STAKEHOLDERS’ PERCEPTIONS OF THE FEASIBILITY AND ACCEPTABILITY OF SCREENING AND BRIEF INTERVENTION 6.1 Background
Chapter 5 discussed the feasibility, acceptability and preliminary outcomes of a PST intervention from the patients’ perspectives. This chapter represents an extension of those findings, by examining the feasibility and acceptability of the same intervention described in the previous chapter, from the perspectives of various stakeholders. A review of the literature pertaining to task shifting interventions was provided in Chapter two and summarised in Chapter 5. This section provides a summary of those South African studies that explored the feasibility and acceptability of their interventions.
Of the nine South African studies reviewed in Chapter 2, three explored the feasibility and acceptability of their interventions. Two of the studies (Myers et al., 2012; Sorsdahl et al., 2015) used screening and brief interventions (one session), primarily focused on outcomes associated with risky substance use, one of which (Sorsdahl et al., 2015) was also concerned with depressive symptoms as a secondary outcome. The third (Petersen, Bhana, & Baillie, 2012a) was a longer group therapy intervention of 12 sessions, aimed at reducing depressive symptoms in adult participants. One was conducted in emergency services using peer counsellors (Myers et al., 2012); another in a primary health care setting using CHWs; while the third (Sorsdahl et al., 2015) was delivered by HIV counsellors to pregnant women attending antenatal care at a MOU.
All three studies listed above found their interventions to be feasible and acceptable from the perspectives of both participants and stakeholders. Concerning stakeholders in particular, staff involved in all three studies felt that the interventions improved the quality of service that they were able to provide. Myers et al. (2012) found that the emergency room personnel did not feel that the intervention interfered with or added to their work. However, they felt the intervention should be made more visible to staff and patients and should be expanded to offer 24-hour support and to address other psychosocial problems. The counsellors experienced varied levels of support and buy-in from staff. A major barrier to the intervention was a lack of space to work privately with participants. In Sorsdahl et al.’s (2015) study, the HIV counsellors found that the intervention materials better equipped them to assist pregnant women in giving up their
substance use. However, MOU staff who were involved in the screening and referral of participants felt that the intervention added to their workloads, representing a potential barrier to the intervention’s sustainability. Understanding more about the feasibility and acceptability of task shifting interventions from the perspective of the relevant stakeholders will contribute to the development of sustainable programmes in PHC settings.
As an extension to the study described in the previous chapter, this component of the study sought to explore the feasibility and acceptability of the screening and brief intervention from the perspective of various stakeholders.
6.2 Methods
Qualitative methods were employed to collect data for this component of the study.
Participants
Six role players were identified by the RC and the Acting Head Sister of the MOU as being the most directly or indirectly involved in, or affected by the project. As seen in Table 6.1, they comprised three staff who were most involved in the screening of participants at their first antenatal visits, the primary liaison person and Acting Head of the MOU, the Community Health Centre’s Social Worker, and the RC. The staff involved in obtaining patient histories at first intake (and who screened participants for the project) were rotated by the facility to different posts at least every three months. Student nurses were also often used to obtain patient histories and were usually rotated on a monthly basis. Only one of the intake staff, the Health Worker, was consistently in that role. For the purposes of protecting the identities of the stakeholders, the letter ‘R’ will be used to represent all of them, except for the RC, who will be represented by the letter ‘M’, and the Social Worker, by the letter ‘J’.
Table 6.1 Stakeholders roles in the project
Title/designation Role in the project
Health Worker Screening and referral
Senior Nursing Assistant Screening and referral Midwife, Nursing Sister Screening and referral
Midwife, Nursing Sister, Acting Head of MOU Referral source, primary liaison
Social Worker (J) Referral source and resource
Procedures
The RC and Head Sister of the MOU were asked to provide the names of the staff who were most involved and affected by the project. Each role-player was contacted and an appointment was arranged to meet for a face-to-face interview with the researcher. Each role-player provided informed consent (see Appendix IV). The RC was interviewed by a colleague of the researcher’s, also a Clinical Psychologist, so as to avoid any conflict of interest (the researcher was the RC’s clinical supervisor).
Data collection and analysis
A semi-structured interview schedule (Appendix IV) guided the interviews with the staff members. A separate semi-structured interview (Appendix IV) guided the interview with the RC. All data were audio-recorded and transcribed. The data were then analysed in NVivo 11 using the Framework Method (Pope et al., 2000), as described in Chapter 5.
Training and supervision
Intake nurses at the MOU, who were responsible for administering the EPDS and referring patients to the RC, were instructed in how to incorporate the EPDS into their standard assessment procedures, as well as how to make referrals to the RC. The quarterly rotation of nurses required that the RC regularly provide this training and remind staff of the project’s procedures. On two occasions, the researcher also arranged refresher sessions with the intake nurses. On these occasions, with the permission of the patients, the researcher would observe the administration of the screening tool during intake and later provide constructive feedback to the staff member concerned, regarding how this process might be improved. These were also opportunities for the staff to provide feedback to the researcher and ask any questions they might have pertaining to the project.
