Efficacy of Online Counseling During Pandemics in Zambia: A Client and Therapist Perspective

doi:10.21203/rs.3.rs-3303288/v1

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Research Article

Efficacy of Online Counseling During Pandemics in Zambia: A Client and Therapist Perspective

https://doi.org/10.21203/rs.3.rs-3303288/v1

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published 08 Mar, 2024

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Population-based studies show that a growing number of counsellors have been providing counselling via the Internet. There are mixed findings regarding the efficacy of online counselling when compared to traditional face-to-face counselling and other modalities. During the COVID-19 outbreak, online counselling services were advanced as the only safe means of attending to mental health conditions, especially during lockdowns. However, the efficacy of online counselling remained unclear especially in developing countries with low digital literacy and poor Internet connectivity. The study's main purpose was to investigate and determine the clients' and therapists' perspectives about the efficacy of online counselling during the pandemic based on the level of preparedness, mode of delivery and challenges faced. The study used mixed methods employing parallel convergent design and collected data from 284 participants (44 therapists and 240 counselling clients). The study found that therapists were not prepared to offer online counselling services but were compelled by high demands for counselling services from clients during the pandemic. Both clients and therapists cited the cost of data bundles to connect to the Internet. Further, both the clients and therapists agreed that the most efficacious platform was video conferencing. Findings also show that therapists observed slowed progress on the client's recovery due to clients missing sessions. Logistic regression results on factors associated with preparedness and positive perception of online counselling showed that older therapists and lay counsellors were more likely to be less prepared and evaluate session as less efficacious respectively. Living in Lusaka (the capital) was associated with a higher odd of perceiving online counselling as efficacious. Client results showed that older clients had lower odds while being female, and the counsellor being prepared increased the odds of the session being efficacious. The researcher concluded that online counselling, in the context of a developing country, was inefficacious due to poor network connectivity, the multiplicity of ICT channels, concerns with privacy, low digital literacy, and lack of knowledge or experience using these platforms.

Online Counselling

Applications

Subjective well-being

Clients

Therapists

In the last 20–25 years, the world has seen electronic mental health services (e-mental) emerge as a promising avenue for intervention because of the advantages they have in accessibility, efficiency over traditional service provision(1, 2). In particular, these services have been advocated for use in public health strategies for young people aged 10 to 24 years who have the highest risk for developing emotional, and mental health problems (3) and are the least likely to seek professional treatment because of a number of help-seeking obstacles (4).

Cyberpsychology is a field of psychology that involves studying human experiences (cognitive, emotional, and behavioural) that are related to or affected by developing technologies (5). One of the areas of cyberpsychology is online counselling, also referred to as e-therapy, e-counseling, e-mental or cyber therapy. Richards and Vigan'o define online counselling as a mental health intervention between the counselee/client and the counsellor or therapist using digital technologies such as computers or smartphones (6). Mallen and Vogel provide a comprehensive definition of online counselling: "any delivery of mental and behavioural health services, including but not limited to therapy, consultation, and psych education, by a licensed practitioner to a client in a non-face-to-face setting through distance communication technologies such as the telephone, asynchronous e-mail, synchronous chat, and video conferencing" (7). In online counselling, there is a therapeutic relationship between the counselee and the counsellor, who are in different locations but communicate via the Internet or computer technologies (8, 9).

While many researchers have debated the nature of online counselling, the advent of the COVID-19 pandemic demanded a change in many practices, including counselling which saw therapists adopting online counselling. Many countries-imposed regulations for working from home, studying from home, social distancing, physical distancing, etc. Furthermore, these adjustments eventually triggered mental health symptoms, such as anxiety, depression, stress, and so on (10, 11). Zambia was not exempted from these changes as it introduced restrictions which demanded that patients/clients generally considered to have non-emergency conditions, such as mental health clients, diabetic and hypertensive individuals, stay at home (12). These restrictions led to the uptake of online counselling. As internet-based interventions continue to increase in number, scope, and usage, there is need for research to be conducted to determine how these interventions can be applied to achieve the best possible outcomes during pandemics in developing countries like Zambia. Specifically, it is important to understand the perspectives of both therapists and clients on the efficacy of online counselling in a developing country context.

