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Task shifting is an effective model for increasing access to mental health treatment via lay counselors with less specialized training that deliver care under supervision. Mobile phones may present a low-technology opportunity to replace or decrease reliance on in-person supervision in task shifting, but important technical and contextual limitations must be examined and considered.
Guided by human-centered design methods, we aimed to understand how mobile phones are currently used when supervising lay counselors, determine the acceptability and feasibility of mobile phone supervision, and generate solutions to improve mobile phone supervision.
Participants were recruited from a large hybrid effectiveness implementation study in western Kenya wherein teachers and community health volunteers were trained to provide trauma-focused cognitive behavioral therapy. Lay counselors (n=24) and supervisors (n=3) participated in semistructured interviews in the language of the participants’ choosing (ie, English or Kiswahili). Lay counselor participants were stratified by supervisor-rated frequency of mobile phone use such that interviews included high-frequency, average-frequency, and low-frequency phone users in equal parts. Supervisors rated lay counselors on frequency of phone contact (ie, calls and SMS text messages) relative to their peers. The interviews were transcribed, translated when needed, and analyzed using thematic analysis.
Participants described a range of mobile phone uses, including providing clinical updates, scheduling and coordinating supervision and clinical groups, and supporting research procedures. Participants liked how mobile phones decreased burden, facilitated access to clinical and personal support, and enabled greater independence of lay counselors. Participants disliked how mobile phones limited information transmission and relationship building between supervisors and lay counselors. Mobile phone supervision was facilitated by access to working smartphones, ease and convenience of mobile phone supervision, mobile phone literacy, and positive supervisor-counselor relationships. Limited resources, technical difficulties, communication challenges, and limitations on which activities can be effectively performed via mobile phone were barriers to mobile phone supervision. Lay counselors and supervisors generated 27 distinct solutions to increase the acceptability and feasibility of mobile phone supervision. Strategies ranged in terms of the resources required and included providing phones and airtime to support supervision, identifying quiet and private places to hold mobile phone supervision, and delineating processes for requesting in-person support.
Lay counselors and supervisors use mobile phones in a variety of ways; however, there are distinct challenges to their use that must be addressed to optimize acceptability, feasibility, and usability. Researchers should consider limitations to implementing digital health tools and design solutions alongside end users to optimize the use of these tools.
RR2-10.1186/s43058-020-00102-9
Most individuals worldwide cannot access needed mental health treatments. Task shifting has emerged as an effective and potentially sustainable solution for addressing the human resource shortages that contribute to the mental health treatment gap [
Research in high-income settings suggests that ongoing supervision is necessary to ensure that EBPs are delivered with fidelity (ie, as intended by intervention developers [
There may be opportunities to leverage digital technology as a tool to supervise lay counselors and to decrease the need for in-person supervision
Psychology and global mental health researchers have called for studies evaluating the potential of digital health tools to improve mental health services [
To maximize the acceptability (ie, satisfaction; [
This manuscript presents the first phase of an HCD research project intended to investigate how mobile phones can be leveraged as digital health tools for the supervision of lay counselors in western Kenya, including potentially replacing in-person supervision. We examined how mobile phones are used for supervision within a National Institute of Mental Health–funded cluster randomized controlled trial, “Building and Sustaining Interventions for Children (BASIC): Task Sharing Mental Health Care in Low Resource Settings” [
This study was conducted as part of a larger study examining the use of mobile phones to supplement or replace in-person supervision with lay counselors in western Kenya [
Supervisors meet in person with each group of lay counselors after training (to practice the intervention and prepare for delivery) and at least four times during their first round of implementing groups. In-person supervision was provided in a group format. In addition to routine administrative supervision, in-person meetings consisted of reviewing past sessions and practicing (role-plays) for upcoming sessions, discussion of any challenging treatment elements, and problem-solving of any unique children and guardian participant needs. Supervision included ad hoc mobile phone communications via SMS text messages and phone calls during times between in-person meetings. Mobile phone communication included both individual and group SMS text messages and calls. Mobile phones were not provided by the BASIC trial, and all lay counselors used their own phones. The COVID-19 pandemic increased the team’s reliance on mobile phones to provide support. Despite the reliance on mobile phones to provide support from a distance, the extent to which mobile phones can be used and systematically implemented to support supervision remains understudied. These results are from the first aim of a pilot trial intended to understand the barriers to and facilitators of mobile phone supervision and co-design and test strategies to optimize its acceptability, feasibility, and usability. See Triplett et al [
