Impact statement
Low- and middle-income countries (LMICs), such as South Africa, often face healthcare resource constraints, with many individuals not accessing the needed support. To identify feasible and effective intervention alternatives for trauma survivors in LMICs, we evaluated a counsellor-supported PTSD Coach mobile application (PTSD Coach-CS) intervention in a randomised controlled trial (RCT) in a South African adult community sample. As part of the evaluation, we explored participants’ experiences of the intervention to inform and complement the findings of the RCT. Participants experienced the intervention procedures positively, especially the counsellor’s support, who practically and effectively introduced them to the application (app), increasing app engagement. Participants experienced a safe space that, together with the app, facilitated self-acceptance of their lived experiences (e.g., trauma and PTSD). The PTSD Coach app was experienced as easy to navigate, and helpful in learning about and managing PTSD symptoms. Participants gained hope for the future and wanted others to benefit similarly. Participants provided valuable insight into the barriers (specific to the intervention and systemic-related) requiring improvement. This included spreading awareness of the PTSD Coach app as freely available, including the counsellor’s support in introducing the app’s features. Furthermore, taking the intervention to the communities may help in overcoming travel and associated financial barriers. Finally, evaluating the PTSD Coach family app in conjunction with a PTSD Coach-CS intervention may improve treatment outcomes. This was the first study to evaluate a counsellor-supported PTSD Coach app in a resource-constrained setting and participants’ experiences thereof. The findings proved useful in understanding how to improve the feasibility, acceptability and usefulness of the PTSD Coach-CS intervention for future use in a resource-constrained South Africa. We build on the existing evidence of internet- and mobile-based interventions for PTSD, suggesting that the PTSD Coach-CS intervention and the app itself can widen access to psychiatric care.
Background
Low- to middle-income countries (LMICs), such as South Africa, face high levels of psychiatric conditions, including post-traumatic stress disorder (PTSD), impacting the daily functioning of those affected (Kessler et al., Reference Kessler, Aguilar-Gaxiola, Alonso, Benjet, Bromet, Cardoso, Degenhardt, de Girolamo, Dinolov, Ferry, Florescu, Gureje, Haro, Huang, Karam, Kawakami, Lee, Lepine, Levinson, Navarro-Mateu, Pennell, Piazza, Posada-Villa, Scott, Stein, Ten Have, Torres, Viana, Petukhova, Sampson, Zaslavsky and Koenen2017; Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017; Ng et al., Reference Ng, Stevenson, Kalapurakkel, Hanlon, Seedat, Harerimana, Chiliza and Koenen2020). For instance, in sub-Saharan African countries, the PTSD prevalence is around 22% (Ng et al., Reference Ng, Stevenson, Kalapurakkel, Hanlon, Seedat, Harerimana, Chiliza and Koenen2020). Timeous and effective interventions can mitigate the debilitating effects of psychiatric conditions like PTSD (Seedat and Suliman, Reference Seedat, Suliman, Nemerhoff and Marmer2018; Bisson and Olff, Reference Bisson and Olff2021). However, compared to higher-income countries, LMICs typically face greater resource constraints limiting access to the appropriate care (Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017; Seedat and Suliman, Reference Seedat, Suliman, Nemerhoff and Marmer2018; Docrat et al., Reference Docrat, Besada, Cleary, Daviaud and Lund2019). Broadly, barriers to appropriate care can be divided into (i) availability of treatments and (ii) accessibility to available treatments, which are influenced by both systemic and personal factors (Docrat et al., Reference Docrat, Besada, Cleary, Daviaud and Lund2019; Knettel et al., Reference Knettel, Mulawa, Knippler, Ciya, Robertson, Joska and Sikkema2019; Sander et al., Reference Sander, Schorndanner, Terhorst, Spanhel, Pryss, Baumeister and Messner2020).
Docrat et al. (Reference Docrat, Besada, Cleary, Daviaud and Lund2019) conducted a large-scale national situational analysis evaluating the costs and resource constraints associated with psychiatric services in South Africa. The public health care (PHC) sector serves 84% of the South African population, with the remainder accessing services with private health insurance. The findings suggest a ratio of 0.31 psychiatrists per 100,000 PHC users. The national ratio of psychologists is slightly higher at 0.97 per 100,000. More promising but still lacking, the proportion of specialised nurses, albeit not all psychiatric nurses, was 80 per 100,000 users (Docrat et al., Reference Docrat, Besada, Cleary, Daviaud and Lund2019). These ratios likely worsened since its publication, given the population increase from approximately 58.8 to 60.6 million registered South African citizens (South African Department of Statistics (Stats SA), 2022). Thus, a hugely under resourced infrastructure hinders the feasibility and sufficient availability of needed psychiatric care in the South African PHC setting.
Despite being under resourced, psychiatric services are available in South Africa, and it is important to recognise the substantial progress made since the inception of the Mental Health Care Act 17 of 2002 and the subsequent South African National Mental Health Policy Framework and Strategic Plan 2013–2020 (The Department of Health, 2013; Petersen et al., Reference Petersen, Fairall, Bhana, Kathree, Selohilwe, Brooke-Sumner, Faris, Breuer, Sibanyoni, Lund and Patel2016). In South Africa, barriers to accessing available PHC services include transport difficulties, work responsibilities and, pertaining more to psychiatric services, the stigma often associated with diagnosing and treating psychiatric conditions (Knettel et al., Reference Knettel, Mulawa, Knippler, Ciya, Robertson, Joska and Sikkema2019). Most PHC users walk or use public transport to reach their destinations (e.g., workplace or hospital) (Stats SA, 2021). Globally and locally, recent exorbitant fuel costs and resultant increases in the cost of living (including public transport fares) hamper the ability to use public transport (Stats SA, 2021). Coupled with a high unemployment rate, the impact of rolling load shedding (i.e., rolling electricity blackouts), and rife and often violent public transport protests, many are unable to access PHC services (Goldberg, Reference Goldberg2015; Laher et al., Reference Laher, Van Aardt, Craythorne, Van Welie, Malinga and Madi2019; Mmakwena, Reference Mmakwena2022). Finally, the harmful effects of stigma often prevent treatment-seeking individuals from accessing services (Knettel et al., Reference Knettel, Mulawa, Knippler, Ciya, Robertson, Joska and Sikkema2019; Booysen et al., Reference Booysen, Mahe-Poyo and Grant2021; Monnapula-Mazabane and Petersen, Reference Monnapula-Mazabane and Petersen2021). This highlights the importance of identifying alternative or supplemental treatment resources and understanding how they may assist in overcoming some of the mentioned barriers.