There are mixed findings regarding the efficacy of online counselling when compared to traditional face-to-face counselling and other modalities. For example, a narrative and critical review of the literature on online counselling found that a growing body of knowledge to date is almost unanimous in showing that online counselling can have a similar impact and is capable of replicating the facilitative conditions as face-to-face encounters(6). Similarly, other studies showed that online counselling can be as efficacious as face-to-face counselling (9, 13). Online counselling is a convenient service since it can be provided at any time of the day and clients can send messages whenever they feel most in need of or interested in therapy (14). Essentially, online counselling is accessible from any corner of the world as long as there is Internet access (15). The downside of online counselling, is that computers simply do not offer the human interaction that is crucial in the counselor’s office (15). As a result, the therapeutic connection may feel less intimate, untrustworthy, and the patient may feel less committed when there is no physical presence involvement. As a result, it could make it harder for the counselor and client to build a therapeutic relationship. There is a higher risk of misinterpretation when there are no visible or audible indicators like body language, facial expressions, or voice tone. Sighs, frustration, terseness, and annoyance, to mention a few important emotions, might be lost during the email exchange (16). A systematic review by Backhaus et al., (17) discussed the feasibility of video conferencing practices in online counseling. However, most of the studies on online counselling are done in developed countries (8, 18–26).

The growth of the Internet has created excellent opportunities for providing accessible counselling via computers and phones. Many counsellors have begun to grasp the enormous opportunity to reach multiple groups of underserved populations who will gain from Internet/Web-based services. Zambia has 10.1 million people with Internet access, and most of these households are in Lusaka province with 18% of the population followed by the Copperbelt province with 15% (27). The COVID-19 pandemic in Zambia showed that many Zambians had turned to online platforms to seek counselling services, and at the time, numerous online platforms, such as Facebook pages were observed to provide such services. These online platforms offer different kinds of services to their clients. What is not known is how efficacious these online counselling services were. This and many other questions are what this research sought to establish. Thus, the study's main purpose was to investigate the efficacy of online counselling in pandemic situations in Zambia. The study objectives were: to establish the therapists' preparedness to offer online counselling sessions during the pandemic; to explore the limitations faced by clients and therapists during online counselling; to establish the applications explored for the provision of online counselling during the pandemic, and to establish the efficacy of online counselling.

The study used mixed methods employing parallel convergent design in conducting this research with the support of evaluative qualitative data collection techniques. It involved non-experimental procedures for the two groups in the study, namely the online therapist group and the client group. Data were collected in two phases, including a questionnaire and focus group discussion consecutively.

2.1 Participants

The study participants were purposively selected from the counselling service providers recognized by the Psychology Association of Zambia (PAZ) drawn from across Zambia. We focused on clients and counsellors in Zambia. The association was chosen because it has a compiled mental health services provider directory which made it easy for the researcher to randomly sample from this list and extend the questions to their clients. The questions were attended to through the Internet during the covid-19 outbreak. The researcher emailed the counsellors and followed up using social media (WhatsApp) to contact their clients whose identity was withheld. In addition, the researchers attended several online group counselling sessions organized by service providers to make announcements about the research. Simple random sampling was applied to select counsellors from the PAZ directory in the study. Sixty-two therapists were selected but due to dropouts and non-responsiveness, only 44 participated in the study. Informed consent was obtained from the therapists and clients to participate in the study. In total, 244 participants (consisting of 240 clients and 44 counsellors) consented to participate in the study. Table 1 presents the details of the demographic information of participants.

Most of the clients (75%) and most of the therapists (61%) were female too. Most of the counsellors were psychologists, followed by religious leaders, and psychiatrists. Most worked at the health or mental clinic, followed by hospital, and university.

