental health service, and a "recipient" who may be in need and with whom the sender may share the information. The study is conducted with a sample of Syrian refugees living in Jordan. In this setting there is a large mental health burden, with roughly 50% of the adult population having symptoms aligned with clinical depression (Stillman et al. 2022). Senders are invited to share with their friends mental health awareness information advertising a free counseling helpline. The sender's choice to share is observed by the researcher, as is the recipient's decision of whether to take-up the helpline. I consider first what constrains sharing of information, and second how message recipients are impacted, both in their probability of using the helpline as well as their perceptions about their own fit for the service relative to the reputational costs of using it. Amendment 8/22/23 This amendment adds a longer-term primary outcome (recipient's desire to be contacted directly by the helpline), and adds a follow-on randomized intervention (when the recipient is directly contacted by the helpline). Citations Stillman, Sarah, Rozo, Sandra V, Tamim, Abdulrazzak, Palmer, I Bailey, Smith, Emma and Miguel, Edward, (2022), The Syrian refugee life study: first glance, Oxford Review of Economic Policy, 38, issue 3, p. 625-653.
Trial End Date November 30, 2023 May 31, 2024
Last Published August 22, 2023 10:32 AM August 22, 2023 11:03 AM
Intervention (Public) The intervention consists of a mental health awareness campaign, delivered over WhatsApp over the course of 8 days. The mental health awareness campaign includes information on identifying psychological distress, self-care tips, and information about a free helpline service. The campaign content was designed and piloted locally by the International Rescue Committee in Jordan. The intervention consists of a mental health awareness campaign, delivered over WhatsApp over the course of 8 days. The mental health awareness campaign includes information on identifying psychological distress, self-care tips, and information about a free helpline service. The campaign content was designed and piloted locally by the International Rescue Committee in Jordan. Amendment 8/22/23 Female recipients from this study and recipients in the separate study AEARCTR-0011928 are together randomized into the second intervention, which is direct contact from the phone counseling helpline. The new intervention consists of being contacted by the helpline directly, with the participant’s prior consent. Which participants are randomly sent first to the helpline to be contacted, and therefore begin receiving counseling services first, is randomized. Delaying some participants’ treatment is necessary due to helpline capacity constraints, providing the rationale for randomization. When first offered the possibility of the helpline call participants are never guaranteed the helpline call, and are informed that even if they do receive the helpline call that, due to capacity constraints, is could be multiple months before they are contacted.
Intervention End Date February 17, 2023 January 31, 2024
Primary Outcomes (End Points) Sender follow-through Take-up of helpline Recipient's perceived mental health benefit relative to reputational cost Recipient’s mental health stigma Sender follow-through Take-up of helpline Recipient's perceived mental health benefit relative to reputational cost Recipient’s mental health stigma Amendement 8/22/23: Interest in helpline direct call PHQ-9 score Deperssion GAD-2 score Anxiety
Primary Outcomes (Explanation) Sender follow-through is defined two ways: - A sender-level binary variable indicating whether the sender shared the content with at least 1 recipient. - A recipient-level binary variable indicating if the sender sent at least 1 message to the recipient. Take-up of helpline: Constructed two ways. First as the number of helpline caller phone numbers that match the recipient phone numbers in each arm, collected via the sender survey and recipient surveys. Mental health benefit relative to reputational cost: The respondent's predicted benefit to self of using mental health services, minus the respondent's predicted reputational cost to self of using mental health services, with both component variables and the final variable normalized relative to the control group. Recipient’s mental health stigma : Recipient’s willingness to share her experience publicly to be used for future IRC content. Normalized score of not willing at, willing when anonymous, to willingness when not anonymous. Sender follow-through is defined two ways: - A sender-level binary variable indicating whether the sender shared the content with at least 1 recipient. - A recipient-level binary variable indicating if the sender sent at least 1 message to the recipient. Take-up of helpline: Constructed two ways. First as the number of helpline caller phone numbers that match the recipient phone numbers in each arm, collected via the sender survey and recipient surveys. Mental health benefit relative to reputational cost: The respondent's predicted benefit to self of using mental health services, minus the respondent's predicted reputational cost to self of using mental health services, with both component variables and the final variable normalized relative to the control group. Recipient’s mental health stigma : Recipient’s willingness to share her experience publicly to be used for future IRC content. Normalized score of not willing at, willing when anonymous, to willingness when not anonymous. Amendment 8/22/23 Interest in helpline direct call: As a new longer-term recipient outcome to the initial intervention, female recipients are contacted by phone directly, roughly 6 months after treatment, and offered the possibility of having the helpline contact them personally, if they are found to be eligible for the helpline phone counseling service. The indicator variable of whether individuals accept that offer is a primary outcome. Treatment heterogeneity in whether the individual was depressed at baseline is of particular interest. Outcomes for the randomized direct helpline contact: PHQ-9 score: Constructed using the 9-item Patient Health Questionnaire. Depression: An indicator for whether the PHQ-9 score is 10 or larger, which follows the standard cutoff guidance for the PHQ-9. GAD-2: Constructed using the 2-item Generalized Anxiety Disorder questionnaire. Anxiety: An indicator for whether the GAD-2 score is 3 or larger, which follows the standard cutoff guidance.