Overall, individuals seem to have limited access to essential services and treatments in the South African context. To improve access to appropriate psychiatric care in resource-constrained settings, researchers increasingly implement and evaluate suitable treatment alternatives that require less specialised resources (e.g., counsellors as opposed to psychologists) and that are less costly (Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017). Internet- and mobile-based interventions are some of the more accessible and low-cost alternatives that can potentially alleviate some of the known challenges to accessing psychiatric care in resource-constrained settings such as South Africa (Olff, Reference Olff2015; Ruzek and Yeager, Reference Ruzek and Yeager2017; Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Mqaisi, Greyvenstein, Kilian and Seedat2022, Reference Bröcker, Suliman, Olff and Seedat2023). Most of South Africa has sufficient cellular coverage with particularly high active smartphone subscriptions (approximately 65 million) (Independent Communications Authority of South Africa [ICASA] 2020). Although internet- and mobile-based augmentation of resources has great potential to meet real needs, with over 300,000 mobile health applications available, concerns regarding the applications’ credibility, privacy, and overall quality must be considered (Byambasuren et al., Reference Byambasuren, Sanders, Beller and Glasziou2018; Chandrashekar, Reference Chandrashekar2018). After reviewing the content and quality of 69 PTSD-focused applications (apps), Sander et al. (Reference Sander, Schorndanner, Terhorst, Spanhel, Pryss, Baumeister and Messner2020) highlighted the freely available PTSD Coach app as a promising treatment option with positive quality ratings. The PTSD Coach app forms part of a 20 mental health-related apps suite developed by the Veterans Affairs of the United States Department of Defence and is available for both Android and iOS users (Gould et al., Reference Gould, Kok, Ma, Zapata, Owen and Kuhn2019; United States Department of Veterans Affairs, 2022). The PTSD Coach app includes trauma and PTSD psychoeducation, tools to manage and track PTSD symptoms, and support resources (visit https://www.ptsd.va.gov/appvid/mobile/ptsdcoach_app.asp for further information). Designed for self-managed use or as augmentative treatment, the PTSD Coach app has approximately one million downloads spanning 115 countries (Hoffman et al., Reference Hoffman, Wald, Kuhn, Greene, Ruzek and Weingardt2011; Owen et al., Reference Owen, Jaworski, Kuhn, Makin-Byrd, Ramsey and Hoffman2015).
To date, evidence of the PTSD Coach app’s feasibility and effectiveness is mostly from high-income countries with comparatively fewer healthcare resource constraints and suggests future research should include a supportive component to intervention delivery to enhance engagement and effectiveness (Kuhn et al., Reference Kuhn, van der Meer, Owen, Hoffman, Cash, Carrese, Olff, Bakker, Schellong, Lorenz, Schopp, Rau, Weidner, Arnberg, Cernvall and Iversen2018; Bröcker et al., Reference Bröcker, Suliman, Olff and Seedat2023). Research in resource-constrained contexts supports the use of less specialised mental health resources (counsellors vs. clinicians) in intervention delivery to widen access to care (Spedding et al., Reference Spedding, Stein and Sorsdahl2015; Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017; De Kock and Pillay Reference De Kock and Pillay2018; Rossouw et al., Reference Rossouw, Yadin, Alexander and Seedat2018).
Study context and rationale
To address the aforementioned gap in the extant literature on PTSD Coach, we conducted a randomised controlled trial (RCT) to evaluate the effectiveness of a brief four-session counsellor-supported PTSD Coach mobile app (PTSD Coach-CS) intervention in South African adults with PTSD (trial registration number: PACTR202108755066871) (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). Study flyers were distributed in the community and promoted on social media. The RCT allocated participants to PTSD Coach-CS or enhanced Treatment-as-Usual (e-TAU) on a 1:1 basis ((Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). RCT participants were aged 19–61 years; female = 89%; black = 77%, owned smartphones, could provide written informed consent, and were conversant in English. The latter was a requirement as the original version of the PTSD Coach app was used.Footnote 1 A registered clinical psychologist conducted the Mini-International Neuropsychiatric Interview for DSM-5 and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) to confirm their PTSD diagnosis (Sheehan et al., Reference Sheehan, Lecrubier, Sheehan, Amorim, Janavs, Weiller, Hergueta, Baker and Dunbar1998; Weathers et al., Reference Weathers, Bovin, Lee, Sloan, Schnurr, Kaloupek, Keane and Marx2018). The psychologist, blinded to intervention allocation, assessed treatment response from pre- to post-treatment at 4 weeks and to 1 and 3-month follow-up. Outcome measures included the CAPS-5 (main outcome), the PTSD Checklist and the Depression, Anxiety and Stress Scale-21 items self-report measures (Henry and Crawford, Reference Henry and Crawford2005; Wortmann et al., Reference Wortmann, Jordan, Weathers, Resick, Dondanville, Hall-Clark, Foa, Young-McCaughan, Yarvis, Hembree, Mintz, Peterson and Litz2016). User experiences of the PTSD Coach app were also collected with self-administered surveys (Kuhn et al., Reference Kuhn, Greenem, Hoffmanm, Nguyenm, Wald, Schmidt, Ramsey and Ruzek2014). RCT participants were not financially compensated but were reimbursed for their transport costs (ZAR200/USD13.30)Footnote 2 at each study visit.