Table 1

Demographics of the Participants
Gender		Practitioners	Work Setting
Clients	Therapists	Psychiatrist 6 (13.6%)	Individual Practice 6 (13.6%)
Male 60 (25%)	Male 17 (39%)	Psychologist 8 (18.2%)	Group Practice 2 (4.5%)
Female 180 (75%)	Female 27 (61%)	Psychosocial Counsellors 10 (22.7%)	Health/Mental Clinic 14 (31.8%)
Total 240	Total 44	Social Worker 7 (15.9%)	Hospital 8 (18.2%)
Totals - Male 77 (27%) Female − 207 (73%)		Clergy 5 (11.4%)	Military 2 (4.5%)
		Lay Counsellors 3 (13.6%)	University 7 (15.9%)
		Mental Health Nurse 2 (4.6%)	Other 5 (11.4%)
		Total 44 Therapists

2.2 Procedure

The participants were informed about the procedure of the study, such as interventions, data collection, and their right to withdraw. The participants were asked to read and sign an online informed consent form before they could proceed with the questionnaires. Having received the informed consent forms, the questionnaires were sent to them through the therapists identified through the Psychology Association of Zambia (PAZ) Directory. Then, they were allocated to one of the two groups (one for therapists and the other for clients that were connected to therapists). Upon completing the questionnaire, the clients were then put in groups to discuss their experiences and perceived efficacy of this relatively new approach to service delivery in the country.

2.3 Study Participants

All therapists were registered for the service they offer with the Psychology Association of Zambia. This meant that by the time of the data collection, these therapists had been offering services for more than two years (based on the year of publication of the PAZ Directory). Before the study, the therapists were engaged to establish the services they offer online and their modes of delivery to select only those that provided online services of interest to the study. Further, the selected therapists were then requested to avail the clients they attended to during the pandemic. The clients required to meet the inclusion criteria of age and consent and having attended counselling sessions from a listed therapy provider in the period under review. This was almost like snowball sampling. Counsellors helped to send the link to their clients as a quality assessment for services they provided. These clients responded to the online questionnaire and later a follow up was made on the same clients through the counsellors to invite them to an information session about a focus group discussion to probe further on online counselling. The nature of the discussion was explained via a zoom call meeting in which it was made clear that the client’s identity was not required therefore, participants were advised to join with a pseudonym and that there was no need for participants to use their camera during the group discussion. Further, it was explained that the call would be recorded but the researcher would only return a writeup transcript which would be used for originality of thoughts. Clients were asked to save a zoom link which was shared in the chat during the virtual meeting (information meeting via zoom). A total of 7 groups of 8 clients participated in recurring meeting schedules one after the other. However, one group was not considered as it only had 5 participants (the researcher and 3 clients). This study only presents submission from 6 groups that had 8 clients with the researchers.

2.4 Research Instruments.

The instruments used in the study were a questionnaire for quantitative data collection and a focus group discussion (FGDs) guide for qualitative data collection. The researcher collected data primarily through online questionnaires in order to obtain detailed information. The questionnaires were used for both clients and therapists because of the ability to collect data from a large sample and their rigidity against biases. Questionnaires also served time during collecting and analysing data, as the data was collected from different samples.

A focus group discussion guide was used in the study. The use of FGDs to generate data in qualitative research was an advantage because it gave more latitude to respondents and interviewers, allowing them to explore issues emerging from the research. Discussions were built around the emerging response of each client rather than being bound by pre-decided issues. A structure of questions was made through a focus group discussion guide but the built up to the discussion was through the researcher asking for clarity and also probing further on emerging issues.

The group discussions were only for 40 minutes (researcher was using the free version of zoom) but it must be noted that they were delays in starting due to poor time keeping by clients. The meetings only started after a minimum of 6 clients joined the virtual meeting. Others that joined while the meeting was on were accepted but only a maximum of 2 while others were requested to join the next meeting. The discussion was guided by the focus group discussion guide which asked open ended questions and the researcher got opinions from 3–4 people while asking follow-up questions as need rose. Debates were allowed and consensus was established on key issues.