To understand how mobile phones were used, interviews were conducted with supervisors and lay counselors who received training in (and subsequently delivered) TF-CBT as part of the BASIC trial. Lay counselor participants were selected via a stratified random sampling approach to balance participants across counselor types (ie, teacher and CHV counselors) as well as those who used mobile phones with varying frequencies. Supervisors categorized 180 lay counselors who had completed TF-CBT delivery into one of three categories: (1) high-frequency users, (2) average-frequency users, and (3) low-frequency users. Supervisors rated all the lay counselors they directly supervised based on frequency of all types of phone contact (ie, phone calls; SMS text messages; and WhatsApp messages, if applicable). Supervisors rated lay counselors relative to the average peer (eg, high-frequency users were those perceived as having a higher-than-average number of contacts). Interviewing “extreme” users—those using mobile phones with high frequency or rarely—is an HCD technique that is intended to more easily illustrate the range of behaviors and needs of a population [
All those invited agreed to participate in the interviews, and for counselors, interviews were conducted where they delivered the treatment. Lay counselor participants were 33% (8/24) men, as were the supervisor participants (1/3, 33%). Owing to a recruitment error, one-third of the participants (8/24, 33%) used their mobile phones with high frequency, and slightly different numbers used their phones with average frequency (9/24, 38%) and low frequency (7/24, 29%). Of the 24 lay counselor participants, 6 (25%) did not have smartphones. These participants were all CHVs and were split across high-frequency (2/6, 33%) and low-frequency (4/6, 67%) users. No other nonparticipants were present in the interviews.
Semistructured interviews were conducted by a trained study interviewer in the language of the participants’ choosing (ie, Kiswahili or English). Although other languages were spoken in the study catchment area, all research activities from the parent trial were conducted in English and Kiswahili as community members indicated a preference for these 2 languages. As such, we opted to conduct interviews in these preferred and official languages. Code switching, or alternating between languages, was observed in some interviews. Participants were free to switch between English and Swahili, although interviewers directed them back to those languages when they spoke other, nonstudy languages (eg, Luhya). Interviewers were both male and female and had at least an undergraduate degree. Interviewers had completed all study interviews for the parent trial and already knew the participants. Each interview lasted approximately 1 hour. No repeated interviews were conducted. Supervisor interviews were completed by the first author, a White male graduate student from the United States. All supervisor interviews were conducted in English.
Interview protocols began broadly, first reminding interviewees of the goals of the study and then asking lay counselors and supervisors to reflect on how they used their mobile phones to communicate regarding treatment delivery in their respective roles. Questions then became more tailored to examine what they liked most about using mobile phones for supervision, the challenges or frustrations with mobile phone supervision, and the degree to which they felt that mobile phones could replace in-person supervision. Drawing from HCD techniques, the final question asked participants to describe how they would use their mobile phones during a specific “scenario of use” [
Interview transcripts were coded and analyzed following the 6-phase framework by Braun and Clarke [
The codebook was considered a “live document” and iteratively refined throughout the coding process. After completing all coding, the results were presented back to the interview participants for member checking at an in-person workshop. This workshop also included other HCD activities, which have been reported elsewhere. Codebook definitions were refined during the workshop; however, no new themes emerged. The codebook team (NST, CJ, and SK) worked together to propose and refine qualitative themes that grouped together the member-checked codes. Qualitative methods and results are presented in concordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research [
The institutional review boards at the University of Washington and Kenya Medical Research Institute approved all study procedures (STUDY00010734). The Kenya National Commission for Science, Technology, and Innovation also reviewed and approved this research (NACOSTI/P/16/28122/14518). Informed consent was obtained from all participants before the interviews were conducted. All the interview excerpts were deidentified. Participants received a small incentive for taking part (equivalent to US $5).
In total, 24 lay providers (n=12, 50% teacher counselors and n=12, 50% CHV counselors) and 3 supervisors were invited and interviewed in June 2021. Of the 24 lay counselor participants, 6 (25%) did not have a smartphone. These participants were all CHVs and were split across high-frequency (2/6, 33%) and low-frequency (4/6, 67%) users. The complete demographics are presented in
Demographic and baseline characteristics (N=25).