The main findings of the RCT included greater improvement in clinician-monitored PTSD and self-reported stress symptoms over time in the PTSD Coach-CS group compared to the e-TAU group (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). The intervention uptake was good, with most participants attending all four intervention sessions. Also, self-reported app use outside of these sessions varied from daily to five times per week (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). Generally, the PTSD Coach app was positively received, and participants rated the app as moderately to very helpful in managing PTSD symptoms. Smartphone ownership was not a significant barrier to intervention implementation, but technical difficulties related to app download were problematic for one participant (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). Overall, the RCT results supported the feasibility and acceptability of both the original version of the PTSD Coach mobile app platform and the notion of involving counsellors in intervention delivery (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). For more information on the original RCT (e.g., counsellor training and protocol fidelity, please see Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024).
Present study aim
One of the secondary objectives of the RCT was a qualitative sub-study to augment the findings of the RCT (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). To this end, we collected qualitative feedback from PTSD Coach-CS participants exploring their experiences of the feasibility (e.g., how they experienced the support received), acceptability (e.g., what they liked about the intervention) and impact (e.g., how the intervention influenced them) of PTSD Coach-CS in a South African community setting. Qualitative data provide a more in-depth understanding of participants’ experiences, which can be used to inform future research and intervention implementation. This manuscript presents the results of the qualitative sub-study.
Methods
We adhered to the COnsolidated criteria for REporting Qualitative research guidelines when writing this manuscript (Tong et al., Reference Tong, Sainsbury and Craig2007).
Participants
Of the 32 participants allocated to the PTSD Coach-CS intervention, four were lost to follow-up at post-treatment, while three participants indicated that they did not have time to complete the qualitative sub-study as they had to return to work. Thus, 25 PTSD Coach-CS intervention participants completed the 12-item questionnaire (see ‘Data collection’ for a more detailed description). Participants in this qualitative sub-study (aged 19–59 years; mean = 38.9; SD = 12.7) were predominantly female (80%), black (77%) and isiXhosa speaking (80%) (see Table 1 for additional socio-demographic information).
Table 1. Baseline socio-demographic characteristics
Intervention
The intervention entailed four weekly in-person counsellor-supported sessions lasting approximately 30–40 min each. These sessions were conducted in English, aligning with the study eligibility criteria that required participants to be conversant in English. However, as stated in the study informed consent, participants were reminded that they could request assistance (e.g., support in their first language) if needed. At each session, the registered counsellor went through and discussed selected tools of the app (see Table 2). The counsellor provided a standard method of support (e.g., assisting with language and technology difficulties without providing therapeutic input) as per the intervention protocol. During session 1, the counsellor assisted in installing the PTSD Coach app on participants’ phones, with mobile data provided by the study. All four sessions followed the same structure: (i) setting an agenda for the session; (ii) gathering feedback on the last session; (iii) reviewing the week and homework; (iv) working through selected symptoms and tools with the counsellor to assist with technical difficulties and (v) agreeing on homework for the following week. The app addresses eight PTSD-related symptoms with accompanying 23 tools and activities. Tools for each session were selected after carefully considering their suitability and appropriateness to our setting. Participants were encouraged to use the app outside the intervention sessions.
Table 2. Intervention content
Data collection
Directly after completing intervention session 4, the counsellor invited PTSD Coach-CS participants to complete the 12-item questionnaire (paper-and-pen).Footnote 4 This self-administered questionnaire elicited data on the feasibility, acceptability and the potential impact of the PTSD Coach-CS intervention (see Supplementary material for further details). Questions also covered the feasibility and acceptability of psychological support in our setting in general, to further inform intervention adaptation and the effects of the COVID-19 pandemic on app use. An open-ended item concluded the questionnaire to collect any additional relevant information. A research assistant anonymised, captured and grouped the responses per question in a Microsoft Excel spreadsheet. The semi-structured and open-ended nature of the questions leant themselves to qualitative analysis.
Data analysis
Two researchers (E.B. and F.S.) with qualitative research experience, independently conducted thematic analysis (Braun and Clarke, Reference Braun and Clarke2006), using Atlas.ti (Version 23.0.8.0) (ATLAS.ti, 2022). E.B. is a registered clinical psychologist and F.S. is a registered research psychologist. We followed the six steps proposed by Braun and Clarke (Reference Braun and Clarke2006): (i) reading and re-reading through the transcripts to familiarise ourselves with the data and obtain a general understanding of participants’ responses; (ii) generating initial codes line by line from the transcripts until reaching saturation (see Supplementary material for further details); (iii) constructing sub-themes from the codes; (iv) reviewing and collapsing the potential sub-themes; (v) defining and naming the main themes and (vi) synthesising the themes into a coherent whole (i.e., writing the manuscript). Considering the shared meaning-making inherently involved in qualitative analysis, the second coder (F.S.) was not involved in the larger study and conducted an independent analysis. Discrepancies in codes, themes and sub-themes were resolved through discussion.
Ethical considerations
The main study (RCT) was approved by the Health Research Ethics Committee (HREC) of SU (N18/03/061/ S18/05/058). During the informed consent process of the RCT, participants were informed of the voluntary nature of all study procedures (including the qualitative sub-study). All trial data were anonymised to protect participants’ privacy and ensure confidentiality.
Results
Three main themes emerged from participants’ responses: (i) experience of treatment procedures, (ii) perceptions of the PTSD Coach app and (iii) barriers to treatment. The themes and sub-themes are presented in Figure 1 and discussed with erbatim quotations supporting our findings.
Figure 1. Thematic map demonstrating themes and sub-themes.
Theme 1: Experience of treatment procedures
Most participants were positive towards the intervention procedures. The counsellor support created a safe space for the participants to talk and ask questions, which, in combination with the PTSD-Coach app tools (see Theme 2), allowed them to experience self-acceptance and understanding of their PTSD diagnosis.