2.5 Data Analysis

For the qualitative data, the thematic analysis approach described by Braun and Clarke (2006) was taken to understand participants’ perceptions about the characteristics of online counselling and factors moderating its efficacy. The thematic analysis involved developing familiarity with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing a report of findings.

The researcher read all transcripts, and then two focus group discussion transcripts were consolidated (i.e., for clients and the other for therapists). The researcher manually defined a set of preliminary codes that did not necessarily conform to the language used in the interview guide. Qualitative themes were only rated once for each participant describing them, irrespective of the number of times that theme was identified across the discussion groups. The final stages of analysis involved the researcher reviewing themes and subthemes to ensure that coded extracts were valid, logical, and reasoned.

A frequency count was applied to specific variables to identify their commonality for providing a consolidated list of experiences and suggestions, wherein the researcher sought to establish those with higher occurrence. Ratings of very strong, strong, moderate, and weak were given if > 80%, > 60%, > 50%, and > 30% of participants endorsed the theme, respectively. Given the small sample size in this study, themes endorsed by fewer than 2 participants were excluded from the analysis on the grounds of low generality.

The quantitative data collected from the online questionnaire was analysed by the use of descriptive statistics in the form of percentages and frequencies. The Statistical Package for Social Sciences (SPSS) version 23 was used to enhance the analysis. Computer-generated tables of frequencies and percentages were used in describing variables which were presented in the form of tables and figures. This allowed objective interpretation for valid generalizations, conclusions and recommendations for future studies.

Lastly, to understand the factors associated with preparedness and positive perception (i.e., that it is efficacious) for counsellors, a logistic regression model was estimated. In the first model for therapists, we categorize preparedness as one if the therapist was prepared and zero if they were not or somewhat prepared, and in the second model we define efficacy as one if they think online counselling is efficacious. We apply the same definition to client’s perception of efficacy of online counselling. We include quantitative variables as independent variables in the regression and recover the odds ratios.

The findings for both questionnaire and focus group discussions (FGD) conducted on the efficacy of online counselling during a pandemic; a client and therapist perspective is presented under themes which were derived from the research objectives. The themes are sub-divided to furnish some relevant data as contained in the questionnaires and FGD schedules.

3.1 Demand for Counselling

In order to establish the views and experiences of therapists on the online counselling service provided to clients, the researcher sought to investigate the demands for counselling from patients before and during COVID-19.

Figure 1 shows that 75% (33) of the therapists reported that they experienced an increased demand for their services during the COVID-19 pandemic, whereas only 25% of the therapists experienced a reduced number of clients. Furthermore, most of the therapists that experienced an increase in demand indicated that the higher demand was especially from women representing 54.5% of all clients.

3.2 Level of preparedness to offer online counselling services

Figure 2 shows below that most (61%) of the clients indicated that therapists were not prepared to deliver counselling services online, while only 18% were of the opinion that their therapists were ready to offer counselling services online. The therapists also recorded similar percentages; about 58% said they were not prepared, while only about 14% said they were prepared. Despite these low levels of preparedness for online counselling, most of the therapists had started offering the services during the second wave of COVID-19.

During the focus group discussion, the researcher sought to understand why participants thought their therapist was not adequately prepared to offer online counselling. Client had several views including confusion over the platforms to use and general lack of consistency: Participants had the following to say:

"It's very easy to tell that one is not ready, you can see from the manner of delivery, the tools to be used; we kept changing the Apps to use for our interaction from video to calls to WhatsApp. It was not like it is for my online class at the university where you have a dedicated portal for the classes." (Male client)

"Check, yes we can understand when there is a dedicated platform but only challenges with Internet, but for my therapist, we had to do trial and error. We ended up just having short sessions on phone calls after trying a number of Apps." (Female client)

"Well my therapist knew what he was doing, and we only had a few disruptions in connection. We used Zoom, our sessions were 30–40 minutes in the evenings. However, some other things, like forms were sent to me on WhatsApp for me to fill out and send back. In my view, he was generally prepared." (Female client)

