A mosque courtyard after Friday prayers, the quiet interior of a church hall, an imambargah during a community gathering, a madrassa classroom, a busy clinic waiting area with patients still holding their token numbers… these are not the settings typically associated with a clinical trial.
But under the SPiRiT-D project, they became exactly that: the frontline of a mental health intervention, built person by person.
A research trial, built for the real world
SPiRiT-D is a hybrid type-II effectiveness-implementation trial, a research design that asks two questions at once: does this mental health intervention work clinically, and can it actually be delivered in the real world? Hybrid designs like this are increasingly favoured in global mental health research precisely because they shorten the long, often frustrating gap between “evidence” and “everyday practice” (Curran et al., 2012).
Implemented under the Centre for IMPACT in partnership with SINA Health, Education and Welfare Trust, the SPiRiT-D trial integrates mental health care for depression and anxiety directly into primary healthcare clinics serving underserved urban populations across Karachi. However, integrating a clinical intervention into a health system is only half the equation.
The other half, arguably the harder half, is getting people to walk through the door in the first place.
This is where community engagement comes in. Not as an add-on, not as a footnote to the “real” trial activities; but as a deliberate, structured implementation strategy, designed from the outset to increase the reach, acceptability, uptake, and long-term sustainability of mental health services implemented as part of the trial.
Borrowing trust instead of building it from scratch
In communities where mental health is rarely spoken about openly, you don’t win trust by giving a diagnosis. You win it by reaching out to where trust already exists.
This is where social capital theory became more than an academic framework, it became our field strategy. Rather than treating clinics as the only entry point, we deliberately engaged the relationships, networks, and respected figures that communities already lean on: imams at mosques, priests at churches, religious scholars at madrassas, and elders leading imambargahs and community gatherings.
These aren’t just alternative venues. They’re repositories of accumulated trust and social capital that took years, sometimes generations, to build. By working with faith leaders rather than around them, we weren’t asking communities to trust something new. We were asking trusted voices to open a door that was already familiar to them.
The reach by numbers
Across mosques, churches, imambargahs, madrassas, and open community spaces, the sessions added up to:
The sessions
Each session used narrative-based storytelling including real life stories that let people recognize their own experiences without ever being handed a diagnosis. Sessions ran as short talks, open discussions, and Q&A, conducted in Urdu or the locally spoken regional language including Balochi, Sindhi, Punjabi, and Pashto; using everyday, non-clinical language and culturally grounded examples standing in for medical terminology.
Just as important as what we said was how we said it: every session was entirely voluntary. No incentives, no obligations. People could engage, simply observe, or step away at any point because trust that’s coerced isn’t trust at all.
What changed?
The results were tangible, and they showed up in ways that mattered both for individuals and for the SPiRiT-D trial itself:
- Improved recognition of depression and anxiety symptoms among clinic attendees
- Increased openness to mental health screening as part of the routine care delivery
- Enhanced trust in SINA’s primary care services
- A strengthened link between community awareness and the trial’s enrolment pipeline
- Strong acceptability of a voluntary, culturally sensitive engagement format
- Direct support to trial recruitment, helping the study meet its target sample size
That last point matters more than it might first appear. Recruitment is often the quiet bottleneck of trials. For us, the community trust did not just improve wellbeing conversations; it moved the trial itself forward.
What approaches are key for the future?
- Fold awareness work into clinical delivery; not beside it, inside it.
- Go further into community and faith-based spaces that already hold trust.
- Treat religious and community leaders as partners in the trial, not hosts for a one-time visit.
- Build structured feedback loops, so we’re not just counting attendees, we are hearing them.
- Test repeat sessions over one-off visits, because trust is built in returns, not appearances.
None of this was without friction. Clinic sessions competed with limited time and patient loads. Community turnout varied by timing and location. Stigma does not dissolve in a single conversation, and language diversity across Karachi’s neighborhoods meant messaging had to be adapted, not just translated.
Measuring the longer-term impact of a single session remains an open challenge we are still working through.
Written by Kinza Zeeshan, Research Fellow/Trial coordinator-SPiRiT-D.
