Background
The treatment gap and task sharing
Evidence of task shared counselling in LAMICs
Cognitive Behavioural Therapy
Problem Solving Therapy
Interpersonal Therapy
The purpose of this study
Methods
Setting
Study design
Sampling and recruitment
Semi-structured interviews
Symptoms of depression 1. Do you think you have depression? Why do you think you have depression? 2. How do these feelings that you have change your daily life? 3. Think about a days when these feelings are really bad. Can you tell me what makes it really bad? Strategies for dealing with depression 4. Can you describe a day you feel better and not so depressed… What makes it better? 5. Was there anything you did yourself? Counselling as an intervention 6. The word/name counselling involves somebody helping you, listening to you talking about your problems, and helping you to find some solution to those problems. It does not mean the counsellor will fix your problems for you, but they can help you find ways to solve some of your own problems by giving you new skills that you can use. This counselling is not the same as HIV counselling. 7. Do you think that counselling could help you with your feelings of depression? 8. In what way could it help you? Logistics of counselling 9. If mental health services are closer to where people live, will it help them to use the services? If you could see a counsellor to help you with depression, would you rather see that person at the clinic or at home? Is distance or transport that make it easy or difficult or money or maybe cost of services or getting someone to go with you? 10. If someone came to your house what will your family think? What will the community think? Characteristics of the counsellor 11. If you could choose, would you want to see a nurse, a community health worker, or an HIV counsellor to get counselling for depression? 12. If you could see a counsellor to help you with depression, would you rather see that person at the clinic or at home? 13. If you could choose, what type of person would you choose to give you counselling? 14. What age should they be? 15. What culture should they be from? 16. Where should they come from? 17. What qualification or training should they have? 18. What language should they speak? 19. How many times in a month would you like to see the person? 20. Would it be best done individually or in a group with other people who are depressed? Please explain. 21. What do you think some of the problems to getting this help might be? |
Counselling experience and support 1. Can you explain to me what your understanding of depression is and how you would know if a person has depression? 2. What typical symptoms do people have who are depressed and how do these symptoms affect their lives? How long do these symptoms usually last? 3. How common is depression in Khayelitsha? Are pregnant women and mothers more likely to be depressed than other people? If so, why? 4. What do you think would be the best way to help pregnant women and mothers with depression in Khayelitsha? 5. What kind of support do you think depressed pregnant women and mothers need? 6. Would you say it would be better to have a CHW or HIV counsellor to do the counselling to the mothers? 7. Do you know what mental health counsellors are? What do mental health counsellors do? 8. Do you have any counselling experience? If so, describe this experience. 9. What skills would you like to learn if you were to provide counselling to depressed pregnant women or mothers of young infants in Khayelitsha? 10. What kind of support and supervision would you need in order to do counselling for depressed mothers in their homes? How often would you like to meet with a supervisor/manager? Characteristics of the counsellor 1. Would you say it would be better to have a CHW or HIV counsellor to do the counselling to the mothers? 2. What kind of counsellor is acceptable to depressed mothers or pregnant women? (Gender, age, qualification, culture, race, locality, relationship/community relations). 3. Tell me about your current work - Which organisation you work for? 4. How often do you see your supervisor and how do you report to your supervisor? 5. If you were working with pregnant women and mothers who are depressed, how many home visits do you think you could manage, over a period of 6 months? [If the person struggles to think about 6 months ask about 1 month or even 1 week and then multiply this by 6 for months and by 26 for weeks]. 6. When in the day and week do you think such home visits would be possible for you? Logistics of counselling 1. Do you visit patients at their homes? And if yes, how often do you do this? What kind of work do you normally do with patients? 2. How comfortable do you/would you feel visiting patients at home – how acceptable is it? (Probe for issues of confidentiality, safety, e.t.c.) 3. What limitations/obstacles do you see in delivering a counselling programme to depressed patients at their homes? 4. What are the potential benefits of counselling women in their homes or clinics that you wouldn’t get if you counselled them at the clinic? |
Data analysis
Panel discussion and intervention development
Manual development
Ethical approval
Results
Theme | Services users | Service providers | Total | Percentage |
---|---|---|---|---|
Counselling as an intervention | ||||
Counselling acceptable | 12/12 | N/A | 12/12 | 100 |
Counselling as advice | 4/12 | N/A | 4/12 | 33 |