On the other hand, therapists in their FGD had different views regarding readiness. They stated that this was a new area and it compelled them to go through a learning process. Some had been used to online platforms but finding the best way to link with client involved a lot of trial and error. Some of them submitted that:

"Personally, during that time, I attended a lot of meetings online and they were no challenges so when I was receiving calls and requests from everywhere, I decided to jump on the online counselling through Zoom. I did not put any special modalities prior to starting, but with time, I could learn from the process. I found myself switching technologies just to try and meet up the shortfalls in one or the other technology adopted" (Male Therapist)

Another therapist added

"In the context of your question, I did not prepare adequately for the service, I simply used the resources available and were in use at the time." (Female Therapist)

3.3 ICT Applications Explored for the Provision of Online Counselling During the Pandemic

Table 2 shows that most 114 (40.1%) of counselling was done using video conferencing. The second most common tool was phone calls, while instant messaging applications were the least used. FGDs revealed that all respondents had used multiple tools due to challenges in one or the other tool.

Table 2

ICT Media Used to Provide the Online Counselling.
	Frequency	Percent
Chat Room (Instant Messaging)	21	7.4
Phone Calls	88	31.0
Video Conferencing	114	40.1
A Combination/ Alternating Tools	61	21.5
Total	284	100.0
(Source: Author, 2022)

During the focus group discussions, the following were the submissions by participants (clients) on the question of the technology used:

"Well, I can't specifically say one technology was used, it was dependent on what worked on that day. What I mean is you would agree to use video conferencing but when you start the zoom call or google meet call, you find that you can't understand each other due to time lag or network connectivity so we were forced to switch to either call or just reschedule the session." (Male Client)

"For me it would start with WhatsApp where I receive the Link for a Google Meet call or Microsoft Teams, then we shift and have our discussion. Sometimes we had to do a back and forth between video call and text on WhatsApp where we share documents and assessment tools. But of course, my most preferred was a zoom call because I could see the person am talking to and that just gave me assurance that what we are doing is serious. Unfortunately, my most preferred technology was the most challenging one to use and was very expensive." (Female client)

We also asked the therapist what influenced the choice of technology to use, therapist stated that this mainly depended on the client and the resources that they had at their disposal. If clients could afford more data they would go for video conferencing but if not, they would settle for calls or texts.

"The technology was dictated by the type of client that I have on that day. Say if I have someone and they can only do phone calls then I am forced to use the phone for the session, for those that would have access to the Internet, I would have options and enjoy the luxury to choose which one will best meet objective of the service being sought. But they are a few occasions when the choice was influenced by other factors such as network or client's preference. Majority of my clients including myself seemed to have preferred video conference. It had challenges but it was still the best." (Female Clients)

"For me it was what I had used before because it gave me an idea how to go about the session. I didn't want to have challenges which I didn't know how to go about solving in presence of my clients. My personal preference was WhatsApp because you can do quite a number of things on WhatsApp. Talk of video call, online voice call, share documents or give instant messages which actually show the client has read or seen my submission." (Female Therapist)

3.4 Limitations Faced by Clients and Therapists in Using Online Counselling.

3.4.1 Challenges faced by Therapist

Therapists enumerated numerous challenges but going by frequency count (Fig. 3), the following emerged as factors that decreased the efficacy of the online counselling service delivery. The most reported issue was the challenge of buying data bundles (Bundles) to access the internet. Unlike in developed countries where there is almost universal access to the WiFi, accessing the Internet in Africa is costly (see Makosa and Mweemba, 2019;). This is consistent with what (Gaved, et al., 2020) stated about Zambia: internet access is too expensive or unreliable. The second issue related to clients’ lack of trust and confidentiality being maintained during the sessions, with most clients questioning if the counsellor is alone. Issues of being suspected to be scammers were also reported, as well as challenges of poor connectivity. Other issues that came out during the discussion included complex problems owing to challenges with assessment and post-counselling monitoring because there were no physical visits, clients missing scheduled counselling sessions, difficulties scheduling and forecasting the direction on the therapy progress as they could not fully assess the clients online.