Characteristic | Teacher counselors (n=10)a | CHVb counselors (n=12) | Supervisors (n=3) | ||||
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Male | 4 (40) | 3 (25) | 1 (33) | |||
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Female | 6 (60) | 9 (75) | 2 (67) | |||
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No | 0 (0) | 6 (50) | 0 (0) | |||
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Yes | 10 (100) | 6 (50) | 3 (100) | |||
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|||||||
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No | 5 (50) | 4 (33) | 0 (0) | |||
|
Yes | 5 (50) | 8 (67) | 3 (100) | |||
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No | 1 (10) | 5 (42) | 0 (0) | |||
|
Yes | 9 (90) | 7 (58) | 3 (100) | |||
Age (years), mean (SD) | 42.7 (8.2) | 50.8 (12.0) | 36.3 (7.8) |
aDemographic data were missing for 2 teacher counselors.
bCHV: community health volunteer.
Lay counselors and supervisors described three subthemes of mobile phone uses to support intervention delivery: (1) requesting and providing advice and updates on clinical content, (2) requesting and scheduling in-person supervision, and (3) requesting and providing advice on research procedures.
Participants described requesting and providing advice on clinical content as well as providing routine clinical updates on clients’ symptoms via mobile phone. When supervisors were unable to provide face-to-face supervision, lay counselors received advice on how to deliver clinical content via phone calls or SMS text messages. Supervisors provided clarifications on clinical content and supported lay counselors when they encountered specific clinical challenges. A lay counselor explained the following:
Maybe I’m doubting something in the session I’m going to present, so I want some clarification about what I’m going to do...Then maybe [my supervisor] will tell me [what to do]...you find that I have solved that problem.
Another counselor discussed the benefits of mobile phones for providing support with clinical issues that arose during sessions:
So I had [a] problem and then in the middle of the session I had to call. When I called, [they] responded very quickly, [they] told me [how to proceed]...so it helped me very much...it was a quick response and it helped me in the middle of the session.
Participants emphasized the value of mobile phones in scheduling and coordinating clinical activities, including clinical practice, sessions, and supervision. Following their in-person clinical training, supervisors “communicated to [lay counselors] on when to start the [intervention] through the phone and...instructed [them] on how [they] should schedule [their] lessons with clients...with the phone, [lay counselors] were able to mobilize clients and started the [intervention].” Lay counselors also used mobile phones to connect and coordinate with their cocounselors, such as planning practice or coordinating clinical duties:
Sometimes we call each other. I can call or text them. But most of all I just call them on the phone.
Beyond scheduling clinical sessions, mobile phones were instrumental in scheduling supervision—both in person and via phone. A counselor explained the importance of communicating before in-person supervision to schedule and coordinate:
If I’m informed on time, maybe I will try to plan as per...I will try maybe telling the supervisor that, “At this time, I will not be available, or I will be available.” If I’m informed on time, I will try to avail myself rather than being ambushed...
Scheduling and coordinating were similarly important for phone calling:
I could just SMS and say it is heavily raining here, maybe we’ll meet later. And then [my supervisor] will respond it’s okay.
A final key use of mobile phones was communicating with supervisors regarding the research procedures for the parent BASIC trial. Supervisors reminded lay counselors about reporting requirements and advised them on issues related to participant recruitment and attendance. Lay counselors photographed and sent anonymized research forms to their supervisors via SMS text message or WhatsApp; they would also request paper copies of forms or other intervention materials via phone. A lay counselor stated the following:
You find that it easy even to send a report through the phone. Because you’re just preparing a report and then if it is taking a photograph and then I’ll send it through WhatsApp...
Finally, lay counselors were provided with airtime or other incentives for participating in the research trial via their mobile phones and mobile money.
