This also explained possible reasons for the non-significant effects of the intervention on the HDRS. This was consistent with significant intervention effects on EPDS scores.
Background, aims and objectives
- Introduction
- The AFFIRM-SA Randomised Controlled Trial
- Aims and objectives
- Thesis outline
First, it reports on an element of AFFIRM-SA's formative research that examined localized ways of describing perinatal depression – idioms of distress – and the experiences and attributed aetiology of perinatal depression in the Khayelitsha context. After conducting the AFFIRM-SA RCT, the following chapters unpack the mechanisms underlying the implementation of the RCT.
Review of literature
Depression in LMICs
A systematic mapping of the evidence by Coast et al. 2012) found that lower levels of education were associated with a higher risk of postpartum depression. Food insecurity has been found to be strongly associated with chronic disorders in LMICs (Lund, Kleintjes et al., 2010).
Treatments for mental disorders through task sharing
The most commonly used treatment for adult depression in LMICs is CBT (Cuijpers, Karyotaki et al., 2018). Recently, Singla et al. 2017) found moderate to strong evidence for task sharing in reducing the burden of common mental disorders.
Requirements for implementing task sharing
These assessments should involve basic counseling skills as well as treatment-specific factors (Pedersen, Lakshmin et al., 2020). They recommend that a training apprenticeship for continuous services (beyond RCTs) can last up to one year (Murray et al., 2011).
Mechanisms of change in task-shared interventions
These endorse those found by Singla et al. 2017), even though they did not come from task-shared situations. Many authors further confirm that the therapeutic alliance contributes to treatment outcome regardless of the type or modality of therapy (Barth, Lee et al., 2012; Norcross and Lambert, 2018;.
Research in task sharing
This depth of feasibility assessment may have contributed to the success of the subsequent intervention (Rahman et al., 2008). Munodawafa (2018) conducted an evaluation of barriers and facilitators to the implementation of the AFFIRM-SA intervention.
Looking ahead for task-shared interventions
Second, tiered care is another element that can be deployed in resource-poor settings (Hanlon, Fekadu et al., 2014). This mode can improve the efficiency and ability to treat more people in the LMICs (Hanlon et al., 2014).
Conclusion
It is clear that there are increasing opportunities for creating task-shared interventions that are more responsive and better suited to contextual needs and local capacities. Elements such as addressing social determinants, eliciting community involvement in treatment, using a tiered or shared model of care, and using mobile and internet-based forms of therapy are suggested as methods to scale the service and improve responsiveness and suitability. and effectiveness of task-shared mental health interventions in LMICs.
Rationale for the thesis
Second, research on shared task interventions for mental illness has grown significantly in the past decade and there is growing evidence of their effectiveness. Fourth, there are still very few process evaluations of joint interventions for perinatal depression.
Thesis methods
Methods: Objective One
Methods: Objective Two
48 Second, the manual, in combination with the grounded theoretical analysis (described below), was read from the point of view of discovering elements that may have influenced the practitioners' ability to use and implement the manual in a way which was easy and understandable for them.
Methods: Objective Three
First, open coding involves the initial reading of the data and the identification of codes and categories that emerge from this process. These were: deviations from the intended counseling protocol, and descriptions by participants of the effectiveness of the counseling sessions. Under the concept of 'effectiveness of the counseling sessions', the two main themes were 'reported positive outcomes' and 'attributions for outcomes of change'.
Formative research for the counselling intervention
- Background and Rationale
- Methods
- Results and Discussion
- Limitations of the study
- Conclusion
Other less frequently mentioned idioms included 'brain crush', 'brain is tired', 'heart palpitations', 'mental troubles' 'being in pain' and 'you're like the weather'. Thus, "stress" is a symptom of depression, but at the same time a reflection of difficulties and misfortunes in women's lives. Of the 14 symptoms identified by the participants, four were not listed as major identifying criteria in the DSM-5 or ICD-10 scales.
Review of the AFFIRM-SA counselling manual
Manual structure and topics
Psychoeducation Provide information about symptoms and causes of depression specific to the local context; delivery of a relaxation CD. The three capacities mentioned above (following the manual, using the therapeutic topics and establishing a genuine therapeutic relationship and basic counseling skills) were all taught to the CHWs in the initial five-day training course. Participants were supposed to practice the skills through homework activities and then provide feedback on the use of the skills in the subsequent session.
Manual critique
To begin with, all sessions had a description of the purpose of the session for the counselor. Purpose of the session: To help the mother use the steps of problem-solving skills in her daily life.” Second, after describing the topics, all sessions began with an abstract instruction to the counselor that said: “Follow up on last week's issues from the session; take into account any issues the mother wants to discuss and address them.
When things fall apart: deviations from intended counselling protocol
Therapeutic breakdowns in the counselling sessions
This may well have been due to the design of the manual itself, and not necessarily the fault of the advisers. This suggests a lack of confidence in the content of the manual and understanding of the concepts; while showing the intention to 'follow' the manual as they have been instructed. It is not the end of life when you are pregnant and you have to be strong for your children.