The RC completed the BPsych degree and was registered with the HPCSA. The majority of her supervised internship training was at the same MOU, where she was one of four interns tasked with delivering counselling services to perinatal women. She was thus well-placed to assume the role of RC for the purposed of this study. Prior to the commencement of the project, the Registered Counsellor attended a three-day training in maternal mental health, delivered by the Perinatal Mental Health Project, which is housed in the University of Cape Town’s Alan J.
Flisher Centre for Public Mental Health under the Department of Psychiatry and Mental Health. Furthermore, she received 18 hours of training over three days in the PST model and manual, which included role-playing applications.
Throughout the implementation of the project, the RC received at least one hour of clinical supervision per week from the researcher, a registered Clinical Psychologist. During the first three months of the PST intervention implementation, this was increased to two one-hour sessions per week. During the course of supervision, the RC was required to present new cases, prioritising those that she felt were in most urgent need of attention and those she had queries about. Procedural matters, case management, and fidelity to the therapeutic protocol were central to this process. Random review of recorded sessions did not reveal any protocol drift. In the event of emergencies, the RC received additional telephonic or email support from the researcher.
6.3 Results
Themes that emerged in the analysis of the data generated by interviews with stakeholders were (a) perceptions of utility to patients, (b) filling a gap for staff, (c) perceived challenges and obstacles, and (d) recommendations and suggestions for improvement of the programme.
a) Perceptions of the programme’s utility to patients
All six stakeholders, perhaps to varying degrees, felt that the programme was worthwhile and made an important contribution to the services provided at the MOU. Perceptions of the ways in which the programme was helpful seemed to vary according to the role that each staff member played or how their own work was impacted upon by it. As one role-player stated:
“I thought - - I still think it’s a wonderful tool and it’s a wonderful programme to have at any facility. I think research shows you know that women, especially women who are pregnant - - um - - and mental health services – it’s not always accessible for women. So to actually come to a facility where somebody actually takes the lead and saying to you ‘you know maybe you need to consider counselling, you need to consider to get assistance with whatever you’re going through’- - I think that’s a wonderful thing - - so I think it’s a very positive thing, yes.”
At least two staff members felt that the screening was useful because it improved their capacity to detect psychological problems, as this staff member reported:
“It was really useful. Because you know what happens when they do the screening here…when M was there, and there was that tick sheet - - it was much easier to get the problem, the problem from the patient, unlike you ask the patient ‘do you have any problems?’ Some of the patients will just say ‘no’ - - but within that screening tool it was much easier to get that and when they are there you can really see that the patient really had the problem.”
All stakeholders agreed that, for the patients, having a counsellor to talk to was the most valuable aspect of the programme. For three stakeholders, having someone that patients could confide in, especially given that the counsellor was a ‘stranger’ and not a member of patients’ families or social networks, was significant. For one role-player, it seemed important that the counsellor was not a permanent member of staff and so might deal with problems differently.
“What worked was - - um - - the patients had somebody else that they could come to and confide in and chat to – just had that personal - - you know on that personal level.”
“Yes I feel it does because sometimes the patients don’t want to speak to people who knows them outside - - like to neighbours or to family - - but they feel more comfortable to speak to somebody here.”
“And having somebody like M was was for some of them a really um um good situation. Because it’s not part of the staff - - really she’s not part of the staff but it’s somebody different that they can go to and chat to and also um her way of dealing.”
b) Acceptability: Filling a gap for the staff
For the most part, the staff seemed to feel that the programme lightened their own workloads, as it gave them a resource to refer distressed patients to, instead of having to manage the patient themselves. Three stakeholders described how interactions with distressed patients could be burdensome and stressful for the staff, in that containing the patient took time and energy from their own limited resources, as highlighted in these extracts:
“They just used to come in and start crying! And I’m like ‘what now? I haven’t said anything, I haven’t done anything but you crying!’ and now I have to ask ‘why are you crying? {Laughs} and then it’s like a can of worms.”
“And I’m just asking [the patient] ‘so why are you smoking such a lot’! …Noooo – but then it end up having - - I end up having to hear about her being abused as a child and her husband is hitting her - - And one question led to - - all of that…Sometimes you just don’t ask …Sometimes you just say, ‘I just want to get through the day, I’m not going to ask’”
“Like I said because the staff - - staff would speak to clients and then you know - - when people become emotional or they say things that they don’t really expect from clients then they don’t know what to do with the patient, so then the best thing is ‘let me get you to a counsellor or get the social worker to come and speak to you’ – that type of thing…there’s fifty other clients waiting so I can’t really spend an hour or forty-five minutes with one person because - - nobody else is going to see to those clients that needs to be seen.”