Counsellor support and safe space
Participants found the intervention procedures allowed them to talk freely about their experiences: “I like that I was able to speak about what was bothering me” (P17). Participant 5 said: “…I can talk about the things….” Since the PTSD Coach-CS intervention protocol instructed the counsellor to maintain strict boundaries and not provide therapy, participants likely referred to the structured elements (e.g., gathering feedback on the previous session) and overall counsellor involvement that was perceived as therapeutic. It is also possible that the participants referred to the monitoring sessions with the psychologist.
Participants’ overall experience with the counsellor was positive. For example, participants said: “Better than good. She was so patient very good” (P2) and “She was very helpful and supportive towards me. She made sure I was welcomed, and she explained everything to me” (P20). The counsellor support was also helpful, specifically related to the app “…because of the way things are explained in details [sic] for you to understand” (P8). Furthermore, the counsellor was integral in creating a safe space that allowed them to talk freely, without judgement. For example, Participant 7 said: “Feels [sic] that I came into a space where I can just be myself and learn”, while Participant 14 said: “It was very good she was understanding and nice, I felt free around her…I liked the fact that I had someone to talk to without a fear of being judged.” Here, Participant 14 also alluded to fearing judgement (which can be linked to stigma) as a barrier to accessing support resources (see Theme 3).
Self-acceptance
The perception and experience of the counsellor support sessions as a safe space where participants felt free to talk and ask questions, in combination with the PTSD Coach app tools (see Theme 2), facilitated participants’ self-acceptance and understanding of their PTSD diagnosis. Participants said that the process “…allows me to know that it is wise to forgive myself” (P4) and “It also helped me change the view I have about myself” (P9). Similarly, Participant 22 said: “Made me realise or shall I say find myself and see things different than before in a better way.” Notably, Participant 20 said: “…it made me realised [sic] that having PTSD is not the end of the world.” The latter links to the barrier of denial (Theme 3). Relatedly, Participant 17 later noted that people do not seek treatment due to “Not being able to accept that they suffer from PTSD.”
Theme 2: Perceptions of the PTSD Coach app
Overall, participants had a positive perception of the PTSD Coach app, with a significant emphasis on learning about and managing their PTSD symptoms, which provided hope for the future. Participants also wanted others to know about the intervention and to benefit similarly. However, some participants noted negative aspects of the PTSD Coach App.
Positive perception of the PTSD Coach app
Most participants found that “PTSD Coach is a very good app and its [sic] very helpful” (P18). Participants also found that “…it was an easy app to understand” (P13) which they could “…use it for life” (P24). There were specific app tools that they found helpful, such as the ‘Inspiring quotes’ tool that “…motivated me (and meditating) about my feelings through video” (P23), and “(t)he exercise that when you feel bad you put headphones on and walk, the connection with mother nature” (P4). Participant 4 likely referred to the ‘Leisure activities’ tool, which together with ‘Inspiring quotes’, were not part of the intervention protocol (see Table 2). This suggests that participants engaged with the app outside the counsellor-supported sessions.
Learning about PTSD and managing symptoms
Participants found the app’s functions of learning about PTSD and managing their symptoms helpful. This was facilitated through the “[e]explanations about PTSD [which] is clear” (P23) and links to the positive perception of the PTSD Coach app as “…an easy app to understand” (P13). Participants mentioned that learning about PTSD helped to “[understand] my symptoms…" (P12) and the app “…help[s] people learning and understanding what they are experiencing” (P21). Learning about and understanding their experiences likely enabled participants to apply the tools to manage their symptoms as the app “…helped [me] to manage my stress from the trauma” (P16). Also, Participant 9 said: “I liked knowing where all the emotions come from and also that I know how to cope and handle those emotions for the first time.” Participants specifically noted that “I don’t feel angry anymore… and I know how to manage my temper…” (P20).
Hope for the future
A valuable impact of the intervention is that participants experienced hope for the future. For example, participants said the intervention made “…me realise there is still hope” (P1) and “…gave me the courage to go out there” (P8). Participant 9 made the following striking comment:
Before I came here, I thought that there isnt [sic] a reason for me to live and since coming here I feel stress free and I have hope for my life. I can now also handle things coming my way.
Want others to benefit
Given the positive feedback about the counsellor and the app, it was unsurprising that most wanted others to benefit from it. Specifically, Participant 1 said that they “[w]ant to share [it] with other people,” and Participant 8 said: “…that even myself [I’m] thinking of helping others the same way I was helped.” Participant 23 who said: “I wish all of us can be reached or having [sic] it in their phones,” also alluded to the possible barrier of treatment (see Theme 3) related to unawareness of the freely available PTSD Coach app as a resource.
Negative perceptions of the PTSD-Coach app
Participant 3 did not find the app helpful, stating: “In my experience the app did not help (instead) the people encouraged me to talk about my feelings and that it is okay,” implying that the counsellor support or possibly the monitoring sessions with the psychologist was of greater help than the app. Some participants were positive towards the app, but they also mentioned that they “…would have wanted more counselling support” (P5) and recommend to “Ask more about emotions during sessions” (P5). While this further highlights the importance of the counsellor-supported aspect of the intervention process, it also implies that fidelity to the RCT intervention protocol was maintained (i.e., no therapeutic input was provided).
Participants also highlighted unhelpful aspects of the app that can be improved on such as “…Unhelpful – that it doesn’t involve the whole family" (P17). Participant 23 mentioned that even though the app helped her to become aware that she struggles with PTSD, she found it “…exhausting with the exercises.” However, one should bear in mind that the intervention protocol involved working through the tools in a specific timeframe, whereas self-guided use of the app does not. Further, Participant 8 said she disliked that “…it does ask me a lot about my experiences of trauma." While the app itself does not require this, it is likely that Participant 8 referred to the monitoring sessions with the psychologist. Participant 8’s comment also alluded to fearing stigma as one of the barriers to accessing support resources (see Theme 3).