Influence of socio-economic context on therapeutic effectiveness
104 AC revealed that she had taken her boyfriend to court because “he wanted to sleep with me without my permission and he beat me” (AC, S2) and BD said that “The father of my baby cheats and beats me a lot and he uses the stones to hit me" (BD S4). Closely related to intimate partner violence were more reports of alcohol abuse by women's partners. He still drinks and I need support for the child... He takes money home, but he drinks it, and now we don't even have money to pay the rent.
Summary
Participating in counseling sessions and listening to recorded sessions at the beginning of the trial. Counselors did not appear to have ownership of the counseling intervention. The above categories can be used to understand the data and results found in the counseling sessions of the participants in this study.
When things come together: reported outcomes and attributions of change
Reported positive outcomes
In the second session, Csr D asked DB, “is there any change for the better in your life since meeting me and having these sessions. In the third session, she answered the question by saying: "I am able to do the work that I was not doing. Likewise, healthy thinking was used interchangeably with examples of behavioral activation to describe the changes participants were making or undergoing.
Attributions for outcomes of change
NG said: “The problem is that people who surround us now can laugh at your problem, so it was difficult for me to talk about all my problems with people before. FC said of her first session: “The session was helpful to me because there was no one I could talk to to get help on that sort of thing. CD said what she liked most about the sessions: “The care; because I would be sad and you would always ask, 'What made you sad these past two weeks?' You help me feel comfortable sharing my pain” (Csr C, CD, S6).
Summary
Discussion, recommendations, and conclusion
Local descriptions of depression
In their qualitative review of explanatory models of distress, Mayston et al. 2020) found that expressions of depression in LMICs were often attributed to economic stress and social adversity, along with relationship problems and HIV-related issues. The most common stressors were interpersonal conflict, family violence and poverty (Kermode, Herrman et al., 2007). In addition, the findings of Chapter Four support previous research that women need specific support and counseling during pregnancy and for a period after birth (Rahman et al., 2008).
Disruptions affecting intervention delivery
The ENACT rating scale for counselors (Kohrt et al., 2015) had only been developed at the time of the AFFIRM-SA trial. This connects with the recommendation above that the demonstration of competence ('shows') is an essential one in training (Kohrt et al., 2015). This was also confirmed in a previous study using AFFIRM-SA trial quantitative data (Schneider, Baron et al., 2018).
Therapeutically effective elements
These may include factors such as the therapist's personal characteristics, the therapeutic alliance, and the client's hopes and expectations (Barth et al., 2012). The precise nature of the therapeutic alliance in this study may be somewhat different from that reported in the literature. Along with the review by Single et al. (2017) contextual model created by Wampold (2015) provides a useful way of organizing and making sense of participants' outcomes and attributions in relation to their context.
Models of implementation processes and outcomes
Another way to look at the data, guided by session outcome reports, is through the lens of connectivity and resilience. This sense of connectedness could help alleviate immediate symptoms of distress, stress, and trauma, create a sense of hope that problems can be resolved, build some form of psychological resilience, improve communication skills, and increase feelings of support. Unfortunately, this sense of connection and support was short-lived and therefore unable to reduce clinical symptoms of depression or provide long-term resilience against the context of extreme poverty.
Discussion summary
Build ownership of the intervention so that CHWs feel they can be flexible when responding to individual needs. Ensure CHWs develop basic psychological skills and competencies, with a thorough understanding of the psychological concepts used. Pilot the intervention with CHWs and participants and then get feedback from both parties on the structure and content of the manual and intervention, using an iterative research design.
Recommendations
Therefore, 165 of the structural systems in which women are located must be developed (Burgess et al., 2020). Supervision should ensure that CHWs can apply the psychological concepts they are using consistently across different participants (Barnett et al., 2018). Similarly, the clinical supervisor should be provided with training in supervisory skills and receive regular supervision and support (Barnett et al., 2018).
Limitations and strengths
The panel approved the acceptability and credibility of the coding and of the distinction between codes, as well as the rationale for coding the data as it had been done. An analysis of counseling session transcripts of participants who did not complete all sessions was beyond the scope of the current dissertation. Change of advisor over time was also not analyzed, as this was not within the scope of the thesis.
Reflexivity
173 still acknowledging that the development of theories and hypotheses based on the data is "co-constructed" by both the participants and the researcher (Mills et al., 2006). Thus, I recognize that the findings and discussion presented in this thesis will have a common thread of my own socio-cultural influences and background.
Conclusion
Psychosocial interventions for common perinatal mental disorders delivered by non-specialist mental health providers in low- and middle-income countries: a systematic review and meta-analysis. Barriers and facilitators of mental health programs in primary care in low- and middle-income countries. Family-based interventions for youth mental health delivered by non-specialist providers in low- and middle-income countries: a systematic review.
14-Item checklist
