Abstract
Background‘Tele-Mental Health (MH) services,’ are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its MH activities across humanitarian and resource-constrained settings to remote format.MethodsFrom June–July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of tele-MH services. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews occurred.ResultsRespondents in 44 countries (6 geographic regions), mostly from Sub-Saharan Africa (39.5%), the Middle East and North Africa (18.5%) and Asia (13.6%) participated. Most tele-MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using these interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using telecommunication platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought tele-MH services had some degree of usefulness, notably improved access to care (37.7%) and time efficiency (32.8%). Qualitative results outlined a myriad of challenges, notably in establishing therapeutic alliance, providing care for vulnerable populations and those inherent to the communications infrastructure.ConclusionTele-MH services were perceived to be a feasible alternative solution to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering tele-MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.
Highlights
The treatment gap for mental health (MH) services in low- and middle-income countries (LMIC) is a chasm, with the ratio of LMIC Mental Health (MH) therapists estimated at only 0.5% of that available in high-income countries [1]
Tele-MH service provision was explored with activity managers from sites that shifted to remote care and those that were not able to, the former answering more detailed questions about feasibility, perceived acceptance and performance. 120 activity managers were invited to participate in an online survey through their official Médecins Sans Frontières (MSF) email address, of which 84 (70.0%) provided consent and 81 (67.5%) participated
Programs provided care for every MH condition regardless of severity, as per MSF policy and most projects represented in the sample had no restrictions in terms of age (69.1%) or gender (91.3%) (Table 2)
Summary
The treatment gap for mental health (MH) services in low- and middle-income countries (LMIC) is a chasm, with the ratio of LMIC MH therapists estimated at only 0.5% of that available in high-income countries [1]. ‘Tele-MH services’ (or care delivered remotely by MH care providers through telecommunications technology) are becoming an increasingly important way to expand care to underserved groups [3] These methods have been highly effective in high-income countries [4,5,6] and their use and effectiveness in LMIC has been seen across diverse settings and MH conditions [7,8,9,10,11,12]. There are numerous advantages to tele-MH solutions, including reduced travel, wait times and costs, and improved access to services [13,14,15,16], especially in understaffed, remote, or insecure areas. Implementation and use of tele-MH care in humanitarian and crisis settings remain understudied
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