Methods: A four-phase study process was paired with a counseling intervention and a training manual designed to train lay health workers. Pilot training of the intervention with three sessions with community health workers resulted in minor adjustments to the counseling evaluation method.
- M ATERNAL M ENTAL H EALTH IN LMIC S AND S OUTH A FRICA
- M ATERNAL M ENTAL H EALTH I NTERVENTIONS IN S OUTH A FRICA
- A IMS AND O BJECTIVES
- T HESIS O UTLINE
Yet there is a lack of evidence-based psychosocial interventions for maternal mental health in the LMICs (Baron et al., 2016), including in South Africa. A division of labor approach is considered an effective and appropriate method to address the scarcity of specialized mental health services in LMICs (Rahman et al., 2013).
- P ERINATAL C OMMON M ENTAL D ISORDERS (PCMD S ) AND A SSOCIATED C ONSEQUENCES
- R ISK F ACTORS OF PCMD S IN LMIC S
- I MPROVING A CCESS TO M ATERNAL M ENTAL H EALTH IN LMIC S
- M ATERNAL M ENTAL H EALTH I NTERVENTIONS IN LMIC S
- C ROSS -C ULTURAL A DAPTATION OF E VIDENCE -B ASED I NTERVENTIONS
- C ONCLUSION
Experiences of violence were consistently identified as a risk factor for resource-poor perinatal women (Brittain et al., 2016). This approach is considered common practice in LMICs with inadequate healthcare services (Lehmann et al., 2009).
- R ESEARCH Q UESTIONS
- S TUDY D ESIGN
- H EALTH S YSTEM S TRENGTHENING IN SUB -S AHARAN A FRICA (ASSET)
- S ETTING
- M ETHODOLOGY
- Phase one: Manual review
- Phase two: Interviews with health service providers and users
- Phase three: Stakeholder engagements
- Phase four: Pilot training
- E THICAL CONSIDERATIONS
- Ethical approval
- Informed consent
- Privacy
- Risks and benefits
- C ONCLUSION
Pregnant women were approached by a member of the ASSET team while waiting in line at the clinic and invited to participate in the study. The researcher and two other team members were involved in coding the transcripts.
- Introduction
- Findings
- Summary of Phase one
The method of delivering a session is also important, eg, a group intervention may be cost-effective (Araya et al., 2006; Siskind et al., 2008), while individual sessions promote confidentiality. These are also important considerations when working in low-resource communities where mental health is stigmatized (Patel et al., 2010). Principles of adult-based learning, which include experiential learning (Bryan et al., 2009), informed the task sharing training manuals.
Another therapeutic intervention designed to reduce substance use among low-resource communities in South Africa showed that a combined motivational interviewing and problem-solving approach was more effective than motivational interviewing alone (Sorsdahl et al. , 2015). In South Africa, Magidson et al., (2019) found an adapted version of BA suitable and acceptable to treat substance use among HIV patients in low-resource communities. In addition to theoretical approaches that informed treatment plans, psychoeducation, a process that provides information about a condition to improve knowledge and competence (Anderson et al., 1980; Sarkhel et al., 2020), was integrated into all interventions.
Spedding et al., (2015) argue for the importance of promoting basic counseling competencies of lay health professionals to improve overall interactions and promote therapeutic processes in task-sharing interventions for mental health (Spedding et al., 2015).
- Introduction
- Findings
- Thematic area 1: Understanding of depression and anxiety
- Thematic area 2: Causes of symptoms of depression and anxiety
- Thematic area 3: Coping mechanisms
- Thematic area 4: Perceived value of counselling support
- Summary of Phase two
Similar to these findings, pregnant women reported more behavioral symptoms of depression (28/37). However, some pregnant women used the word "stressed" interchangeably to describe both depression and anxiety (6/37). While some pregnant women were unsure of the difference between depression and anxiety, others struggled to identify how they felt or why they felt the way they did.
You want to sit alone in the corner and not see the rest of the world (Professional health HP01). The second thematic area reflected health service providers' and users' perceptions and experiences of the causes of depression and anxiety through the following three themes: social circumstances, unintended pregnancy as a stressor, and interpersonal conflict, domestic violence and abuse. While most of the pregnant women felt that they could rely on at least one family member.
Some of the ladies just don't talk about physical abuse or violence” (Professional health worker BL05).
P HASE T HREE : H EALTH S YSTEM S TAKEHOLDER E NGAGEMENTS
- Introduction
- Description of multiple stakeholder engagements
- Main outcomes of stakeholder engagement and health system needs
While interviews revealed that some of the pregnant women in this setting struggled to understand what they were experiencing, others reported feeling "different" but were unable to elaborate on the reason for their physical and emotional change. Having presented Phase Two in the sections above, outlining thematic areas and themes, and summarizing the key findings of the phase, the focus now shifts to Phase Three of the research, which is presented below. In the current study, multi-sector stakeholder meetings formed a critical part of intervention development.
This initiative involved the rollout of the first national health worker program called "department-based outreach teams". Engagements with community organizations and service delivery actors clarified the implementation details of the WBOTs and identified community-based. While recommendations from stakeholders at all three levels predicted the most suitable means of delivery and environment, the duration of the intervention design had to be negotiated and adapted to align with the needs of the health system.
This concludes the introduction and discussion of the first phase (Section 4.1), the second (Section 4.2) and the third (Section 4.3) and the related themes that emerged from the data analysis.