Theme 3: Barriers to treatment
Most participants found the PTSD Coach-CS intervention positive and the app itself beneficial, but there were some barriers to its implementation. These were both specific to the current intervention process and related to systemic barriers to accessing support in our setting.
Barriers to engaging with the PTSD Coach-CS intervention
Two participants noted that the distance they travelled to attend the sessions was problematic. Likewise, travelling concerns were mentioned as a systemic barrier to accessing support.
Participants indicated that people are unaware of the PTSD Coach app as a freely available resource and noted a need for the app to be explained first. For example, while Participant 23 said “…everyone should have it on their phones…,” they continued, ”… in hospitals someone to help them using the app." Accordingly, Participant 17 said: “Being introduced to the app that I can also use at home was very helpful.” Additionally, participants highlighted that the intervention could be beneficial “By attending sessions” (P12) and “By listening [to] what it said and practice it” (P15).
Concerning the recent COVID-19 pandemic and the impact thereof on accessing support, it was promising that participants’ use of the PTSD Coach app was mostly unaffected by the pandemic at the time: “It has no impact to [sic] me because I am able to open my app anytime and anywhere” (P4). While two participants noted a negative impact, it was not clear if they meant regarding the use of the app (i.e., having less time to use the app as they had to look for new job opportunities) or regarding a general deleterious effect of the pandemic ("Negatively impact regarding job seeking“ (P11); and ”… negatively because some people lost their jobs and their loved ones“ (P22), respectively).
Systemic barriers to accessing treatment
Barriers to accessing treatment included travel distances and associated costs, unawareness of needing help and existing resources, stigma associated with accessing psychiatric support and language barriers.
Travelling
Participants said: ”Travelling takes too long to travel with taxis" (P1) and “…many people do not have travel money” (P2). While referring to intervention procedures, Participant 18 said: “The money provided is really helping because I take three taxis to attend a session.” This highlights that our intervention procedures addressed some systemic barriers to accessing support related to transport and financial constraints. Importantly Participant 19 said that ”…others are afraid of traveling [sic] every time", possibly referring to violent taxi protests or general crime as an added barrier in our setting.
Unawareness
Unawareness of existing resources was reported as a barrier: “…lack of information, some people do not know where to go in order to get the treatment” (P16); “We don’t know where to seek help ….” (P20); and “… [people] are not aware that there is treatment for it and that they can get help” (P18).
Additionally, unawareness of needing help, or denial, was mentioned as a barrier for people to accessing support: “Some people don’t see that they need help until something happens …” (P3), and “They are in denial or they do not want to accept their situation or scared of what people will say” (P14).
Stigma
Participant 14’s statement that they are “… scared of what people will say…" signals the barrier of fear of accessing existing support. Participants said that “[t]hey are afraid to get help because they feel they are going to be judged” (P5). Participant 12 noted culture-related stigma as a barrier: “They think you’re insane or too western,” suggesting cultural disapproval of accessing support. Participant 7 mentioned gender-related stigma since in “[t]he past it was just for women and children … men were seen as weak when they seeked [sic] support.”
General “stigma” (P3) about accessing mental health support was reported by participants: “I think people that ’bully’ a person with PTSD are barriers” (P13). Most participants heard about and became involved in the intervention through word-of-mouth, indicating that peer referral and support may decrease fear and stigma and increase social acceptability of receiving help. Further, this fear and acceptability of receiving help was demonstrated by Participant 14 who said: “I can now see there is no problem in seeking help.”
Support
Participants’ responses indicated a perceived lack of resources as contributing to treatment barriers, noting “Availability of counsellors,” (P4) and that “The clinics in SA does not provide the support people want – Therefore people have nowhere to go” (P11).
Conversely, some participants mentioned an unwillingness to engage with existing resources as a factor that prohibits people from receiving the care they need. This unwillingness was multi-layered as some of it was related to counselling specifically as “People don’t take counselling serious” (P16) and “They think it’s a waste of time…” (P21). More general comments were that “…they don’t want to tell strangers their problems” (P17) and “Others they decide not to seek help…” (P22). These factors likely connect with previously discussed themes as a lack of awareness of what available services constitute and stigma could be drivers of these perceptions. There was also the perception that accessing support will “Remind them of their trauma” (P6). One participant mentioned language as a barrier, saying that while some people do not know how to access care, “others can’t speak English…” (P21).
Discussion
This qualitative study explored participants’ experiences of a PTSD Coach-CS intervention for adults with PTSD in a South African resource-constrained setting. The emergent themes related to (i) experience of treatment procedures, (ii) perceptions of the PTSD Coach app and (iii) barriers to treatment. Overall, participants experienced both the counsellor support and the PTSD Coach app as positive. The findings indicated that participants perceived the human interaction component of the treatment procedures as particularly positive and beneficial. While the counsellor and psychologist’s involvement in the intervention and monitoring sessions were not meant as therapeutic, participants seemed to have experienced it as such (Brown et al., Reference Brown, Strauss, LaBar, Gold, McCarthy and Morey2014; Christopher et al., Reference Christopher, Appelbaum, Truong, Albert, Maranda and Lidz2017; Thong et al., Reference Thong, Foo, Sum, Capps, Lee, Ho and Sim2016). This links to participants’ concerns regarding the lack of human interaction mentioned during a study evaluating experiences with a PTSD Coach Online programme (using a web-based platform) intervention (Ellis et al., Reference Ellis, Hosny and Miller-Graff2022). Thus, our findings further support the value of a blended (i.e., human component and mobile-based) approach noted in PTSD Coach-focused research (Owen et al., Reference Owen, Jaworski, Kuhn, Makin-Byrd, Ramsey and Hoffman2015; Cernvall et al., Reference Cernvall, Sveen, Bergh Johannesson and Arnberg2018; Shakespeare-Finch et al., Reference Shakespeare-Finch, Alichniewicz, Strodl, Brown, Quinn, Hides, White, Gossage, Poerio, Batras, Jackson, Styles and Kavanagh2020).