Lay counselors and supervisors described both likes and dislikes associated with using their mobile phones to support treatment delivery. Likes were categorized into three subthemes: (1) decreased lay counselor and supervisor burden, (2) facilitated clinical and personal support, and (3) increased independence. Dislikes were also categorized into two subthemes: (1) limited information transmission and (2) affected ability to build rapport. The differences in the percentage of interviews in each use category that mention each acceptability theme are presented in
Participants frequently described how using mobile phones for supervision decreased burden for the entire team—both lay counselors and supervisors. Using mobile phones for clinical supervision allowed counselors and supervisors to decrease travel required for in-person supervision, saving time and costs:
mobile communication [allows] the supervisor to reach interior places without a problem...During the rainy season, the supervisors get a very big problem in traveling. Therefore, when there is a mobile communication, the teacher and the supervisor will just communicate.
This was frequently associated with decreased risks of in-person supervision, both in terms of decreasing travel risks and protecting against the spread of COVID-19. A lay counselor stated the following:
The government is encouraging digital devices because the supervisor can travel from the office to school...Through the mobile phone they will only communicate, but the virus will not spread.
Before the adoption of mobile phones for communication, lay counselors and supervisors also communicated through written letters. Participants described the use of mobile phones as decreasing the burden of letter writing.
The aforementioned benefits of mobile phone supervision saved time for counselors and supervisors and resulted in lay counselors feeling that their counseling duties were more manageable. A counselor stated the following:
Once you call, you’re given a way forward, and you do it immediately without wasting time.
The time saving and convenience of mobile phone supervision also made providing supervision to lay counselors more feasible for supervisors. Counselors described this as something they liked about using mobile phones:
Personally, I will be satisfied [with mobile phone supervision]...Whatever I want, [they] can help me, even by phone...[they] will also be saving [their] time to serve us counselors because I know we are many. [They] will satisfy everyone.
Participants often discussed the benefits of mobile phones in facilitating support—both for clinical skills and personal well-being. Lay counselors were able to easily and frequently reach supervisors for support via mobile phone. A supervisor explained that they encouraged their lay counselors “if something pops in your head, or if you have a question, you can just text or just [call and hang up to avoid being charged], anytime
I had that problem and then in the middle of the session I had to call. When I called [they] responded very quickly...it helped me very much.
Lay counselors also appreciated the ease of access to support for nonurgent matters, which enabled them to obtain answers promptly without waiting for an in-person supervision meeting.
Participants also discussed the personal benefits of using mobile phones for supervision. Supervisors used mobile phones as tools to build morale and encourage lay counselors, often sending “good luck” or other inspirational messages to their lay counselors. A counselor described their feelings when receiving these messages:
[my supervisor was] encouraging me to do the job and also to encourage my colleagues to just work hard...I loved it so much, it made us work hard.
Mobile phone supervision was also a place for lay counselors to communicate with one another and get to know each other better:
As [lay counselors], we used the phone to get to know each other...
Finally, some lay counselors expressed an appreciation for the privacy and confidentiality afforded by mobile phone supervision. A supervisor described this as follows:
talking to them individually through phone, to me, it’s very helpful because they will be opening up, telling you how the session was. When you talk [to the group] everybody wants to be perfect, they don’t want to appear like they did something wrong...
Finally, lay counselor participants specifically discussed how mobile phone supervision afforded them increased independence as counselors and, as a result, increased their confidence in their own abilities and teamwork. Mobile phone supervision indicated to lay counselors that supervisors trusted their ability to provide quality care:
You know sometimes when you leave people with freedom and trusting them, they even work better than just when you’re on their back...I feel good [as a result]...I feel trusted.
The independence afforded by mobile phone supervision also enabled lay counselors to trust each other more and develop more cohesive group dynamics:
phone communication made us trust each other and work without questioning each other.
In addition to the many aspects of mobile phone supervision that the participants liked, certain dislikes arose from the qualitative interviews. Lay counselors disliked how communicating through phone with supervisors limited the transmission of information. Given that some lay counselors did not have smartphones, SMS text messages tended to be very brief. As such, phone calls allowed them to communicate in greater detail; however, brevity was also a challenge with calls, likely because of the pressure to reduce airtime use. A lay counselor stated the following:
You will briefly talk on [the] phone, but not about everything you need to know.
Lay counselors also disliked that receiving support over the phone did not lend itself well to demonstrations of clinical techniques. A counselor explained the following:
I want to believe that when it comes to those demonstrations, then face-to-face [supervision] cannot be replaced by mobile for clarity.
