Understanding Lay Counselor Perspectives on Mobile Phone Supervision in Kenya: A Mixed Method Human-Centered Design Study

Introduction: Mobile phones may present a low-tech opportunity to replace or decrease reliance on in-person supervision in task-shifting, but important technical and contextual limitations must be examined and considered. Guided by human-centered design methods, we aimed to understand how mobile phones are currently used when supervising lay counselors, determine the acceptability and feasibility of mobile phone supervision, and generate solutions to improve mobile phone supervision.Methods: Participants were recruited from a large hybrid effectiveness-implementation study in western Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy. Lay counselors (N=24) and supervisors (N=3) participated in semi-structured interviews in the language of the participants choosing (i.e., English or Kiswahili). The participants included high frequency, average frequency, and low frequency phone users in equal parts. Interviews were transcribed, translated when needed, and analyzed using thematic analysis. Themes were compared across frequency of phone use following a mixed methods data transformation and integration approach. Results: Uses included: clinical updates, scheduling and coordinating, and supporting research procedures. Participants liked how mobile phones decreased burden, facilitated access to clinical and personal support, and enabled greater independence of lay counselors. Participants disliked how mobile phones limited information transmission, limited relationship building between supervisors and lay counselors, and disrupted communication flows. Mobile phone supervision was facilitated by access to working smartphones, ease and convenience of mobile phone supervision, mobile phone literacy, and positive supervisor-counselor relationships. Limited resources, technical difficulties, communication challenges, and limitations on which activities can effectively be performed via mobile phones were barriers to mobile phone supervision. Lay counselors and supervisors generated 27 distinct solutions to increase the acceptability and feasibility of mobile phone supervision. Differences emerged in specific themes pertaining to acceptability and feasibility by frequency of use.Conclusion: While mobile phone supervision was acceptable to both lay counselors and supervisors, there were also distinct challenges with feasibility. Researchers considering how digital technology can be used to increase mental and digital health equity must consider limitations to implementing digital health tools and design solutions alongside end-users to increase acceptability and feasibility.

“We need our own clinics”: Adolescents’ living with HIV recommendations for a responsive health system

Adolescents living with HIV comprise a significant patient population in sub Saharan Africa but are poorly retained in care with consequent increased mortality and morbidity. We conducted in-depth interviews with 25 adolescents living with HIV engaged in care from five clinics in Johannesburg regarding their recommendations for the healthcare system. Findings included advocating for adolescent clinics, recognizing the importance of clinic-based support groups, valuing the influence lay counselors have in providing healthcare to adolescents, improving widespread education of vertical HIV transmission and meaningfully linking clinics to the community. Our study offers guidance to the differentiated care model recommended for adolescent treatment highlighting that a positive youth development approach and use of lay and peer counselors may act as cornerstones of this model. Serving the mental health needs of adolescents living with HIV in a responsive manner may strengthen their use of the system and elevate it to a source of resilience.

Perceptions, attitudes, and knowledge of teachers serving as mental health lay counselors in a low and middle income country: a mixed methods pragmatic pilot study

Background Low and middle-income countries (LMICs) lack trained child mental health professionals. While teachers’ child development experience potentially positions them to fill the gap as lay mental health counselors, they have rarely delivered indicated child mental health care in LMICs. As part of assessing the feasibility of teachers serving as lay counselors, we explored teachers’ perceptions of serving as lay counselors and their mental health attitudes and knowledge. Methods In 2018, with training and supervision, 19 primary school teachers from five rural, low cost private schools in Darjeeling, India, served as lay counselors in their classrooms. Using mixed methods, we examined teacher perceptions of serving as lay counselor and mental health attitudes and knowledge through a survey (n = 15), a summative assessment (n = 14), and semi-structured interviews (n = 17). For the survey and summative assessment, pre-training, post-training, and post-intervention mean scores were compared using paired t tests. Post-intervention interviews were coded for teachers’ perceptions of serving as lay counselor and mental health attitudes and knowledge. Results Qualitatively, teachers expressed being willing to serve as lay counselor, having more inclusive mental health attitudes, and retaining mental health knowledge as applicable to use during instructional time or incorporation into the knowledge transfer process, their primary duty. By contrast, quantitatively, teachers’ attitudes appeared to become more inclusive on the study-specific survey pre versus post-training, but reverted to pre-training levels post-intervention. Teachers’ mental health knowledge on the summative assessment did not change pre-training versus post-training versus post-intervention. Conclusions Training, supervision, and serving as lay counselors led to teachers’ willingness to serve as lay counselors. Teachers served as lay counselors by utilizing therapeutic techniques during class time and incorporating them into their typical instruction, not through delivering traditional office-like care. Teacher practices may be pointing to the potential emergence of an “education as mental health therapy” system of care. Their changes in attitudes and knowledge reflected their emerging practices. Quantitative measures of knowledge and attitude changes did not capture these nuanced changes. Trial Registration The parent feasibility trial was registered on January 01, 2018 with Clinical Trials Registry – India (CTRI), reg. no. CTRI/2018/01/011471, ref. no. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27..