Clinic visits preferred | 6/12 | 3/14 | 9/26 | 35 |
Individual sessions preferred | 7/12 | N/A | 7/12 | 58 |
Group sessions preferred | 5/12 | N/A | 5/12 | 42 |
Barriers to counselling | 4/12 | 8/14 | 12/26 | 46 |
Middle aged, Xhosa woman, | 11/12 | 5/14 | 16/26 | 62 |
Willingness to counsel & positive attitude | N/A | 2/14 | 2/14 | 14 |
CHWs recommended | 6/12 | 8/14 | 14/26 | 54 |
Already had counselling training | N/A | 4/14 | 4/14 | 29 |
No skills for counselling | N/A | 2/14 | 2/14 | 14 |
Avoidance | 9/12 | N/A | 9/12 | 34 |
Aggression and withdrawal | 6/12 | 8/14 | 14/26 | 54 |
Exacerbating factors | ||||
Financial Stressors | 5/12 | 6/14 | 11/26 | 42 |
Anxiety | 7/12 | 5/14 | 12/26 | 46 |
Coping strategies | 11/12 | N/A | 11/12 | 92 |
Phase 1: assessing participant views
Samples
Counselling as an intervention
It’s going out from the house to meet a family friend and talk and share our problems and, that’s how I get better. I see that I am a person to other people. (Pregnant Woman 4)
I can’t go next door to ask for a nappy, if they give me today what about tomorrow. I can’t go there tomorrow. I can’t make my problems hers. (Pregnant Woman 7)
Sometimes it won’t be easy to go for counselling. And also for us it is a cultural thing. Most of the people they don’t value the counselling. What I notice is that people go for counselling when they have a problem. We don’t go when there is no problem… Normally there is this thing of we go when things went very, very bad, it is when you will go for help. (Community Health Worker 4)
Characteristics of preferred counsellor
I would say preferably a woman, because I think they will be more comfortable and be able to open up if they are speaking to a woman. Um, with race it, it really doesn’t matter as long as our women understand what she is saying and they can be able to communicate. At least there mustn’t be any communication barrier. (Midwife 1)
There are always changes within the maternity setting, there are always things that are being added, just an addition of work, but no staff…. I don’t like psychiatry, but I do like psychiatric patients, but I just don’t want to be there! But I do have a background of psychiatry at home, with my aunt, which really affected me in a way that I don’t want to work in psychiatry. (Midwife 1)
We had some basic training for emotional counselling in our HIV counselling training. If we think someone is depressed, we refer them… (HIV Counsellor 2)
Clinic versus home visits
People like to look at other people, they will wonder why the counsellor is at my house. (Mother 1)AndYou get away from the family, which is often the problem. It is easier to open up, and you get away from the problem. (HIV Community Health worker 1)
The mothers would have to wait too long at the clinic. If they get hungry or tired, they sometimes just give up and go home. So we need to be able to refer them straight to a psychologist. (HIV Community Health Worker 3)
Transport will be another obstacle because they are far, some of the mothers stay in shacks, where there are no proper streets, and you know mos [colloquial expression], crime is also another thing there. So safety will also be another thing to look at… (Midwife 2)
Intervention content
People are scared to talk to me, because they say I am always angry, sitting alone in the room. It affects me. I’m always at home I don’t go anywhere. I’m not in the mood for anything not even for washing, nothing…I don’t like to be with people; when my child does something wrong; even if it’s small I shout at him and make it a big a thing. Even when I regret it, I don’t know how to say sorry. (Mother 4)
When I am short of stuff the baby needs. Not having the money to go buy them and not getting support. Then I have those thoughts if only I did not have it… It’s when the father does not support you. You see yourself alone. (Mother 2)
What made me worry was that, when you are pregnant you must have the HIV test. I was worried about that…. What made me worry is that, my husband before was adulterous. (Mother 3)
Coping strategies
That feeling ends when I listen to music. (Mother 1)If I go jogging at least the brain has some peace of mind. …For now I tell myself that I will never try to kill myself again. These are small things; maybe god has many things in store for me. (Mother 2)
Phase 2: Intervention development
The task shared intervention
Features of the intervention | Description |
---|---|
Theoretical basis | Psycho-education, Cognitive Behavioural Therapy techniques, such as healthy thinking adapted from the Thinking Healthy programme by Atif Rahman, and Behaviour Activation. |
Structure of the intervention | Manual based individual therapy and psycho-social support provided over 6–8 clinic based sessions. Session 1: Psycho-education on depression Session 2: Problem solving Session 3: Behaviour Activation Session 4: Healthy thinking Session 5: Psycho-education on birth preparation and Relaxation. Session 6: Termination and evaluation |
Structure of the sessions | 3 step process in all the sessions Step 1: Introduction – greeting and follow up on issues from previous meeting or session, or homework discussion. Step 2: Exploration – discussion of purpose of the session and topic, probing and clarification of issues Step 3: Termination - homework, follow up date and termination |
Tools | Counselling manual, voice recorder, relaxation CD, activity workbook and resource list for participants. |