The positive perception of the PTSD Coach app in our setting is encouraging. Similar to prior PTSD Coach-focused research, our participants found the app’s functions concerning learning about and managing PTSD symptoms helpful (Miner et al., Reference Miner, Kuhn, Hoffman, Owen, Ruzek and Taylor2016; Cernvall et al., Reference Cernvall, Sveen, Bergh Johannesson and Arnberg2018; van der Meer et al., Reference van der Meer, Bakker, van Zuiden, Lok and Olff2020). Learning about PTSD refers to psychoeducation, which plays a vital role in treatment and often forms the foundation for more specialised intervention strategies (Whitworth, Reference Whitworth2016; Taylor, Reference Taylor2022). Previous PTSD Coach-focused research commented on participants’ increased openness for further support after learning about and understanding their symptoms (Kuhn et al., Reference Kuhn, Greenem, Hoffmanm, Nguyenm, Wald, Schmidt, Ramsey and Ruzek2014; Ellis et al., Reference Ellis, Hosny and Miller-Graff2022). Participants’ negative perceptions of the app align with dissatisfaction with the app, noted in prior PTSD Coach app research (i.e., perceived need thereof) (Pacella-LaBarbara et al., Reference Pacella-LaBarbara, Suffoletto, Kuhn, Germain, Jaramillo, Repine and Callaway2020; Hensler et al., Reference Hensler, Sveen, Cernvall and Arnberg2022;). The lack of family involvement mentioned reiterates that PTSD affects both the family and the trauma-exposed individual. To this end, the PTSD Family Coach app was developed to assist families of those affected by PTSD (Gould et al., Reference Gould, Kok, Ma, Zapata, Owen and Kuhn2019). Participants’ dislike of detailed enquiry about the experiences of trauma was likely in reference to the monitoring sessions with the psychologist rather than the intervention or the app itself (Bröcker et al., Reference Bröcker, Olff, Suliman, Kidd, Greyvenstein and Seedat2024). This potential participant discomfort during PTSD-focused research is reported in the literature with caution requested when conducting such research (Legerski and Bunnell, Reference Legerski and and Bunnell2010; Brown et al., Reference Brown, Strauss, LaBar, Gold, McCarthy and Morey2014). However, it could also be that participants were alluding to the stigma associated with accessing psychiatric support and a lack of knowledge or misconception of what treatment entails (Morgan et al., Reference Morgan, Ross and Reavley2018; Knettel et al., Reference Knettel, Mulawa, Knippler, Ciya, Robertson, Joska and Sikkema2019; Booysen et al., Reference Booysen, Mahe-Poyo and Grant2021).
Other negative comments were largely related to the desire for more human interaction and more counselling. This highlights participants’ desire for direct assistance/therapy that they may not be receiving due to resource constraints (Docrat et al., Reference Docrat, Besada, Cleary, Daviaud and Lund2019). The counsellor support in combination with the PTSD Coach app created a safe space for participants to learn about and understand their lived experiences and to accept their PTSD diagnoses. Mental illness and associated diagnoses can elicit varied reactions with equally varied consequences (Hundt et al., Reference Hundt, Smith, Fortney, Cully and Stanley2019). While it can result in a denial of diagnosis and prevent treatment seeking and accessing appropriate support, it appears that for many participants, it initiated a healing process and post-traumatic growth (PTG) (Hundt et al., Reference Hundt, Smith, Fortney, Cully and Stanley2019; El-Gabalawy et al., Reference El-Gabalawy, Mackenzie, Starzyk and Sommer2021). The renewed hope for the future and wanting others to benefit similarly is associated with PTG.
The importance of hope in the context of adversity, including mental and physical illness, is central to supporting individuals facing such adversities (Long, Reference Long and Gallagher2018). Diminished hope tends to drive suicidal ideation, while fostering a sense of hope is often pivotal in managing mental illness such as PTSD (Long, Reference Long and Gallagher2018; Koenig et al., Reference Koenig, Youssef, Smothers, Oliver, Boucher, Ames, Volk, Teng and Haynes2020). The renewed sense of hope resulted in participants experiencing the ability to see new possibilities and a feeling of self-empowerment (El-Gabalawy et al., Reference El-Gabalawy, Mackenzie, Starzyk and Sommer2021; Levi et al., Reference Levi, Liechtentritt and Savaya2012). Furthermore, participants wanting others to benefit similarly speaks to a sense of altruism and prosocial behaviour, which also forms part of PTG (El-Gabalawy et al., Reference El-Gabalawy, Mackenzie, Starzyk and Sommer2021). This notion of wanting others to benefit was noted in the first study to evaluate the PTSD Coach app with participants recommending the app to friends and family (Kuhn et al., Reference Kuhn, Greenem, Hoffmanm, Nguyenm, Wald, Schmidt, Ramsey and Ruzek2014). Consideration of the intervention-specific and systemic treatment barriers is important to inform and increase the usefulness of the PTSD Coach-CS intervention in our setting. Participants suggested both an unawareness of the freely available app and the need for an introduction to the app as barriers to intervention engagement. This emphasises earlier discussion on the value of augmenting internet- and mobile-based interventions with guidance (i.e., human interaction) to increase both awareness of the app and engagement (Owen et al., Reference Owen, Jaworski, Kuhn, Makin-Byrd, Ramsey and Hoffman2015; Cernvall et al., Reference Cernvall, Sveen, Bergh Johannesson and Arnberg2018; Shakespeare-Finch et al., Reference Shakespeare-Finch, Alichniewicz, Strodl, Brown, Quinn, Hides, White, Gossage, Poerio, Batras, Jackson, Styles and Kavanagh2020). The described unawareness of the app extends to the systemic barrier of unawareness of existing resources. As mentioned, while the South African PHC system is overburdened, services are available and substantial progress has been made since implementing the South African National Mental Health Policy Framework and Strategic Plan 2013–2020 (The Department of Health, 2013). Lack of information on available services and difficulty navigating a referral or treatment pathway is a known global barrier to accessing support (Newman et al., Reference Newman, O’Reilly, Lee and Kennedy2015; Muhorakeye and Biracyaza, Reference Muhorakeye and Biracyaza2021). This highlights the importance of creating awareness of available services (i.e., clinics) and the clinics remaining informed of relevant intervention studies where individuals can receive support and alleviate overburdened PHC services. Continuous fostering of a good relationship between academia (e.g., research studies’ sites) and practitioners on the ground is mutually beneficial (Rynes et al., Reference Rynes, Bartunek, Richard and Daft2017). The barrier of travelling and associated costs is common in resource-constrained settings and is well documented in South Africa as many people use public transport or walk to their destinations (Syed et al., Reference Syed, Gerber and Sharp2013; Schmitz et al., Reference Schmitz, Serbanescu, Arnott, Dynes, Chaote, Msuya and Chen2019; Stats SA, 2021). In our setting, many factors influence this barrier, such as increased public transport fees attributable to exorbitant fuel price increases and rolling blackouts, high unemployment rates, violent public transport protests or general crime (Goldberg, Reference Goldberg2015; Laher et al., Reference Laher, Van Aardt, Craythorne, Van Welie, Malinga and Madi2019; Mmakwena, Reference Mmakwena2022). Therefore, bringing psychological support to the communities can further overcome barriers to treatment (Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017; Rossouw et al., Reference Rossouw, Yadin, Alexander and Seedat2018).