We also asked the therapist on their experience with Video Conferencing Technology and they stated that clients really preferred this method one of the therapists stated;

"Video conferencing was good especially for clients that thought we were just scammers and not properly trained and licensed. We could use it to verify most of these and also to see the client just to gain more insight about what is at hand. The biggest challenge which I believe was two sided was more bundles required and pathetic connectivity." (Female Therapist)

On the question of network connectivity, we also asked them which network was the most challenging with connectivity. One of the therapists advanced that;

"It was difficult to tell whose network was a challenge since we both needed connectivity. I personally don't remember asking my client what network they were using. So, it's safe to say, generally all networks had issues because connectivity was a problem for most clients I had." (Male Therapist)

We asked the therapist about their experience with instant messaging and they stated that not many participants preferred texting. How they often received the request for counselling via a text message on their Facebook or WhatsApp account.

"Mostly, I would receive my request for counselling or therapy via instant messaging either on my FB page, my WhatsApp number or a phone call. Sometimes through that same call we would have a long talk and next we start setting up sessions with hopes of using different technology like google meet or zoom... Texting and phone calls were manageable by almost everyone without much challenges but most people just wanted to see the 'therapists' thus very few often showed interest in phone counselling. But we used it as a backup when we experience challenges." (Male Therapist)

Among other challenges that came out of the FGDs, digital literacy was one of them. We found that many experienced therapists were not computer literate, and this defeated the whole concept of introducing online counselling in such a difficult situation, which called for expertise and experience. One of the therapists stated that:

"Most of us counsellors are not computer literate therefore making it difficult for us to participate effectively in the digital world. As most of us are still comfortable with the traditional face-to-face kind of providing counselling, yet the world is moving from that aspect." (Female Therapist)

3.4.2. Challenges faced by the Clients

The clients listed a number of challenges which were also subjected to frequency count to remain with only a few strongly held perceptions. Figure 4 summarises findings gathered from the questionnaire on the challenges faced by clients as they were receiving online counselling services. The most common according to the questionnaire results was the issue of network and limited bundles for connecting to the online platforms. Other issues were privacy as well as lack of confidence by the therapist while using the platform.

The following were the main challenges expressed by clients during the FGDs: The multiplicity of media/applications used in service delivery resulted from poor network connectivity; Insufficient funds for bundles, especially for the most perceived efficacious media - video conferencing; Not having an established platform for the services as it seemed a trial and error venture; Confidentiality of information they share with a total stranger they only meet virtually.

On the question of individual experience on video conferencing technology, clients stated that it had potential and it was the best option, however it was also riddled with many challenges including poor network and costs, clients had the following to say;

"It is the most promising technology for me as it gives assurance, I was able to see who is with the therapist in the room and is the closest to the normal therapy sessions. However, it required more bundles, network was a challenge and was limited to 40 minutes since we were using free version for Zoom." (Female client)

"It was very irritating when the call cuts and a new link has to be created for us to continue the session. This was despite the breakages which were experienced. The whole thing was just making me anxious." (Female client)

On the issue of poor connectivity, the researcher sought to establish of there was a particular network which was the most challenging with connectivity. One client stated that:

"The network was generally bad because I tried out using bundles for my two Sim-card for popular network providers but there was no much change. Am not sure but it's even possible network was bad on my therapist side" (Male client)

The researcher also probed the focus group discussion participants about their experience with instant messaging and the outcomes show that not many clients preferred texts, instead they were not many who used the option of texts. However, those who did use it found the texts to be confidential and fast. These were some of the responses;

"I didn't use much of text messages except when setting up sessions or when receiving documents to work with" (Male client)

Another man said, "Texting especially via WhatsApp was not the main medium of giving the therapy sessions but was just a backup and so i had no challenges with it". (Male client)

"I preferred WhatsApp instant messaging because it was fast and also the person talking to me was unknown to me and didn't know me so I could open up.” (Female client)

3.5 The Efficacy of Online Counselling

Figure 5 shows that a majority (53%) of the clients were not satisfied with online counselling as they called for improvement, with about 30% saying it was not efficacious at addressing their problems. Only a small proportion (9%) of the clients thought it was efficacious. Fifty percent of the therapists indicated that online counselling needs improvement, while 32% saw it as not efficacious and the rest thought it was efficacious. The proportion of therapists who saw online counselling as efficacious was slightly higher than the proportion of clients. Overall, the majority of both clients and therapists didn’t see online counselling as efficacious.

