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

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Study Justification:
– The study addresses the immense mental and behavioral health needs among adolescents and young adults in low-to-middle income countries (LMIC), particularly during the COVID-19 pandemic.
– It explores the potential solution of remote delivery of mental health services via technology to overcome barriers such as distance to healthcare sites and limited number of providers.
– The study aims to understand the benefits and challenges of telephone-delivered treatment in Zambia and provide insights for optimizing telehealth delivery.
Highlights:
– The study involved 16 adolescents and young adults (15-29 years) in Lusaka, Zambia who received telehealth delivery of the Common Elements Treatment Approach (CETA).
– Three major response themes emerged: advantages of telehealth delivery, disadvantages or barriers to telehealth delivery, and recommendations for optimizing telehealth.
– Findings indicate that telehealth delivery reduces access barriers to mental health care provision in Zambia.
– Logistical and sociocultural barriers, such as providing phones to participants and facilitating face-to-face meetings with providers, need to be addressed for the success of remotely delivered services.
Recommendations:
– Address logistical and sociocultural challenges identified in the study to optimize the feasibility of telehealth delivery.
– Support the integration of virtual mental health services in the Zambian health system.
– Provide AYA with phones to use for telehealth sessions.
– Facilitate face-to-face meetings with providers to establish rapport and trust.
Key Role Players:
– Mental health service providers
– Telehealth technology experts
– Policy makers and government officials
– Community leaders and organizations
– Funding agencies
Cost Items for Planning Recommendations:
– Procurement of phones for AYA to use for telehealth sessions
– Training and supervision for providers in telehealth delivery
– Resources for face-to-face meetings with providers
– Infrastructure and technology for telehealth services
– Outreach and awareness campaigns to promote virtual mental health services

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. To improve the evidence, the abstract could include more specific details about the study design, such as the sampling method and inclusion criteria. Additionally, providing information about the data collection and analysis methods would enhance the transparency and credibility of the study. Finally, including some quantitative data or statistics to support the findings would further strengthen the evidence.

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.

Based on the provided description, here are some potential innovations that could be used to improve access to maternal health:

1. Telehealth services: Implementing telehealth services, similar to the telephone-delivered Common Elements Treatment Approach (CETA) mentioned in the description, can provide remote access to maternal health care. This allows pregnant women to receive consultations, check-ups, and counseling from healthcare providers without the need for physical visits to healthcare facilities.

2. Mobile applications: Developing mobile applications specifically designed for maternal health can provide women with access to information, resources, and support throughout their pregnancy journey. These apps can offer features such as personalized health tracking, appointment reminders, educational content, and access to healthcare professionals via messaging or video calls.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services in remote or underserved areas can greatly improve access to care. These workers can conduct antenatal visits, provide health education, and facilitate referrals to higher-level healthcare facilities when necessary.

4. Mobile clinics: Setting up mobile clinics that travel to rural or hard-to-reach areas can bring essential maternal health services closer to the communities in need. These clinics can offer antenatal care, vaccinations, screenings, and basic treatments, ensuring that pregnant women have access to necessary healthcare services.

5. Public-private partnerships: Collaborating with private sector organizations, such as telecommunications companies or technology companies, can help leverage their resources and expertise to improve access to maternal health. For example, partnering with a telecommunications company to provide free or subsidized mobile data for accessing maternal health information or telehealth services.

6. Health information systems: Implementing robust health information systems that can securely store and share maternal health data can improve coordination and continuity of care. This allows healthcare providers to access relevant patient information, track progress, and make informed decisions, even in remote settings.

7. Maternal health hotlines: Establishing dedicated hotlines or helplines that pregnant women can call for immediate support, advice, or emergency assistance can be a valuable resource. Trained healthcare professionals can provide guidance, answer questions, and direct women to appropriate care when needed.

8. Transportation solutions: Addressing transportation challenges by providing affordable and accessible transportation options for pregnant women can help overcome barriers to accessing maternal health services. This can include initiatives such as subsidized transportation vouchers, community-based transportation services, or partnerships with ride-sharing companies.

These are just a few potential innovations that can be explored to improve access to maternal health. It’s important to consider the specific context, resources, and needs of the target population when implementing these innovations.
AI Innovations Description
The recommendation to improve access to maternal health based on the study is to optimize telehealth delivery in Zambia. The study found that telehealth delivery of the Common Elements Treatment Approach (CETA) reduced some access barriers to engaging in mental health care provision in Zambia. However, there were logistical and sociocultural challenges that need to be addressed for the success of remotely delivered services.

To optimize telehealth delivery, the following recommendations were made by the adolescent and young adult participants:

1. Provide AYA with phones to use for sessions: One of the barriers identified was the lack of access to phones for telehealth sessions. Providing AYA with phones would ensure that they have the necessary technology to participate in remote mental health care.

2. Facilitate one face-to-face meeting with providers: Participants suggested that having at least one face-to-face meeting with providers would help establish a personal connection and build trust. This could be done at the beginning of the treatment process to establish rapport.

By addressing these logistical and sociocultural challenges, the feasibility of telehealth delivery can be optimized, and virtual mental health services can be integrated into the Zambian health system.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Telehealth Services: Implementing telehealth services can help overcome barriers such as distance to healthcare facilities. Pregnant women can receive virtual consultations, check-ups, and counseling from healthcare providers through video or phone calls.

2. Mobile Clinics: Setting up mobile clinics that travel to remote areas can improve access to maternal health services. These clinics can provide prenatal care, vaccinations, and other essential services to pregnant women who may not have easy access to healthcare facilities.

3. Community Health Workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and pregnant women in underserved areas. These workers can provide education, support, and basic healthcare services to pregnant women in their communities.

4. Health Education Programs: Implementing comprehensive health education programs can empower pregnant women with knowledge about prenatal care, nutrition, and healthy practices. These programs can be conducted through community workshops, mobile apps, or radio broadcasts.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the number of prenatal visits, percentage of women receiving skilled birth attendance, or maternal mortality rates.

2. Collect baseline data: Gather data on the current state of access to maternal health services in the target population or region. This can include information on healthcare facilities, healthcare providers, and utilization of maternal health services.

3. Define the intervention: Specify the details of the recommended innovation, including the target population, implementation strategy, and expected outcomes.

4. Simulate the intervention: Use mathematical modeling or simulation techniques to estimate the potential impact of the recommended innovation on the defined indicators. This can involve creating a hypothetical scenario where the innovation is implemented and projecting the changes in the indicators based on available data and assumptions.

5. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the simulation results. This involves testing the impact of different assumptions or parameters on the outcomes to understand the potential variability or uncertainty.

6. Interpret and communicate the results: Analyze the simulation results and interpret the findings in terms of the potential impact on improving access to maternal health. Communicate the results to stakeholders, policymakers, and healthcare providers to inform decision-making and prioritize interventions.

It’s important to note that the specific methodology for simulating the impact may vary depending on the available data, resources, and context. Consulting with experts in the field of maternal health and simulation modeling can provide further guidance on the appropriate methodology to use.

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