Chapter 8: Discussion, recommendations, and conclusion
8.7 Limitations and strengths
169 In conclusion, the AFFIRM-SA RCT has shown that task-shared interventions for mental health in LMICs need to be more responsive to the contextual drivers of depression. They should include a limited number of therapeutic elements or mechanisms of change that are locally feasible and acceptable. Adequate training and supervision are essential for success. Once these interventions are tested in pilot studies, they may be evaluated in fully powered RCTs.
170 the loss of some non-verbal nuances that occurred in the sessions, as well as there being potential mis- translations of particular words into English.
Fifth, due to the nature of grounded theory, the data were rated and analysed only by one rater. Thus inter- rater reliability of the identified codes and themes could not be assessed. This limitation was compensated for by conducting a workshop with an expert panel that was consulted on the reliability and acceptability of the codes themselves, as well as the acceptability of the data that had been categorised into the codes. The panel endorsed the acceptability and trustworthiness of the coding and of the distinctions between codes, as well as the rationale for coding the data the way it had been done.
Sixth, an analysis of counselling transcripts from participants who did not complete all six sessions may have contributed to further data on ‘deviations’ from the counselling protocol. The data might have identified possible reasons for participants not completing sessions that related to counselling style and participant response. In addition, those who received fewer than six sessions may have reported fewer benefits or positive outcomes from the sessions This could have been a reason for non-completion. An analysis of counselling session transcripts of participants who did not complete all sessions was beyond the scope of the current thesis.
Relatedly, the 39 participants in this study may have completed all six counselling sessions because they were
‘getting’ something out of them, leading to inflated responses of the positive outcomes of the sessions.
Nevertheless, these responses were still helpful to retrieve effective therapeutic elements and did not hinder the availability of data demonstrating deviations from protocol.
An in-depth analysis of the styles particular to each counsellor was not conducted as it would have required a more specific focus on each counsellor and would have diverted attention from the more generalised research questions about the intervention. Counsellor change over time was also not analysed as this was not within the scope of the thesis.
There are also limitations that relate to the sole use of qualitative methods in this thesis. This study design did not allow for an analysis of causal relationships between therapeutic elements and treatment outcome, nor could it conduct an analysis of potential mediating and moderating variables such as food insecurity, economic status, and time taken to complete sessions, on treatment outcome. These would make for valuable contributions for mental health interventions in the future.
171 Last, the common therapeutic elements that were identified through the grounded theory are correlational reports applicable only to this study. However, the identified elements do add to the growing body of evidence of component studies contributing evidence that appears to be corroborating across interventions and different therapeutic modalities.
8.7.2 Strengths
The thesis also has many strengths. The use of qualitative analysis afforded an in-depth examination of data that accessed a deep and contextual view of the realities of the implementation of the trial. A grounded theory methodology allowed coding and categories to emerge from the data itself rather than being imposed on it. In opposition to the concern of possible desirability bias, this provided more of an ‘unmediated’ perspective, in which participants were not ‘observed’ or questioned by a researcher. This uncovered elements from the RCT that researchers had not been aware of at any stage in the trial.
The analysis of counselling sessions themselves provided insight into strategies that counsellors employed in sessions that cannot easily be assessed through retrospective feedback from counsellors themselves. It also accessed reflections from participants in the immediacy of the therapeutic moment. Interviews conducted after completion of the intervention deliver different data than that collected during sessions, as responses from participants can be mediated through time, reflection, and potential desirability bias. This contributes a different form of data than that retrieved from the standardised instruments for the outcome assessments conducted by the fieldworkers.
To my knowledge, this thesis is the first large-scale study of processes and mechanisms occurring within actual counselling sessions, across a number of counsellors and participants, in a task-shared intervention for perinatal depression, or even for CMDs, in an LMIC. This approach has traditionally only been conducted in Western contexts within therapeutic interactions between one client and one therapist, largely to examine the nature of the therapeutic relationship between the two (Norcross and Lambert, 2018). This process highlighted many contextual and therapeutic challenges that are faced in task-shared psychosocial interventions. It also provided a unique perspective on the therapeutic elements that participants themselves found valuable, and adds to the relatively small database of common elements appropriate for task-sharing.
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