Mobile phone supervision also hindered lay counselors’ and supervisors’ ability to convey and examine body language and gestures. A supervisor noted the following:
The only problem [with mobile phone supervision] is that sometimes I can’t really observe the body language in terms of maybe the nonverbal gestures.
Lay counselors and supervisors stressed the importance of complete communication and examining body language with more complex treatment elements, such as completing children’s trauma narratives (ie, imaginal exposure).
Lay counselor participants often highlighted the importance of establishing a strong relationship with supervisors and noted that mobile phone supervision limited their ability to establish a trusting relationship. A lay counselor explained that meeting face-to-face first is essential and then they “will have what it takes to express [themself] better than on the phone.” Another lay counselor agreed, saying that “face-to-face sometimes also enhances that particular...public rapport...between the supervisor,” which leads to closeness that will “also enhance or will encourage good relations.” Counselors also expressed concerns that increasing reliance on mobile phone supervision would result in fewer incentives from their supervisors, such as small meals or snacks during in-person supervision meetings.
Facilitators were categorized into four subthemes: (1) access to working smartphones, (2) ease and convenience of smartphones, (3) cellphone literacy, and (4) a strong supervisor and counselor relationship. Barriers were also categorized into four subthemes: (1) limited resources and time, (2) technical difficulties, (3) communication challenges, and (4) contextual limitations on which activities can be effectively performed via mobile phone. The differences in the percentage of interviews in each use category that mention each feasibility theme are presented in
Participants noted that having a working smartphone with access to reliable internet, cellular service, and electricity allowed lay counselors and supervisors to engage in mobile phone supervision. A lay counselor summarized it as follows:
if you get a good phone, which can access all those things, there is such a possibility that the work [supervision] should be done by phone without any doubt.
Another lay counselor mentioned that “if the network is available, we can communicate at all times.” Some lay counselors stated that access to alternative phones when personal phones were not available facilitated mobile phone supervision.
In addition, lay counselors and supervisors described ways in which mobile phone supervision provides an easy and convenient alternative to in-person supervision. A lay counselor highlighted the following:
Anytime you call, [my supervisor’s] phone is always on. So, [they] have been a good supervisor because sometimes you can be in the middle of a session and maybe call and don’t get [them]...but...I’ve never called, and I missed my supervisor.
Decreased costs in terms of travel and time associated with mobile phone supervision also made supervision more feasible. The utility of mobile phone supervision in routine instances (eg, when a question arises during a session) also contributed to lay counselors reporting mobile phone supervision as feasible and easy to use. A lay counselor explained that, “in areas where things move on well without many hitches, then mobile supervision can work.”
Participants reported that the trust and cooperation between supervisors and lay counselors contributed to the feasibility of mobile phone supervision. A lay counselor explained that “I think it’s just a matter of cooperation between the supervisor and the counselor...” A warm and supportive supervisory relationship may be particularly important in mobile phone supervision where visual cues may not be as clear (eg, body language and facial expressions). A lay counselor expanded on this idea:
Because without trust and cooperation I can send something [to my supervisor], I can send anything even if it is useless. It’s not good. But if we trust each other and work together here...the phone call is real.
A final important facilitator that counselors noted was familiarity with the platform (eg, WhatsApp or SMS text messages) used in mobile phone supervision:
after getting that information [about WhatsApp], then I can easily connect with the supervisor and communication takes place.
When counselors and supervisors are knowledgeable about the platform on which they are communicating, mobile phone supervision is possible. Supervisors and lay counselors noted how COVID-19 had increased mobile phone literacy, which had made mobile phone supervision easier to use in some instances.
Participants noted a few tangible barriers to remote supervision, often discussing issues of phone airtime and the challenges of balancing competing priorities during phone calls. Participants repeatedly mentioned lack of airtime, which hindered their ability to connect with their supervisors:
Airtime. You may not have it. Maybe I have no money to buy it. And I want to talk to my supervisor. You see there is a problem.
Further challenging participants was the cost of owning a working smartphone, which some felt was needed to have the best experience with mobile phone supervision (ie, sending photos and videos and accessing WhatsApp). Finally, participants expressed challenges with balancing many competing priorities in their limited time. A participant said the following:
[our supervisor advised us that] we are going to have a session on mobile phone. Then during that time, we are doing an exam [with the children]...So, it becomes difficult to use that mobile phone at that time...
