81 online surveys were completed (67.5% response rate) from activity managers located in 44 countries and 6 world regions. The majority of responders were located in Sub-Saharan Africa (39.5%), the Middle East (18.5%), and Asia (13.6%). The implementation of digital MH interventions was subject to concurrent and complex challenges (Fig. 1), but 61 (75.3%) of the total number of participants managed to overcome these barriers and initiate a transition to digital care, despite providing a wide variety of MH care. Notably, the large majority of digital MH interventions depended on audio-only platforms (80%), with video consultation available for only 20% of projects.
Among the projects that implemented digital MH services (n = 61), nearly a third (30%) of activity managers reported that more than half of their patients could not be reached using remote digital care. Poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%) were the leading obstacles reported preventing good outreach using digital solutions. Nearly half of activity managers (42.6%) thought children were most often excluded when digital MH services were exclusively used, while nearly a third (29.5% and 31.1% respectively) thought this of the elderly and people with severe MH conditions. Thirty-three participants reported that there were at least some patients showing increased engagement when care was transitioned to digital MH platforms, and 36.4% reported that adults engaged better than other age groups, with no gender difference. Half (54%) of the respondents reported that patients indicated concerns about the privacy of the digital consultations, with a lack of a private space for confidential conversations cited as a primary worry. A notable 42.4% of respondents perceived this as linked to fear of sexual or interpersonal violence. Other reported concerns were stigma (6.1%) and a lack of trust in MSF (3%). Language barriers, the difficulties of incorporating interpreters into digital care models, missed appointments or scheduling conflicts, a lack of non-verbal cues during audio-only interviews, and a lack of clear protocols and guidelines were also cited as barriers to successful digital MH care.
Activity managers indicated that their staff had variable capacity to conduct important patient assessments, with 21.3% of managers reporting some staff unable to conduct a full MH assessment digitally, and 31.3% reporting some staff unable to conduct a protection risk assessment digitally. Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using digital platforms, with few reporting a similar (19.7%) or increased (3.3%) ability to provide comprehensive care. When asked to rate their project’s perception of the effectiveness of digital MH services compared to in-person sessions, most thought staff had a negative (46%) or mixed (42%) impression of remote care. The most common digital MH care needs cited by managers were training (41.7%) (including on care delivery, patient management, and remote MH assessments), clear guidelines and protocols (22.9%), and communications devices (12.5%) for both patients and staff. Nevertheless, despite the challenges, almost all MH activity managers (96.7%) thought digital MH services had some degree of utility as an alternative to in-person consultations, most commonly citing improved access to care (37.7%) and greater time efficiency (32.8%) as reasons for its continued use.
Following the completion of the online survey, 48 participants consented to in-depth interviewing on the topic. After interviews with the first 13 respondents, investigators believed that a point of saturation was achieved, and no further IDIs were pursued. IDI participants represented 5 geographic regions as well as multiple MH program types. Two participants came from programs that had not succeeded in implementing digital health strategies and seven mentioned having no previous experience with digital MH care prior to the COVID-19 pandemic.
Advantages of Digital MH Care
Overall, activity managers interviewed felt grateful that remote care options were available during the pandemic, though all still expressed a preference for in-person care. They described greater accessibility for some patients, time efficiency (more consultations, better time management), and less unnecessary travelling and related costs for both patients and MH care providers.
[Counselors can] stay in the office and call every patient, every week quite easily! That is why I think it is time efficient, because [before] we spent so much time on the road
I would always recommend tele-counseling to most mental health programs because they are an option for people who cannot come to the facility… [and] offer…services regardless of the day and time.
Notably, prior to providing digital MH services in their facilities, half of the IDI participants described thinking it would not be feasible to do so in their clinical setting, assuming that these services would have low acceptance by patients, that there would not be enough communication devices, internet, phone network, or call credit, and that their team’s organization and abilities would be insufficient for the task. These interviewees described being positively surprised by the experience of being forced to provide remote care, with one manager stating “Now, everything we thought has changed because…we realized that [digital MH services] will be important…and they worked; the teleconsultations really had a positive impact.”
Challenges Providing Digital MH Care
Some patients cannot do in-person sessions. In this case, tele-counseling really helps a lot. Other than this, there are mostly disadvantages...
