Experiences and Perceptions of Telephone-delivery of the Common Elements Treatment Approach for Mental Health Needs Among Young People in Zambia During the COVID-19 Pandemic

Background: Mental and behavioral health needs are immense in low-to-middle income countries (LMIC), particularly for adolescents and young adults (AYA). However, access to mental health services is limited in LMIC due to barriers such as distance to a health care site, low number of providers, and other structural and logistical challenges. During the COVID-19 pandemic, these barriers were significantly exacerbated and, thus, mental health services were severely disrupted. A potential solution to some of these barriers is remote delivery of such services via technology. Exploration of AYA experiences is needed to understand the benefits and challenges when shifting to remotely delivered services. Methods: Participants included 16 AYA (15–29 years) residing in Lusaka, Zambia who met criteria for a mental or behavioral health concern and received telehealth delivery of the Common Elements Treatment Approach (CETA). AYA participated in semi-structured qualitative interviews to explore feasibility, acceptability, and barriers to telephone-delivered treatment in this context. Thematic coding analysis was conducted to identify key themes. Findings: Three major response themes emerged: 1) Advantages of telehealth delivery of CETA, Disadvantages or barriers to telehealth delivery of CETA, 3) AYA recommendations for optimizing telehealth (ways to improve telehealth delivery in Zambia. Results indicate that logistical and sociocultural barriers i.e., providing AYA with phones to use for sessions, facilitating one face-to-face meeting with providers) need to be addressed for success of remotely delivered services. Conclusion: AYA in this sample reported telehealth delivery reduces some access barriers to engaging in mental health care provision in Zambia. Addressing logistical and sociocultural challenges identified in this study will optimize feasibility of telehealth delivery and will support the integration of virtual mental health services in the Zambian health system. Adolescent and young adult (AYA) participants were randomly selected to participate from a larger T-CETA pilot study in Lusaka, Zambia. The pilot study included 25 participants ranging in age from 15 to 29 who reported experiences of mental or behavioral health problems, traumatic experiences, substance use, physical or sexual violence, or stress related to COVID-19. Participants were recruited through a range of service delivery settings in Lusaka including primary health clinics, hospital/university settings, and community care sites, leveraging multiple service delivery systems (e.g., HIV care, maternal care, education, social and religious settings). Sixteen pilot participants (8 females and 8 males) were randomly selected to participate in the qualitative interviews and are included in the present analysis. All participants provided written consent prior to the commencement of data collection. Parental permission and assent were also obtained for AYA under age 18. The Johns Hopkins Bloomberg School of Public Health Institutional Review Board, the University of Zambia Biomedical Research Ethics Committee, the George Washington University (GWU) Institutional Review Board Office, approval number—IRB# NCR191797, and the World Health Organization (WHO) Research Ethics Review Committee—ERC.0003192 approved this study. A telephone-delivered version of CETA (T-CETA) was developed in response to the COVID-19 pandemic and associated public health guidelines and safety restrictions. The CETA manual was adapted for T-CETA following a review of evidence-based telehealth strategies, ethical guidelines, and clinical recommendations from telehealth providers. Additions to the manual included telehealth-specific discussions of confidentiality and privacy, adaptation of worksheets to be completed with blank paper, added verbal checks for understanding and attention, troubleshooting connection challenges, and a telehealth preparedness checklist (among other adaptations). In addition, local providers in Zambia reviewed the telehealth modifications and provided input that was incorporated into the final T-CETA manual. The CETA providers in Lusaka were provided additional training and supervision in T-CETA, including assessment of their foundational helping competencies using the Enhancing Assessment of Common Therapeutic factors Tool (ENACT) and related EQUIP resources (11). Similar to CETA, T-CETA was developed for delivery by a range of providers, including nonprofessional providers without formal mental and behavioral health education or training. In this study, existing CETA providers were provided phones, data, and talk time to use for T- CETA sessions and weekly supervision. The T-CETA manual includes adaptations for video and telephone synchronous delivery, and both options were offered to all T-CETA clients. However, only telephone was feasible for all participants in this study. Each provider worked with their clients to set consistent weekly times for sessions, when the client was home and in a private and safe space. T-CETA clients received weekly, 1 h phone sessions. T-CETA providers were supervised via telephone by their respective supervisors 2 h each week. Semi-structured qualitative interviews were conducted with AYA following their T- CETA treatment via the telephone to maintain COVID-19 safety guidelines in December 2020. All interviews were conducted by the first author (SM), in either Bemba, Nyanja, or English, according to interviewee preference and primary language spoken. The interviewer ensured all AYA were in a private, confidential space. Interviews lasted approximately 30 min. Interviews were not audio recorded due to privacy concerns via telephone and participant preference. Instead, the interviewer obtained permission from participants to keep detailed notes and record verbatim key quotes. No compensation was provided to participants. Interview questions aimed to explore AYA experiences and perceptions of receiving telephone-delivered CETA for mental health needs among young people in Zambia during the COVID-19 pandemic. Interview questions were designed to mitigate positive bias by including a balance of open- and close-ended questions that elicited both the strengths and challenges of telehealth CETA. For the full interview guide, see Supplementary Materials. An inductive approach was used to collect and analyze the data, which allows for data- driven findings guided by study aims and research questions. Coding and analyses were conducted in Microsoft Excel. The first and second authors (SM, CF) created a final guidebook through the following processes: (1) review of all transcripts, (2) four interviews were randomly selected for consensus coding, (3) coders met to review codes and create initial codebook, (4) two additional interviews were coded according to preliminary codebook, and (5) coders reviewed codes and generated final codebook. The remaining interviews were split coded according to the final codebook. Reporting patterns were tabulated according to themes within the research aims, including advantages, barriers, and recommendations for telehealth delivery of CETA in Zambia. Analyses were conducted in line with the thematic approach to explore response patterns that cross-cut interview questions and participants (17). Accordingly, analyses aimed to develop response-driven concepts that illuminate mental telehealth experiences in this population and context according to research aims. Broader sociocultural conditions that impact telehealth delivery and reception were integrated into the explanations and discussion of study aims. The full research team included both Zambian and American clinical researchers. Study design development, research aims, interview guide, implementation, translation, coding, member checking of results and manuscript preparation was completed collaboratively with Zambian and American team members, according to Community Based Participatory Action Research principles (18). The full team reviewed findings and provided input for final analyses and results.