Denial about needing support, and stigma (e.g., fear of judgement, and associated concerns about the social acceptability of accessing support) were mentioned as systemic barriers to treatment (Hundt et al., Reference Hundt, Smith, Fortney, Cully and Stanley2019; Ciccolo et al., Reference Ciccolo, Louie, SantaBarbara, Webster, Whitworth, Nosrat, Chrastek, Dunsiger, Carey and Busch2022; Rice et al., Reference Rice, Oliffe, Kealy, Seidler and Ogrodniczuk2020). The harmful effects of general stigma associated explicitly with mental illness are well-known (Clement et al., Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs, Morgan, Rüsch, Brown and Thornicroft2015; Knettel et al., Reference Knettel, Mulawa, Knippler, Ciya, Robertson, Joska and Sikkema2019; Booysen et al., Reference Booysen, Mahe-Poyo and Grant2021; Monnapula-Mazabane and Petersen, Reference Monnapula-Mazabane and Petersen2021). Notably, a systematic review and meta-analysis indicated that stigma is one of the most common barriers to seeking care (Morgan et al., Reference Morgan, Ross and Reavley2018). The stigma and fear of social rejection may be further influenced by both cultural and gender-related factors (Venter et al., Reference Venter, Fischer, Lalla-Edward, Coleman, Lau Chan, Shubber, Phatsoane, Gorgens, Stewart-Isherwood, Carmona and Fraser-Hurt2019; Rice et al., Reference Rice, Oliffe, Kealy, Seidler and Ogrodniczuk2020; Ciccolo et al., Reference Ciccolo, Louie, SantaBarbara, Webster, Whitworth, Nosrat, Chrastek, Dunsiger, Carey and Busch2022), highlighting the need for sensitivity towards cultural and gender-based concerns when developing and promoting support resources (Ciccolo et al., Reference Ciccolo, Louie, SantaBarbara, Webster, Whitworth, Nosrat, Chrastek, Dunsiger, Carey and Busch2022). A PTSD Coach Online (web-based) study describes their process of fully adapting the programme and creating PTSD Coach Online-Arabic (Miller-Graff et al., Reference Miller-Graff, Ellis and Hosny2021; Ellis et al., Reference Ellis, Hosny and Miller-Graff2022). Their procedures highlighted the significant role of language, gender and cultural stigma in treatment-seeking individuals in the Middle East. Our findings also indicated that language should be considered when promoting support resources, including translating intervention content into various languages, especially in a country such as South Africa. South Africa has a multicultural and multilingual population, and individuals accessing healthcare services, and healthcare providers, face language barriers. Addressing these barriers in an effort to improve linkages to care is a priority (Tate et al., Reference Tate, Hodkinson, Meehan-Coussee and Cooperstein2016; Tönsing et al., Reference Tönsing, van Niekerk, Schlünz and Wilken2019; Hagan et al., Reference Hagan, Hunt, Kilian, Chiliza and Swartz2020; van Vuuren et al., Reference van Vuuren, van Dyk and Mokoena2021).
Conclusion
This was the first study to qualitatively evaluate a counsellor-supported PTSD Coach app in a resource-constrained setting. We build on the existing evidence of internet- and mobile-based interventions for PTSD, specifically for the PTSD Coach app, and suggest that the counsellor support and the app itself are useful in our resource-constrained setting and can widen access to psychiatric care. Further, our qualitative findings are useful in understanding how to improve the feasibility, acceptability and usefulness of the PTSD Coach-CS intervention for future use. Our findings suggest that participants experienced the PTSD Coach-CS intervention as positive, especially the counsellor’s support, as they enabled a practical and effective introduction to the app and increased engagement with the app. This also created a safe space that, together with the app, facilitated participants’ self-acceptance of their lived experiences. Similarly, the PTSD Coach app itself was positively received, easy to navigate and helpful to learn about and manage their symptoms. Participants gained hope for the future and wanted others to know about the intervention and the app to benefit similarly.