Experimental Design (Public) “Senders” will be invited to share mental health awareness content with their friends. Conditional on stating their willingness to do this, the senders are randomized to either a control group, which receives no information until after the study, or a treatment group. The treatment group senders receive the intervention information (the mental health awareness campaign) over WhatsApp over the course of 8 days. Each time they are requested to share the information with their friends, who have been identified prior to the randomization. Each treatment sender will be randomized to one of three different message framings. The intended recipients of the messages form the recipient sample. They are surveyed 3 weeks after the intervention ends, and asked about mental health care-seeking and stigma attitudes. “Senders” will be invited to share mental health awareness content with their friends. Conditional on stating their willingness to do this, the senders are randomized to either a control group, which receives no information until after the study, or a treatment group. The treatment group senders receive the intervention information (the mental health awareness campaign) over WhatsApp over the course of 8 days. Each time they are requested to share the information with their friends, who have been identified prior to the randomization. Each treatment sender will be randomized to one of three different message framings. The intended recipients of the messages form the recipient sample. They are surveyed 3 weeks after the intervention ends, and asked about mental health care-seeking and stigma attitudes. Amendment 8/22/23 Participants that agree to be contacted by the helpline and are found eligible in a short screening consisting of the PHQ-9 and GAD-2 are then randomized on a roughly weekly basis to “Treatment Now” or “Treatment Later 1” or “Treatment Later 2”.
Randomization Unit Senders Senders Amendment 8/22/23: For the direct helpline intervention randomization is at the individual participant level.
Planned Number of Clusters 900 senders 900 senders Amendment 8/22/23: 600 participants in the direct helpline contact experiment
Planned Number of Observations 3600 recipients and 900 senders 3600 recipients and 900 senders Amendment 8/22/23: 600 participants in the direct helpline contact experiment
Sample size (or number of clusters) by treatment arms 225 senders control, 675 senders treatment. 225 senders per message framing in the treatment group. 225 senders control, 675 senders treatment. 225 senders per message framing in the treatment group. Amendment 8/22/23: Direct helpline contact experiment: 180 in Treatment Now; 180 in Treatment Later 1; 240 in Treatment Later 2.
Power calculation: Minimum Detectable Effect Size for Main Outcomes Sender follow-through (binary variable): 10.4 percentage point difference in follow-through assuming 50% follow-through in the benchmark framing (standard deviation .5). Follow-through measured at the recipient and sender levels. Take-up of helpline (binary variable): 5.0 percentage point difference in follow-through. Baseline mental health care-seeking in this population is 7% with a standard deviation of 25 percentage points. Measured at the recipient level. Sender follow-through (binary variable): 10.4 percentage point difference in follow-through assuming 50% follow-through in the benchmark framing (standard deviation .5). Follow-through measured at the recipient and sender levels. Take-up of helpline (binary variable): 5.0 percentage point difference in follow-through. Baseline mental health care-seeking in this population is 7% with a standard deviation of 25 percentage points. Measured at the recipient level. Amendment 8/22/23 Based on baseline levels of depression and anxiety in the eligible population the MDEs on the primary outcomes comparing Treatment Now to the pooled Treatment Later groups are: PHQ-9 score: 1 point change in the score. Depression: 6.8 percentage point change in rate of depression. GAD-2 score: 0.4 point change in the score. Anxiety: 10.6 percentage point change in rate of anxiety.
Intervention (Hidden) Amendment 8/22/23 Approximately 600 total participants are expected in the experiment with roughly 100 new participants identified weekly, though this will depend on both participants’ interest in the helpline and the survey rate of the enumerators. The helpline has capacity constraints that prevent it from admitting more than approximately 30 new beneficiaries per week. (This number is subject to change as the helpline learns through experience.)
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