Filling the gap: development and qualitative process evaluation of a task sharing psycho-social counselling intervention for perinatal depression in Khayelitsha, South Africa

Perinatal depression is a major public health issue which contributes significantly to the global burden of disease, especially in low resource settings in South Africa, where there is a shortage of mental health professionals. New psychological interventions delivered by non-specialists are needed to fill the treatment gap. Task sharing of psycho-social interventions for perinatal depression has been shown to be feasible, acceptable and effective in low and middle-income countries. However; there are limited data on process evaluations of task shared interventions for perinatal depression. This thesis attempts to address this gap by presenting four papers based on a study that undertook a qualitative process evaluation on a task shared psycho-social intervention. The thesis integrates all the papers under one primary aim (a process evaluation) which triangulated data from four sources which were published literature, perspectives of local depressed women, and perspectives of the counsellors in the trial and recipients of the intervention in the trial. The thesis will be presented in six chapters. The first chapter provides a background with current issues in global mental health, psycho-social interventions, task sharing in low and middle income countries and the United Kingdom (UK) Medical Research Council (MRC) framework for developing and evaluating interventions. A second chapter presents a systematic review on qualitative evidence of process evaluations of task sharing interventions for perinatal depression in LAMICs in relation to the UK MRC framework for conducting process evaluations. The systematic review reveals a paucity of qualitative evidence of process evaluations together with several crucial factors related to context, implementation and mechanisms of an intervention including: content and understandability, counsellors facilitating trust and motivation to conduct the intervention and participant factors such as motivation to attend the sessions and willingness to learn and change their behaviour. The third chapter provides information on development of the intervention and determining the feasibility in line with the MRC framework. Qualitative semi-structured interviews were conducted with 26 participants, including service providers and service users at a clinic in Khayelitsha. After the semi-structured interviews, a workshop was conducted with mental health experts on evidence-based psychological interventions for depression, together with a document review of counselling manuals for community health workers in South Africa. The feasibility study showed that a task sharing counselling intervention was acceptable and feasible for depressed women in Khayelitsha, under the following conditions: (1) respondents preferred a female counsellor and felt that a clinic based individual sessions should be provided at least once a month by an experienced Xhosa speaking counsellor from the community; and (2) the content of a counselling intervention should include psycho-education on cognitive and behavioural effects of depression, how to cope with interpersonal problems, and financial stressors. Based on these conditions, the review of manuals and expert consultation, key components of the counselling intervention were identified as: psycho-education, problem solving, healthy thinking and behaviour activation. These were included in the final counselling manual. The fourth chapter, presents the first of two perspectives of the post-intervention qualitative process evaluations, with lay counsellors. Post intervention qualitative semi-structured interviews were conducted with six counsellors from the AFrica Focus on Intervention Research for Mental Health (AFFIRM-SA) randomized controlled trial on their perceptions of delivering a task shared psycho-social intervention for perinatal depression. These interviews revealed that facilitating 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 including counsellors’ confidence and motivation to conduct the sessions and 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, younger age, and avoidance of contact with counsellors. Fidelity ratings and dropout rates varied substantially between counsellors. The fifth chapter presents the second of two perspectives of post intervention qualitative process evaluation with participants. Stratified purposeful sampling based on non-attendance, partial attendance and complete attendance of the intervention resulted in 34 participants being selected for semi-structured interviews. All interviews were recorded, transcribed and translated. Transcripts were analysed using a framework analysis in NVivo v11. Several factors acted as either barriers or facilitators of the participants’ context, mechanisms of the intervention and the implementation of the intervention. Contextual factors included the nature of problem such as unplanned pregnancy, interpersonal difficulties and location of the counselling. Mechanisms included participant factors such as willingness to learn new skills and change behaviour, counsellor factors such as motivation and empathy and intervention factors such as the content of the intervention. Implementation factors included the perception of the use or inability to use material such as the counselling manual, homework book and relaxation CD. The majority of the participants found the following sessions to be most valuable; “psycho-education for depression”, “problem solving” and “healthy thinking”, although a few participants did not have good recall of the sessions. The final chapter presents a discussion of key findings together with their implications for researchers, policy makers and other stakeholders. The chapter concludes with recommendations for future research in order to understand the contextual, participant, counsellor and intervention factors involved in the implementation of task sharing interventions

Task-sharing of psychological treatment for antenatal depression in Khayelitsha, South Africa: Effects on antenatal and postnatal outcomes in an individual randomised controlled trial