Notably, the data provided insight into the barriers and what needs to be improved on in terms of intervention implementation. For instance, training registered counsellors, preferably from the respective communities, to provide the PTSD Coach-CS intervention at local clinics under supervision limits travel and associated costs. Utilising counsellors from the same communities as participants, who are more likely to be of similar culture and language as the treatment seeking individuals, can also overcome cultural and language barriers in part, as well as assist with reducing stigma associated with receiving psychiatric support. Adapting the PTSD Coach app culturally and language-wise (e.g., isiXhosa or Afrikaans) can further assist in greater intervention adoption and usefulness; however, the counsellor support might be a better use of resources and of value to PTSD sufferers.
Finally, it would be prudent to evaluate whether a PTSD Coach Family app intervention administered in conjunction with an individual PTSD Coach app intervention yields better outcomes. In summary, this study showed that the PTSD Coach-CS intervention can be a suitable intervention in a resource-constrained setting such as South Africa and provides guidance for future research and clinical use.
Limitations
This study has several limitations. First, the nature of the data collection (i.e., paper-and-pencil questionnaires) did not allow for clarification and further exploration of responses as a verbal interview would have. Future research should use verbal interviews to allow for clarification and richer data. Relatedly, adding a usability questionnaire, such as the mHealth App Usability Questionnaire, can further enrich the data. Second, while the immediate completion of the questionnaires limited recall bias as the intervention experience was still fresh, the counsellor’s proximity may have influenced their response to be more favourable towards the counsellor. Future research should employ an independent team member to gather qualitative data. Finally, while attempts were made to contact non-completers of the RCT, none were reached. It should be noted that non-completers may have provided valuable insights into improving the app and intervention as they presumably had reasons for dropping out of the study.
In summary, this is the first study to evaluate the PTSD Coach app’s feasibility and utility in an LMIC resource-constrained setting. The findings suggest that a four-session PTSD Coach app intervention is a more accessible, low-cost alternative to treatment that can be augmented with counsellor support, which constitutes suitable care for South African adults with PTSD.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2024.34.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2024.34.
Data availability statement
The data that support the findings reported in this study are not shared publicly for reasons of privacy; however, they can be made available from the corresponding author (E.B.) upon reasonable request.
Acknowledgements
This project and its valuable findings would not have been possible without the participants who travelled to attend sessions, shared their experiences and opinions and ultimately contributed knowledge to inform appropriate interventions in our setting. Also, the findings would not have been possible without the involvement of the registered counsellor (Lyrése Greyvenstein) in the main study who was instrumental in intervention delivery.
Author contribution
E.B. was the doctoral student who together with her supervisors conceptualised, designed and conducted the RCT (inclusive of the present study), undertook data analysis and interpretation and drafted and revised the manuscript. F.S. was involved as a second independent coder and assisted with data analysis and interpretation. S.Su., M.O. and S.Se. provided extensive input into the conception and design of this RCT and the manuscript. All authors approved this manuscript for publication.
Financial support
E.B. is supported by the National Research Foundation Thuthuka Funding Scheme, the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the SAMRC Bongani Mayosi National Health Scholars Programme of the South African National Treasury and the SAMRC through the Extramural Genomics of Brain Disorders Unit. F.S. is supported by a Postdoctoral Research Fellowship from the Brain Behaviour Unit in the Department of Psychiatry and Mental Health, University of Cape Town. S.Su. was supported with funding from the SAMRC through a Self-Initiated Research Grant. S.Se. is supported by the South African Research Initiative in PTSD, funded by the Department of Science and the National Research Foundation and the SAMRC Extramural Unit on the Genomics of Brain Disorders. The content herein is the authors’ sole responsibility and does not necessarily represent the official views of the SAMRC and other funders.
Competing interest
The authors declare none.
Ethical standard
The research team complied with the national (HREC, SU) as well as international (Helsinki Declaration of 1975, revised 2008) standards, including but not limited to informed consent, voluntary participation and the right to withdraw at any stage during the study procedures.
Open access
Comments
Dear Editor
We wish to submit two manuscripts for consideration by Cambridge Prisms: Global Mental Health. The first is titled ‘A clinician-monitored ‘PTSD Coach’ intervention versus enhanced treatment as usual in a resource-constrained setting: A randomised controlled trial’ and the second ‘Participants’ experience of a PTSD Coach-CS intervention in a resource-constrained setting.” These manuscripts align with the scope of the journal as we aimed to address treatment gaps by identifying and evaluating an intervention that may widen access to psychiatric care in a South African resource-constrained setting. We confirm that these manuscripts are original, have not been published, nor are they submitted elsewhere.
In the first manuscript, we report on a randomised controlled trial (RCT) that evaluated the effectiveness of a four-session counsellor-supported PTSD Coach (PTSD Coach-CS) mobile application intervention in reducing PTSD, depression, anxiety, and stress symptoms in a South African adult community sample. The PTSD Coach mobile app is freely available, and supplementing delivery with counsellor support aimed to both increase intervention uptake and address upscaling of human resources to address the needs of an overburdened public healthcare system. The findings indicated symptom improvement in clinician-monitored PTSD symptoms and self-reported stress over time as well as good intervention uptake and satisfaction.
The second manuscript reports on the findings of a qualitative sub-study that formed part of the RCT procedures. These findings augment the quantitative results and provided valuable information to inform PTSD Coach-CS intervention amendments to increase its usefulness in a South African resource-constrained setting.
This was the first time the PTSD Coach app was evaluated in a resource-constrained setting such as South Africa and the first to supplement intervention delivery with less specialised mental health services. Our findings are encouraging and support that a low-cost more accessible PTSD Coach-CS intervention is a feasible and potentially effective treatment alternative for adults with PTSD. Identification of alternative or additional treatment strategies is of particular importance based on the envisioned transition to the National Health Insurance (NHI) in South Africa. The transition towards NHI will provide quality affordable health services to all South Africans, irrespective of their socioeconomic status and is an important step towards narrowing longstanding treatment gaps. However, this may place an extra burden on an already stretched public health care system and the availability of low-cost scalable interventions can mitigate this burden.
We hope that our submission will be favourably considered.