Transforming Access to Care for Serious Mental Disorders in Slums - The TRANSFORM-Bangladesh, funded by the NIHR UK.

The primary objective of the TRANSFORM project was to improve access to evidence-based care for serious mental disorders (SMDs) among slum communities in Bangladesh by strengthening the capacity of community-level informal providers through a co-designed, culturally appropriate training and referral model.

Specific objectives included:

- To engage the Korail slum community through sustained trust-building and participatory co-design processes to ensure community ownership of the intervention.
- To co-develop distinct, contextually appropriate training programs for two key informal provider groups: traditional and faith-based healers, and community health workers and medicine sellers.
- To train informal community providers to identify serious mental disorders and facilitate timely referrals to formal mental health services, particularly the National Institute of Mental Health (NIMH).
- To conduct structured supportive supervision to ensure quality and continuity of care following training.
- To measure the impact of the intervention on patient referral rates to biomedical mental health care.
- To produce research outputs — including journal publications, policy briefs, training manuals, and community resources — that can inform national and global mental health policy and practice.

The TRANSFORM project was implemented over four years using a community-participatory research design, with the Korail slum community in Dhaka as the primary study site. The methodology comprised four interconnected phases.

Phase 1: Community Engagement and Trust Building
From the outset, the research team embedded itself within the community — listening, learning, and building relationships rooted in mutual respect. Community engagement workshops were conducted to establish trust with residents, traditional healers, medicine sellers, community health workers, and other local stakeholders. Community engagement was not a one-time activity but remained central throughout the entire project lifecycle.

Phase 2: Co-Design and Co-Development of Training Materials
Training materials were co-developed through an iterative, community-centred process involving five co-design workshops and dedicated co-writing sessions. Community members, traditional healers, and informal providers actively shaped the content and delivery methods alongside researchers. Feedback from mental health professionals, policymakers, and community leaders was integrated through stakeholder and expert consultations. Materials were piloted and refined through community validation before implementation.

Phase 3: Community Provider Training
Two distinct three-day training programs (delivered one day per week) were developed for two provider groups:

- Traditional and Faith-Based Healers (TFH): 77 healers trained across four batches, with a gender distribution of 53 male and 24 female participants.
- Community Health Workers and Medicine Sellers (CHW/MS): 76 providers trained across four batches, with a gender distribution of 37 male and 39 female participants.

In total, 153 community providers were trained to identify serious mental disorders and refer patients to the National Institute of Mental Health (NIMH) for biomedical care.

Phase 4: Supportive Supervision
More than 50 supportive supervision visits were conducted by the TRANSFORM team across the study period to monitor implementation quality, address challenges, and ensure continuity of care.

The TRANSFORM project achieved significant outcomes across community engagement, workforce development, and care transformation.

Community Engagement
Sustained community engagement resulted in the establishment of trusted partnerships with traditional and faith-based healers, medicine sellers, community health workers, and community residents. Co-design and co-writing workshops produced contextually relevant, community-validated training materials that were accessible and appropriate for informal providers with varying levels of literacy.

Workforce Development
A total of 153 community providers were successfully trained across eight batches:
- 77 traditional and faith-based healers completed training across four batches.
- 76 community health workers and medicine sellers completed training across four batches.
Gender-balanced participation was achieved, with representation from both male and female providers across both training streams.

Care Transformation and Referral Impact
The most significant measurable outcome of the project was a fivefold increase in patients from the Korail slum community seeking biomedical care at NIMH following training. Prior to the intervention, 33 patients visited NIMH from the community. Following training, this figure rose to 157 patients — representing a dramatic improvement in referral rates and formal care-seeking behaviour.

More than 50 supportive supervision visits were completed, reinforcing implementation quality and supporting trained providers in sustaining their new competencies.

Research Outputs
The project produced a range of research and knowledge products including peer-reviewed journal publications, policy briefs, a training manual, an audiobook, and community leaflets — all available through the TRANSFORM platform.

The TRANSFORM Bangladesh project demonstrates that a community-participatory, co-designed training model can meaningfully transform access to mental health care in some of the most underserved urban settings in a low-income country context. By working with — rather than for — the community, the project built the trust and local ownership necessary for sustainable change.

The fivefold increase in patients seeking biomedical care at NIMH is a particularly compelling finding. It suggests that equipping informal providers — who already serve as the first point of contact for mental health concerns in slum communities — with basic skills for identifying serious mental disorders and facilitating referrals can produce substantial improvements in formal care-seeking, without requiring large-scale expansion of specialist infrastructure.

The co-design methodology adopted by TRANSFORM offers an important model for community-based mental health research in similar settings. Involving community members as active co-authors of the training content — rather than passive recipients — ensured cultural relevance, accessibility, and community trust in the materials and the broader initiative.

The sustained supportive supervision component was critical in bridging the gap between training and practice, reinforcing skills and maintaining the quality of referral pathways over time.

Limitations and future directions include the need to assess long-term sustainability of referral behaviours beyond the project period, the potential for scaling the model to other slum communities across Bangladesh, and the importance of continued advocacy for integrating community provider training into national mental heal