The study's objective was to determine the effectiveness of a task-sharing psychological treatment for perinatal depression using non-specialist community health workers. A double-blind individual randomised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha, Cape Town. Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale (EPDS) were randomised into the intervention arm (structured six-session psychological treatment) or the control arm (routine antenatal health care and three monthly phone calls). The primary outcome was response on the Hamilton Depression Rating Scale (HDRS) at three months postpartum (minimum 40% score reduction from baseline) among participants who did not experience pregnancy or infant loss (modified intention-to-treat population) (registered on Clinical Trials: NCT01977326)

Process evaluations of task sharing interventions for perinatal depression in low and middle income countries (LMIC): a systematic review and qualitative meta-synthesis

Background Perinatal depression is common in low and middle income countries (LAMICs). Task sharing interventions have been implemented to treat perinatal depression in these settings, as a way of dealing with staff shortages. Task sharing allows lay health workers to provide services for less complex cases while being trained and supervised by specialists. Randomized controlled trials suggest that these interventions can be effective but there is limited qualitative information exploring barriers and facilitators to their implementation. This systematic review aims to systematically review current qualitative evidence of process evaluations of task sharing interventions for perinatal depression in LAMICs in relation to the United Kingdom (UK) Medical Research Council (MRC) framework for conducting process evaluations. Methods We searched Medline/ PubMed, PsycINFO, Scopus, Cochrane Library and Web of science for studies from LAMICS using search terms under the broad categories of: (a) “maternal depression’” (b) “intervention” (c) “lay counsellor” OR “community health worker” OR “non-specialist” and (d) “LAMICs”. Abstracts were independently reviewed for inclusion by two authors. Full text articles were screened and data for included articles were extracted using a standard data extraction sheet. Qualitative synthesis of qualitative evidence was conducted. Results 8420 articles were identified from initial searches. Of these, 26 full text articles were screened for eligibility with only three studies meeting the inclusion criteria. Main findings revealed that participants identified the following crucial factors: contextual factors included physical location, accessibility and cultural norms. Implementation factors included acceptability of the intervention and characteristics of the personnel. Mechanisms included counsellor factors such as motivating and facilitating trust; intervention factors such as use of stories and visual aids, and understandability of the content; and participant factors such as shared experience, meeting learning needs, and meeting expectations. Conclusions While task sharing has been suggested as an effective way of filling the treatment gap for perinatal depression, there is a paucity of qualitative research exploring barriers and facilitators to implementing these interventions. Qualitative process evaluations are crucial for the development of culturally relevant interventions

Engineering the free world: the emergence of the OECD as an actor in education policy 1957–1972

This chapter analyzes the OECDs emerging role in education policy and retraces the early history of the Center for Educational Research and Innovation (CERI), which has become highly influential through the launch of the famous Program for International Student Assessment (PISA). It argues that the OECD’s engagement in education policy was driven by a network of technocrats aiming to produce the “right kind of people,” or engineering the West. Paradoxically, the failure of this quantitative planning project opened the doors for the OECD to get involved with more qualitative aspects of education planning. Catalyzed by the United States, and in particular the Ford Foundation, goal-oriented sciences were used by the OECD as governing means, allowing an organization that lacked binding policy instruments to professionalize its soft-law governance

Additional file 3: of A process evaluation exploring the lay counsellor experience of delivering a task shared psycho-social intervention for perinatal depression in Khayelitsha, South Africa

Consolidated criteria for Reporting Qualitative Research (CORE Q 32. Item checklist). A checklist of 32 items that should be included in qualitative research. (DOCX 15 kb

Additional file 4: of Process evaluations of task sharing interventions for perinatal depression in low and middle income countries (LMIC): a systematic review and qualitative meta-synthesis

Critical Appraisal Skills Programme (CASP) qualitative data checklist. A checklist for the assessment of qualitative data. (DOCX 12 kb

Additional file 2: of Process evaluations of task sharing interventions for perinatal depression in low and middle income countries (LMIC): a systematic review and qualitative meta-synthesis

Preferred Reporting Standards for Systematic Reviews and Meta-analysis (PRISMA) Statement. A statement detailing the preferred reporting standards for systematic reviews. (DOCX 16 kb

Additional file 1: of Process evaluations of task sharing interventions for perinatal depression in low and middle income countries (LMIC): a systematic review and qualitative meta-synthesis

Search strategy. A document which shows the search terms and search strategy that was used for the study. (DOCX 20 kb