Despite some advantages, the challenges surrounding the sudden transition to digital MH services were numerous. Some types of remote sessions were considered particularly challenging, especially psychiatric assessments of new patients and counseling prior to initiating a long-term medical treatment. More routine MH services (such as general and adherence counseling, psychosocial counselling, psychological care, psychiatric care, etc.) was described by one respondent as “difficult…but doable”.
i. Communications Infrastructure
Respondents described the many device-related challenges they faced when transitioning to digital MH care: indigent patients often lacked the phones, tablets, computers, internet access, cell phone signal, and money or credit necessary for a digital MH consultation. Most MSF staff provided remote MH care using nothing more than basic, non video-enabled mobile phones. Group therapy sessions with participants in multiple locations were not possible. When automated billing plans were unavailable (as is common in many LMIC), both the patient and provider’s phone would have to be periodically ‘filled’ with pre-paid credit. IDI respondents described the stress associated with digital sessions; often running longer than in-person consultations, that were interrupted or unfinished because of insufficient phone credit. Moreover, mobile phone network coverage was often dependent on location and time, particularly in rural sites and during peak hours, which also led to dropped calls, background or other noise, and other connection difficulties that could be particularly stressful when patients were at high-risk of serious MH sequelae or other harm.
Additionally, many of MSF’s diverse settings depend on language translators as part of the therapeutic environment. This proved difficult to replicate virtually, with complex three-way calling procedures in some mobile networks, network and connection challenges, confidentiality issues, and a lack of available translators overall during the pandemic period.
ii. Excluded and Vulnerable Populations
Many patients did not own a communication device and thus could not access care without sharing or borrowing someone else’s. This was particularly the case for female, pediatric, and geriatric MH patients and, in some cases, potentially left some individuals more vulnerable to controlling or abusive family members during the period of remote MH care. However, phones provided by MSF could also trigger issues of privacy and household power dynamics that could threaten the robustness of MH care provision. Participants reported that abusive individuals (husbands, parents, etc.), who would usually be excluded from the consultation room prior to COVID-19, had a tendency to normalize a patient’s suffering, intensify MH stigma, and sometimes impede contact with MH professionals.
When we are talking about children, the family members say: ‘he or she is okay’ …But it doesn't mean that the child is exactly okay. Maybe a child is suffering, maybe being abused…we don't know. And they will not tell us because if we can reach [the children], the family is going to be around...So how can we know what is happening to a child in this context?
It is not nice for some women to receive a call [from a male counsellor]. Sometimes this can be an issue because we have only three women counsellors...Women often don’t want to share their problems due to fear or their family members’ negative attitudes (often a husband or a mother-in-law). Therefore, they refuse to receive help.
IDI participants described how pediatric and female patients would sometimes participate in consultations with other family members present, either because a household member wanted to actively monitor the session (out of fear that the patient would disclose certain information) or because the reality of their living situation prevented private communication. In these cases, the remote therapeutic process was seriously hindered.
Even if we get consent from the parents [of a pediatric patient], it is not possible for children to have a whole room to themselves. They can misspeak because the parents are scared that a child will express something negative about the family…. For women, this is when there are scenarios related to domestic violence…
Vulnerable populations also included those with underlying risks that need to be assessed and managed (violence survivors, attempted suicide, etc.), a task that was particularly difficult remotely. This was enough of a concern that four MSF projects providing emergency MH services continued in-person care despite COVID-19 considerations.
iii. The Therapeutic Alliance
…when you have the patient face to face, you can tell by their non-verbal language, what is going on with the patient... So, it helps a lot, it helps a lot to see consistency in what the patient is saying and what you are actually observing
The challenges of MH care provision over the phone or through a screen were described by most respondents. Audio-only remote consultations, a reality for most MSF settings, were often a serious limitation, and managers described some staff even using their own personal smartphones or computers to provide remote video consultations. However, not all felt that way; a few participants described audio-only sessions as advantageous with populations or care providers who may not have been as accustomed to interacting through a screen:
“Some people are not comfortable on camera…because it is a different connection. Like I'm talking to an image – not to a person – and the environment is different. I need to feel comfortable when talking with someone because my own voice, tone, and image are different. We don't have [these things] when we are at an [in-person] session. You go, you see the patient, and we talk.”
Staff Needs and Recommendations
Nearly half of interviewees described the difficulty related to not having protocols or guidelines to advise them on digitally supported MH care. Some described hastily adapting other groups’ protocols to fit their patients. Scheduling conflicts and difficulty managing remote appointments, especially with new patients, missed appointments, long sessions, and overtime work for staff (due to increased caseloads, 24/7 availability, and increased session lengths and frequency) were all unexpected challenges that managers felt they could be better prepared for in the future. Most managers were not keen to continue the new remote care models except for “short periods” or for specific patients, especially those who travel long distances to care. Some managers also advised that, moving forward, supervisors should pay better attention to the emotional needs of their team members and encourage teamwork.