A process evaluation exploring the lay counsellor experience of delivering a task shared psycho-social intervention for perinatal depression in Khayelitsha, South Africa

Abstract

BackgroundTask sharing of psycho-social interventions for perinatal depression has been shown to be feasible, acceptable and effective in low and middle-income countries. This study conducted a process evaluation exploring the perceptions of counsellors who delivered a task shared psycho-social counselling intervention for perinatal depression in Khayelitsha, Cape Town together with independent fidelity ratings.MethodsPost intervention qualitative semi-structured interviews were conducted with six counsellors from the AFrica Focus on Intervention Research for Mental health (AFFIRM-SA) randomised controlled trial on their perceptions of delivering a task shared psycho-social intervention for perinatal depression. Themes were identified using the framework approach and were coded and analysed using Nvivo v11. These interviews were supplemented with fidelity ratings for each counsellor and supervision notes.ResultsFacilitating factors in the delivery of the intervention included intervention related factors such as: the content of the intervention, ongoing training and supervision, using a counselling manual, conducting counselling sessions in the local language (isiXhosa) and fidelity to the manual; counsellor factors included counsellors’ confidence and motivation to conduct the sessions; participant factors included older age, commitment and a desire to be helped. Barriers included contextual factors such as poverty, crime and lack of space to conduct counselling sessions and participant factors such as the nature of the participant’s problem, young age, and avoidance of contact with counsellors. Fidelity ratings and dropout rates varied substantially between counsellors.ConclusionThese findings show that a variety of intervention, counsellor, participant and contextual factors need to be considered in the delivery of task sharing counselling interventions. Careful attention needs to be paid to ongoing supervision and quality of care if lay counsellors are to deliver good quality task shared counselling interventions in under-resourced communities.Trial registrationClinical Trials: NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry: PACTR201403000676264, registered on 11/10/2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-017-1397-9) contains supplementary material, which is available to authorized users.

Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions

“…Several talented home visitors have resigned because the work was too hard and/or too painful and required too much of them. This has been found to be true in other high‐risk settings (see Atif et al., , and Munodawafa et al., ). Subsequently, in later recruitment drives, program management looked specifically for emotionally stronger women who had some degree of “street smarts,” and the dropout rate has reduced.…”

“…A number of studies and reviews have been conducted to try to determine the efficacy of the use of lay health workers to deliver mental health interventions (Betancourt & Chambers, ; Casillas, Fauchier, Derkash, & Garrido, ; Chowdhary et al., ; Munodawafa, Lund, & Schneider, ). While some inconsistency has been found, what has emerged is that the most effective interventions involve careful recruitment, training, regular reflective supervision, and program fidelity monitoring (Betancourt & Chambers, ; Casillas et al., ).…”

“…The majority of lay counselors in South Africa are trained in a client‐centred approach to counseling, which tries to instill the assumption of a position in which the counselor does not impose his or her own values on the client. However, in practice, more directive, health‐advising, or advice‐giving counseling techniques tend to be used alongside a more client‐centred style (Munodawafa et al., ; Rohleder & Swartz, ; Schneider & Lehmann, ). This increases the risk of prioritizing “advice” over the more difficult task of remaining emotionally present with the mother–infant dyad to help manage distress, persecution, fear, and other strong dysregulating feelings.…”

“…Program fidelity evaluations and dropout rates have been found to vary significantly among lay mental health workers (Munodawafa et al., ), highlighting the importance of effective selection. Appropriate selection of lay community mental health workers must consider emotional suitability for the role as well as motivation (Atif et al., ).…”

“…Many barriers to effective intervention are associated with cultural and contextual factors. These include stigma associated with mental illness, women's lack of autonomy in more patriarchal cultural settings, cultural beliefs that diverge with program teachings, lack of engagement or avoidance of counselors by some high‐risk mothers, and resistance to program participation from extended families (Atif et al., ; Baradon & Bain, ; Munodawafa et al., ). Within the two South African programs, cultural interfacing challenges have presented themselves within the day‐to‐day practicalities of the interventions as well as within the interactions between the home visitors and the mother–infant dyads, and also the home visitors and their supervisors and program management.…”