Acceptability and feasibility of the CHARISMA counseling intervention to support women’s use of pre-exposure prophylaxis: results of a pilot study

Background Women may need or seek male partner approval to safely and consistently use oral antiretroviral pre-exposure prophylaxis (PrEP) or vaginal microbicides. We developed CHARISMA, a counseling intervention to support women’s relationships and their ability to consistently use HIV prevention products. Methods In a pilot study with 95 female participants in Johannesburg, South Africa, lay counselors implemented CHARISMA, assessing participants’ relationship(s) with their male partner(s) and barriers or facilitators to HIV prevention method use, and then providing tailored, interactive counseling. We conducted study participant surveys and clinic staff interviews to evaluate CHARISMA’s feasibility and acceptability. Results The CHARISMA pilot study indicates that a two-session relationship counseling intervention with 6-month follow-up to support women’s ability to safely and effectively use vaginal microbicides was generally acceptable and feasible. Most participants thought CHARISMA was relevant, helpful, and about the right length, and that it had a positive impact on their relationships with their partners and their product use. Staff estimated that the intervention took 1.5–2 h to implement at enrollment and 45 min to an hour for the month 1 visit. They thought that overall CHARISMA was generally feasible to implement. Conclusions Findings from this study suggest several lessons learned that may be relevant to others developing interventions supporting women’s use of oral PrEP or vaginal microbicides. The use of lay counselors instead of nurses to deliver counseling appeared to be successful, but the counselors experienced significant stress from hearing about participants’ traumatic experiences and required emotional support to avoid burnout. Although staff and participants felt that having multiple intervention sessions over time was valuable, a similar level of intensity may not be feasible in other settings. Further research is needed to determine an intervention delivery mode and follow-up period that optimally balances participant needs and clinic resources. Male engagement was a challenge, as it has been in previous studies of vaginal microbicides. Alternative strategies to reach men that do not require them to come to the clinic or rely on their female partners may be more effective.

Utilizing passive sensing data to provide personalized psychological care in low-resource settings

Background: With the growing ubiquity of smartphones and wearable devices, there is an increased potential of collecting passive sensing data in mobile health. Passive data such as physical activity, Global Positioning System (GPS), interpersonal proximity, and audio recordings can provide valuable insight into the lives of individuals. In mental health, these insights can illuminate behavioral patterns, creating exciting opportunities for mental health service providers and their clients to support pattern recognition and problem identification outside of formal sessions. In the Sensing Technologies for Maternal Depression Treatment in Low Resource Settings (StandStrong) project, our aim was to build an mHealth application to facilitate the delivery of psychological treatments by lay counselors caring for adolescent mothers with depression in Nepal. Methods: This paper describes the development of the StandStrong platform comprising the StandStrong Counselor application, and a cloud-based processing system, which can incorporate any tool that generates passive sensing data. We developed the StandStrong Counselor application that visualized passively collected GPS, proximity, and activity data. In the app, GPS data displays as heat maps, proximity data as charts showing the mother and child together or apart, and mothers’ activities as activity charts. Lay counselors can use the StandStrong application during counseling sessions to discuss mothers’ behavioral patterns and clinical progress over the course of a five-week counseling intervention. Achievement Awards based on collected data can also be automatically generated and sent to mothers. Additionally, messages can be sent from counselors to mother’s personal phones through the StandStrong platform. Discussion: The StandStrong platform has the potential to improve the quality and effectiveness of psychological services delivered by non-specialists in diverse global settings.

Applying human-centered design to maximize acceptability, feasibility, and usability of mobile technology supervision in Kenya: a mixed methods pilot study protocol

Background Although research continues to support task-shifting as an effective model of delivering evidence-based practices (EBPs), little scholarship has focused how to scale up and sustain task-shifting in low- and middle-income countries, including how to sustainably supervise lay counselors. Ongoing supervision is critical to ensure EBPs are delivered with fidelity; however, the resources and expertise required to provide ongoing supervision may limit the potential to scale up and sustain task shifting. Opportunities may exist to leverage mobile technology to replace or supplement in-person supervision in low-resource contexts, but contextual variables, such as network connectivity and lay counselor preferences surrounding mobile technology, must be examined and considered when designing and implementing mobile technology supervision. Methods This study builds from an existing randomized trial in Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy as lay counselors. The study will use an iterative and mixed methods approach, with qualitative interviews and a Human-Centered Design (HCD) workshop informing a non-randomized pilot trial. Semi-structured interviews will be conducted with lay counselors and supervisors to understand how mobile technology is currently being used for supervision and determine the barriers and facilitators to mobile technology supervision. Data from these interviews will inform an HCD workshop, where lay counselors and supervisors “re-design” supervision to most effectively leverage mobile technology. Workshop participants will also participate in focus groups to gather perceptions on the use of HCD techniques. The final outcome of the workshop will be a set of refined workflows, which will be tested in a mixed method, nonrandomized pilot with newly trained lay counselors and existing supervisors. The pilot trial will evaluate the acceptability, feasibility, and usability of mobile technology supervision through self-report questionnaires as well as perceptions of effectiveness through qualitative interviews with a subset of lay counselors and all supervisors. Discussion This study will provide a launching point for future research on supervision and methods to engage stakeholders to design and tailor interventions and implementation supports to fit low-resourced contexts. Trial registration The parent trial from which this study builds was registered on ClinicalTrials.gov on August 9, 2017 (NCT03243396).