“It really does drain you. Especially if you look at the counselling skills that I have compared to the counselling skills that M has - - she’s trained to do that. The counselling skills that I have is this that we pick up here in there in the perinatal and all that type of stuff - - and it tires you to have to listen to that {Laughs} - - to the problems.”
All of the staff talked about the ways in which having a counsellor at the MOU relieved some of the demand that distressed patients represented. Having a professional resource to refer patients to seemed to be the most significant and meaningful contribution that the programme made to the MOU staff.
“Because before then I had to sit for hours and listen to all the stories and then - - um - - but with M here it was ((I’d say)) ‘Just come with me’ {Laughs} It made my work easier!”
“Yes it gave us the opportunity to refer our high-risk patients - - somebody who - - umm - - you wouldn’t normally know where to send them.”
“But we knew if we’ve got a problem, there is M - - we call M - - and she even make an appointment maybe if that day is full for her.”
“On the other side, like now if the patient have a problem we have to sit with the patient and it’s time - - time consuming. So when M was here all the problems, we used to refer them - - to M, so that was the only impact that the patient - - because with people who has a problem, uh-uh, you can go and look for help somewhere else - - you have to be with the patient, trying to find out exactly so that you can be able to refer where necessary.”
“I think how it impacted on my work is that a lot of the clients that was actually screened to be seen by M eventually didn’t come to me because if she wasn’t there I’m sure that a lot of those cases would have come to me so it impacted on my caseload going down.”
This was clear to the RC who experienced the staff’s need to have a resource to refer to, as she points out here, recognising that in part, the value of her role was in providing some relief to staff:
well - - I found there was an appreciation, that there was a safety net - - [as if quoting staff] ‘I don’t always know what to do, I’m going to make this problem that lady’s problem’ - - so I found that and then again also - - there were cases where you know they just see tears and they’re like ‘okay don’t worry, just sit there in front of that lady’s office, she’ll see you’”
An additional benefit of the programme was seen in the way it forged connections between existing CHC resources or staff who were not well-connected before. For example, the MOU staff began to make more contact with the CHC’s social worker (J), as highlighted in this excerpt:
We were not very much in contact with J until this programme started…Yes…we were not making use of J much before then - - J was also just a name of someone
c) Perceived challenges and obstacles
The stakeholders highlighted several challenges associated with the programme, many of which appeared to be related to an overburdened system. As referrals increased, the RC had less time to immediately see all patients referred to her and in some instances would need to arrange an appointment on another day instead. When asked what she thought was problematic about the programme, one role-player had this to say:
“The amount of patients that was referred…Because - - um - - I don’t think M could keep up with all the all the patients - - And uh umm - - then she’s - - then she used to say she can’t see somebody now, she must get a date or whatever then the staff just stopped referring.”
Stakeholders felt that this was a problem and that the programme should have had more capacity as a walk-in service:
“See with pregnant women I found that you must just be available. You mustn’t have that situation that ‘you not booked for today so I can’t see you’. You must be there for them. That is how I- I deal with our pregnant moms. And just to be there whenever ah- ah- they feel comfortable and ready to see you. But if I’m busy with you obviously they can see “hang on” or tomorrow they in the town centre and they feel “Ahhh I can go over and chat”, you know we must have an open door - -situation.”
“The only thing that really concerned me was - - I felt that the patient had – on that specific day she needs help - - but then M said no she’s going to phone them - - but sometimes the patients don’t want to come in or - - maybe they need - - that day they need - - that’s the only thing that could - -why couldn’t they be seen on that specific day.”
The role that the programme played in relieving staff seemed to be echoed in this way and perhaps highlighted a sense of inadequacy or anxiety about having the capacity to manage a distressed patient. One role-player alluded to this:
“But even those patients really need help so if - - I mean if M - - I mean J is not there on that particular day or maybe….or maybe or if J is fully-booked, so she has to give the other days…and you send the patient home without - - being helped…because you can talk to the patient but you feel that it’s not enough, maybe it’s not enough. Of course I understand for the patient because there is somebody there that they talk, they going to feel much better but for you that you’ve been talking to the patient you think, I don’t think I gave enough.”
However, one role-player felt that a walk-in service would mean that counselling is treated as a “crisis service”. She felt that this would send the wrong message to women about taking care of their mental health:
“I don’t know how effective that is also um - - because it also creates the wrong perception with the client in terms of intervention and what can be done - - and again in my opinion I think it would be better to say to people you know, mental health is a thing that you should pay attention to continuously and not only when you are in crisis or when there’s a problem.”
Every role-player made reference to the overburdened and under-staffed state of the system and the demands placed on staff as a result. Interestingly, while the value of the programme to