Another common barrier to remote supervision was related to physical issues with the phones themselves (eg, broken or with weak batteries) as well as problems with the network connection. Participants mentioned that keeping the phone charged was especially challenging when there was unreliable electricity and rolling blackouts. Lay counselors also had issues with the network where they were unable to place calls and other times where a poor network connection affected the quality of the phone call in such a way that they could not understand their supervisor clearly. All the aforementioned issues were complicated by weather, which affected both the power supply and network access. A participant explained the following:
Even if you can call someone on phone, then you are told that they are not available. Yet, their phone is on...the rain is coming this way...You find there is no network at my end.
Remote supervision inherently affects the nature of communication between supervisor and counselor, and some of these changes were cited as barriers by the participants. The time delay between asking supervisors a question and receiving an answer also posed issues and increased the possibility of miscommunication. A participant noted the following:
Sometimes you could call the supervisor and then maybe [they’re] also engaged in a meeting, [they’ll] tell you, “I’ll call you later.” And sometimes [they] might call very late when that issue has been left or has been left unresolved like that, or you have solved within your knowledge.
Furthermore, participants experienced occasions in which phone conversations felt rushed or when they were interrupted or distracted because they did not have secure and confidential locations in which to conduct mobile phone supervision.
The most cited barrier to remote supervision was that participants felt that there were some supervisory activities that could not occur over the phone. This code captured a range of challenges, from not being able to physically hand a supervisor a report or receive COVID-19 supplies (eg, hand sanitizer and masks) to concerns that lay counselors may not be taken seriously by management unless supervisors were seen in person. In addition, some participants said that remote supervision takes some of the responsibilities off the supervisor and puts them on the lay counselors themselves, such as conducting treatment sensitization with the administration and guardians or terminating treatment groups. Finally, many participants noted concerns that, without in-person supervision, other counselors may cut corners and not do their job as thoroughly:
You can’t put a worker in a field and expect him or her (to) weed out everything without your supervision. He’ll just tell you he’s weeded. And if you go you get grass. He has not weeded out the dirt.
Lay counselors and supervisors offered 27 discrete solutions or suggestions to improve the acceptability and feasibility of mobile phone supervision. Providing airtime and phones were among the most mentioned strategies to improve the acceptability and feasibility of mobile phone supervision. Lay counselors searching for and identifying locations with optimal network connection to take phone calls for supervision was also frequently mentioned. A lay counselor stated the following:
We always just look for [network connection]. You can stand somewhere where it can come all, or maybe you’re sitting somewhere where that network is not there. So, it needs you to move so that you get it.
Another less frequently mentioned strategy was to provide training on mobile phones and apps such as WhatsApp to facilitate use for lay counselors who may lack knowledge of mobile phones. Some lay counselors described the clinical and personal benefits of learning new features on their mobile phones:
The phone was a tool that helped me a lot especially at that time I came to learn how to use WhatsApp...I found myself in a new world through that part of the WhatsApp group.