Applying Human-centered Design to Maximize Acceptability, Feasibility, and Usability of Mobile Technology Supervision in Kenya: A Mixed Methods Pilot Study Protocol

Background: Although research continues to support task-shifting as an effective model of delivering evidence-based practices (EBPs), little scholarship has focused how to scale up and sustain task-shifting in low- and middle-income countries, including how to sustainably supervise lay counselors. Ongoing supervision is critical to ensure EBPs are delivered with fidelity; however, the resources and expertise required to provide ongoing supervision may limit the potential to scale up and sustain task shifting. Opportunities may exist to leverage mobile technology to replace or supplement in-person supervision in low-resource contexts, but contextual variables, such as network connectivity and lay counselor preferences surrounding mobile technology, must be examined and considered when designing and implementing mobile technology supervision.Methods: This study builds from an existing randomized trial in Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy as lay counselors. The study will use an iterative and mixed methods approach, with qualitative interviews and a Human-Centered Design (HCD) workshop informing a non-randomized pilot trial. Semi-structured interviews will be conducted with lay counselors and supervisors to understand how mobile technology is currently being used for supervision and determine the barriers and facilitators to mobile technology supervision. Data from these interviews will inform an HCD workshop, where lay counselors and supervisors “re-design” supervision to most effectively leverage mobile technology. Workshop participants will also participate in focus groups to gather perceptions on the use of HCD techniques. The final outcome of the workshop will be a set of refined workflows, which will be tested in a mixed method, nonrandomized pilot with newly trained lay counselors and existing supervisors. The pilot trial will evaluate the acceptability, feasibility, and usability of mobile technology supervision through self-report questionnaires as well as perceptions of effectiveness through qualitative interviews with a subset of lay counselors and all supervisors.Discussion: This study will provide a launching point for future research on supervision and methods to engage stakeholders to design and tailor interventions and implementation supports to fit low-resourced contexts.

Perceptions, Attitudes, and Knowledge of Teachers Serving as Mental Health Lay Counselors in a Low and Middle Income Country: A Mixed Methods Pragmatic Pilot Study

Background: Low and middle-income countries (LMICs) have a dire need for trained mental health professionals, especially for children. While teachers’ child development expertise potentially positions them to serve as lay counselors, they have rarely delivered indicated child mental health care in LMICs. As part of assessing the feasibility of teachers serving as lay counselors, we explored teachers’ perceptions about serving as mental health lay counselors on top of typical professional duties and their attitudes towards and knowledge about mental health after serving as lay counselors.Methods: In 2018, 20 primary school teachers from five rural, low cost private schools in Darjeeling, India, received training and supervision to serve as lay mental health counselors in their classrooms. Using mixed methods, we measured teacher mental health attitudes and knowledge and perceptions of serving as lay counselor with study-specific assessments and through semi-structured interviews. Pre-training, post-training, and post-intervention mean scores were compared using paired t tests. Post-intervention interviews were coded for teachers’ mental health attitudes and knowledge and perceptions of serving as lay counselor. Results: Interviews revealed teachers qualitatively having more inclusive mental health attitudes, expressing a willingness to serve as lay counselor, and retaining mental health knowledge as applicable to what may be used during instructional time. By contrast, quantitatively, teachers’ attitudes appeared to become more inclusive on the study-specific survey pre versus post-training, but reverted to pre-training levels post-intervention. Teachers’ mental health counseling knowledge on the quantitative study-specific assessment did not change pre-training versus post-training versus post-intervention.Conclusions: Training, supervision, and serving as lay counselors led to teachers’ willingness to serve as lay counselors. Teachers served as lay counselors by incorporating therapeutic techniques into their student interactions during class time and as part of their typical instruction, not through delivering one-on-one office-like traditional care. Their changes in attitudes and knowledge reflected those expected within an “education as therapy” emerging system of care. Quantitative measures of knowledge and attitude changes did not capture these nuanced changes.Trial Registration: The parent feasibility trial was registered on January 01, 2018 with Clinical Trials Registry – India (CTRI), reg. no. CTRI/2018/01/011471, ref. no. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27