Narrowing down to the tool considered most efficacious (Fig. 6) at delivering online counselling, there was agreement between clients and counsellors that video conferencing tools were the best followed by phone calls and that the least efficacious were text messages. This presented a challenge for both clients and therapists given that video conferencing used more bandwidth and there were reported affordability challenges.

3.5.1 Factors Associated with a Positive Perception of Online Counselling

We begin with exploring what factors were associated with therapists’ preparedness and a positive perception of online counselling efficacy. The estimated logistic regression results are presented in Table 3. According to the logistic regression analysis we identified several factors that were associated with (1) preparedness of therapists to use online counselling platforms and (2) the efficacy of the online counselling services. There was a higher and significant association between a positive perception and belonging to the age group 26–37 years (OR 2.9, p < 0.05) compared to the reference group of 18–26 years. However, results show that older therapists (57–64 years) had significantly lower odds of being prepared for the online sessions. Being in Lusaka (the capital) was associated with higher odds of categorising the online counselling as efficacious. This could be because of the better connectivity in Lusaka compared to other small towns. There was also a high association between preparedness and profession. Specifically, the analysis showed that Mental Health Nurses and Psychiatrist had high odds ratios, but these were also not statistically significant.

Table 3

Factors Associated with Therapists’ Preparedness and Positive Perception of Online Counselling: Logistic Regression
	(1)	(2)
VARIABLES	Prepared (0/1)	Efficacy (0/1)
Sex (1 = Male)	-3.718**	1.012
	(1.593)	(1.101)
Age (reference: 18–26 year)
27–36 years	1.999	0.907
	(1.273)	(1.296)
37–46 years	2.003	2.903**
	(1.702)	(1.481)
57–64 years	-2.834*	2.664
	(1.621)	(1.819)
Private practice (Reference: public)	-1.512	0.799
	(1.198)	(1.282)
Lusaka (reference: other towns)	0.597	2.143**
	(0.977)	(0.978)
Profession (reference: Religious leaders)
Lay counsellor (0/1)	2.034	-3.507**
	(1.994)	(1.373)
Mental Health Nurse	2.356
	(5.054)
Psychiatrist	5.570**	-0.006
	(2.576)	(1.619)
Psychologist	-1.607	-0.520
	(1.417)	(2.697)
Psychosocial counsellor	-2.559*	-1.322
	(1.346)	(1.104)
Social worker	-0.382
	(1.502)
Constant	0.519	-0.671
	(1.468)	(1.299)
Observations	44	37
Robust standard errors in parentheses
* p < 0.01, p < 0.05, * p < 0.1

On the client’s analysis we tested for the association of demographic, media used, and experience with counselling with efficacy of online counselling services (Table 4). Results show that older clients (age group 45–50) have lower odds of perceiving online counselling as efficacious. Females had higher odds of having a positive perception compared to male clients. Phone calls were about three times more likely to be perceived as efficacious compared to other ICT tools that were used. However, the most important factors determining the efficacy of online counselling from the clients’ perspective seem to be therapist’s preparedness for the session. The odd of perceiving online counselling as efficacious barely changed when the counsellor was not prepared and when prepared but not satisfactorily. However, when the counsellor was prepared, online counselling was three times more likely to be perceived as efficacious compared to when the counsellor is not prepared.