Each of the solutions, along with its definitions and the challenges it was intended to address, is presented in
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Lay counselors should plan to
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Lay counselors and supervisors can quickly
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Supervisors can ensure that they are sending
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Lay counselors should always feel empowered to
Although lay counselors and supervisors reported some dislikes with mobile phone supervision, it was overall reported to be acceptable and feasible. Lay counselors and supervisors generated unique solutions to improve the acceptability and feasibility of mobile phone supervision that are currently being explored in a pilot trial [
Most research on clinical supervision has been conducted with US graduate students or community mental health providers, the latter of which has shown that clinical supervision largely focuses on case management [
Although participants mentioned several facilitators, access to working smartphones was mentioned by almost every lay counselor participant (23/24, 96% of the total). Although access to and use of mobile phones continue to rise worldwide [
The work presented in this paper represents a first step in our co-design process, which has been followed by further work to refine solutions and develop implementation guidance for lay counselors and supervisors. It became clear that there was no singular solution that would be acceptable or feasible across all communities. Recognizing the importance of tailoring approaches to the distinct contexts in which each lay counselor group operates, our research approach shifted from developing specific “solutions” to which all lay counselors should adapt to presenting all possible solutions and facilitating lay counselors in identifying and prioritizing solutions that they felt would work best in their respective contexts. Noting recent critiques of design thinking as a form of colonialism [
To honor the voices of our participants, we felt it was important to present all the solutions. The solutions discussed included workarounds that the lay counselors or supervisors were already using; additional workarounds that they could use (although perhaps at considerable added cost or time to the counselors and supervisors); or outcomes that would better facilitate their work, although without a clear path or resources to achieve them. Many of the solutions generated by lay counselors and supervisors seemed to place the responsibility and burdens of addressing challenges on themselves. This may reflect a focus on short-term solutions that could be implemented with minimal resources and a resourcefulness developed from living in marginalized and underserved communities—another lasting impact of European settler colonialism. These solutions also highlight a limit of the co-design method used in this study: it supported sharing techniques and tips among participants in the room, but many solutions that could truly enhance their work required additional resources that neither they nor we were going to design our way out of needing. To equitably implement and sustain task-shifting models, especially when driven by US investment, resources must be allocated appropriately such that additional burdens (financial, logistical, and emotional) are not unduly placed on providers. This includes ensuring that research projects and support systems appropriately acknowledge and address barriers by providing financial support and resources to lay providers and other partners in low-resource settings.
Given the tremendous gaps in access to mental health care worldwide, scalable and sustainable solutions are needed to increase access to care for the most underserved populations. There has been increased attention on the potential of digital tools such as mobile phone apps or internet-based treatments to address the mental health treatment gap by directly targeting clients and patients [
These findings should be considered within the context of their limitations. The HCD approach used in this study allowed supervisors and lay counselors (ie, end users) to provide feedback and suggestions for the improvement of mobile phone supervision. However, as a result, our findings speak specifically to the use and optimization of mobile phones for lay counselor supervision in western Kenya. Although some findings may transfer to other settings or contexts, future work should aim to continually engage users across contexts and design and adapt solutions with these contexts in mind. Our number of supervisors for the study was also limited (n=3), which affects our ability to extrapolate from supervisor interviews but also underscores the importance of scalable and sustainable supervision. Similarly, 25% (6/24) of our lay counselors did not have smartphones, which affected their experience with supervision and qualitative responses. Finally, when appropriate, the interviews were translated, and all qualitative analyses were completed in English. In addition, the interviewers had ongoing relationships with supervisors and lay counselors, which may have affected reporting accuracy. Interview scripts and prompts were designed to investigate specific facilitators and barriers to remote supervision (eg,
Task shifting offers an effective and potentially sustainable solution for closing the mental health treatment gap in low-resource settings; however, its scale-up and sustainment are limited by the need for ongoing supervision. Lay counselors and supervisors highlighted key benefits and challenges of using mobile phones and offered 27 distinct solutions to improve mobile phone supervision. Our findings underscore the benefits—and limitations—of co-designing solutions to improve the use of digital health tools and can serve as a foundation for future work that addresses barriers to the use of digital health tools in lower-resource settings.
Final interview guide.
COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist.
Qualitative themes by use category.
Building and Sustaining Interventions for Children
community health volunteer
Consolidated Criteria for Reporting Qualitative Research
evidence-based psychotherapy
human-centered design
low- to middle-income country
trauma-focused cognitive behavioral therapy
The authors thank the Ace Africa trauma-focused cognitive behavioral therapy supervisors, community mobilizers, and interviewers: Elijah Agala, Moses Malaba, Emmanuel Muli, Micah Nalianya, Bernard Nabalia, Michael Nangila, Daisy Okoth, Omariba Nyaboke, Annette Sulungai, Sylvia Wafula, and Nelly Wandera. Their hard work, dedication, and high integrity made this research possible. The authors are also grateful to the Kenyan Ministry of Health, Ministry of Education, Teachers Service Commission, schools, communities, children, and families who took part in this trial and the parent trial.
The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.
The authors declare that the research was conducted in the absence of any substantial commercial or financial relationships that could be construed as a potential conflict of interest. NST has received honoraria for speaking engagements with the Robert Wood Johnson Foundation, a funder of this work. SD has received grants and honoraria for providing training and consultation on the treatment model that was adapted and delivered by the lay counselors (trauma-focused cognitive behavioral therapy).