D EVELOPMENT OF A P ILOT C OUNSELLING I NTERVENTION AND T RAINING M ANUAL
- Introduction
- Features of the counselling intervention
- Intervention design and primary approaches
- Counselling session content
- Structure of a counselling session
- CHW counselling manual
Furthermore, the results from the manual review, together with the results from the interviews with the pregnant women and health professionals, contributed to the design of a specific counseling intervention to address the lived experiences and mood of perinatal women in resource-poor settings. The third session is a follow-up on the problem-solving steps to determine whether the perinatal mother was able to put the action steps into practice. The idea behind the five-step structure was to keep the delivery of each session consistent while achieving all the intended goals of the session and in turn used this format to train a non-specialist health worker to manage a counseling session from start to finish. the end in a professional and ethical manner.
The training manual was designed to facilitate the training of CHWs, to serve as a reference guide for ongoing counseling skill development, and to promote fidelity of the intervention (Balaji et al., 2012). The sections are structured in a sequence to facilitate knowledge and skill development of non-specialist health professionals prior to the introduction of the treatment-specific evidence-based counseling intervention and additional treatments. The content of each section of the manual has been developed based on adult-based training methodologies (focused on experiential learning), and consists of a combination of reflective exercises, case scenarios, group activities, discussion points, role plays, demonstrations and illustrations to highlight key concepts. and emphasize learning opportunities.
After the design of the intervention, the content of the consultations and the composition of the counseling manual, a pilot training had to be carried out in order to determine whether changes or adaptations were necessary.
P HASE FOUR : P ILOT T RAINING
- Introduction
- Description of pilot training findings
This section introduces the three-session counseling intervention and provides a detailed step-by-step guide that walks a counselor through the goals and objectives of each session in a structured manner. This section provides information and application of the four basic coping skills to help manage distress and improve the problem-solving process. Most participants related better to the concept of problem solving when using examples of personal experiences or practical problems in their lives, rather than unfamiliar scenarios.
A training technique that was found to be most effective for introducing coping skills during the training process involved a three-step process, namely: (1) Present the rationale, (2) trainer demonstration, and (3) role play and participant feedback. . Participants found the coping skills most helpful and could relate to the personal benefit of belly breathing, mindfulness and helpful thoughts. Morning debriefing sessions with participants showed that the introduction of coping skills increased their level of awareness and ways to cope with their distress.
Role play observations underscored the following two challenges: (1) CHWs consistently veered "off the rails" during the.
F INAL C OUNSELLING I NTERVENTION , T RAINING M ANUAL AND A SSOCIATED R ESOURCES
C ONCLUSION
D ISCUSSION AND S UMMARY OF F INDINGS
In line with several other maternal mental health studies in South Africa, this study identified social stressors as precipitators of perinatal depression and anxiety (Hartley et al., 2011; Nyatsanza et al., 2016; van Heyningen, 2017). An impairment in daily functioning and withdrawal can have a negative impact on infant care and development as well as mother-child bonding (Cooper et al., 2009). This closely matched a Khayelitsha task-sharing intervention study for perinatal depression that examined local explanations of depression (Davies et al., 2016).
In order to develop counseling content that builds on participants' existing worldviews and internal capacities (Summerfield et al., 2012), a metaphor of a “depression and anxiety pit” was used. This concept of additional treatment components and level of flexibility is similar to the Common Elements Treatment Approach (CETA) (Murray et al., 2014; Murray et al., 2018). In addition, this study suggests that a structured manual is imperative to ensure high quality, standardized training practice (Balaji et al., 2012; Dawson et al., 2015).
This is further substantiated by a systematic review of psychological treatments in LMICs by Singla et al., (2017), which identified five widely recognized and endorsed nonspecific guidance elements that are integrated into the task.
L IMITATIONS OF THE S TUDY
Furthermore, a review of South African task-shifting psychosocial interventions in the mental health field, Spedding et al., (2015), further emphasized that the quality of the counseling relationship transcends the therapeutic approach (Lundahl et al., 2013; Spedding et al., 2015). , 2015).
R ECOMMENDATIONS
While contextually relevant content is vital, the use of evidence-based psychological therapies should inform a counseling intervention framework, especially when considering a task-sharing approach. As part of this intervention, evidence-based components such as PST, BA and CBT (all previously evaluated in rigorous randomized controlled trials) provided an effective basis for tailoring and delivering the intervention. To address the large perinatal mental health treatment gap in low-resource settings, it is essential that effective interventions become more widely available.
On a broader scale, this includes processes such as training clinical and counseling psychologists in training and supervising non-specialist health providers and fulfilling a more public mental health role within the health care system. Routine supervision is essential to promote quality care, skill development and support of mental health facility and/or community workers. Therefore, mental health counseling training and routine supervision practices, as part of health system protocols, require further research to promote sustainability and scalability of mental health interventions.
C ONCLUSION
Do you need any assistance (for example I can refer you to a social worker or the police). Do you think that counseling can help you with your feelings of depression/anxiety or experiences of violence? Do you know who the Community Health Workers are in the area where you live.
What do you think about introducing routine screening for depression and anxiety at antenatal clinic visits. Do you think counseling can be helpful in treating women with symptoms of depression and/or anxiety? Do you think it is better to counsel women at the clinic or in their homes.
What do you think about using smartphones or tablets to monitor women for depression, anxiety and experiences of violence. Do you think a group chat to support women with depression or anxiety would work. Do you think it is better to counsel mothers at the clinic or at their homes.