Table 4

Factors Associated with Client’s Positive Perception of Online Counselling: Logistic Regression
	(1)
VARIABLES	efficacious
Age of client (Reference: <25)
25–30	0.592
	(0.656)
31–34	-0.287
	(0.914)
35–40	0.143
	(0.674)
41–44	0.002
	(0.724)
45–50	-1.586*
	(0.932)
>50	-1.423
	(0.867)
Sex (1 = Female)	0.842*
	(0.445)
Taken counselling before COVID	0.486
	(0.450)
ICT tool used (Reference: other)
Phone calls	2.802*
	(1.607)
Texting (0/1)	-1.850
	(1.537)
Video conferencing (0/1)	0.638
	(1.591)
Counsellor prepared but not satisfactorily (0/1)	-1.058**
	(0.494)
Therapist prepared (0/1)	2.997***
	(0.979)
Constant	0.325
	(1.332)
Observations	240
Robust standard errors in parentheses
* p < 0.01, p < 0.05, * p < 0.1

3.6 Views around online counselling during a pandemic outbreak

To further understand challenges and success around online counselling, the researcher sought to get participants' overall opinions, especially during an outbreak. More and more participants in the focus group discussions expressed disappointment with the attitude of therapist whom they suggested had not made deliberate efforts to ensure quality of service. Other things that made the service unsatisfactory were poor network connectivity and the fact that it was expensive. All these challenges ended up stressing the participants. Below we summarise some of the thoughts of clients and therapists during the discussions.

Clients had the following opinions:

"Normally, we would see a counsellor either at church or school or even just a doctor at hospital. But the Covid-19 pandemic imposed restrictions which brought more fear in us; the disease was new then we heard and saw people dying some our loved ones, then we began to experience some of the same signs and symptoms. We needed this service but it could not be accessed physically so we thought of reaching out online. Unfortunately, not so much was done to support this avenue by therapist or even government. I can generally say this is viable but from my experience, it was not effective as it brought stress anxiety in trying to get help instead of helping." (Female Client)

"Let them make a special Application like what those in education have for e-learning. This try and error was not serving the purpose." (Male Client)

Therapist had the following opinions:

"This area needs investment to reach a desired standard. You can imagine the outbreaks we have as a country, Lusaka for example is known for Cholera, the family involved require support but this may not be provided physically. Therefore, it becomes imperative for online services. If possible, there should be regulation of who can offer online services depending on equipment and facilities they have. In its current state I feel we are not doing justice to the system. Looking at the dropouts and the inconsistency in attending sessions, I can safely say we are not yet there." (Female Therapist)

"For me this was a learning experience, when I just started I had challenges and yes if I was to judge at that time I was going to say this was not effective. But now after seeing all the adjustments I have done to improve my services I can confidently say it is effective. We rushed into it but with time we started stabilizing. I also agree with the previous speaker that submitted the need for regulating who provides these services not only based on facilities but qualification and experience too." (Male Therapist)

The aim of this study was to investigate and confirm the clients and therapists' perspectives about the efficacy of online counselling during pandemic situations based on the level of preparedness, mode of delivery and limitations they faced in Zambia. The study found that during the COVID 19 pandemic, therapists were not prepared to provide counselling services online despite the fact that they started providing the services during the second wave of the pandemic. Further findings showed that therapists were pushed by demand from clients to offer these services online as it was the only 'safe' alternative available at the time especially during partial lockdowns. This study also found that numerous Information Technology application/media were used including video conferencing, Text messaging, Phone calls and a combination of these technologies as a result of challenges faced. The study found that therapists faced complex problems owing to challenges with assessment and post-counselling monitoring; environmental or security and trust issues, and sometimes being regarded as scammers; network and connectivity issues; clients missing scheduled counselling sessions; and scheduling and forecasting the direction on the therapy progress.

Findings from this study are in line with a previous study that showed that services were offered in a forced transition situation during the pandemic. Within the context of this forced transition resulting from the global COVID-19 pandemic, most psychotherapists identified a somewhat positive attitude toward online psychotherapy, suggesting they were likely to use online psychotherapy in the future (28). In another study, they indicated that Online counselling has become one of the very few possible ways to engage and intervene with students who are facing emotional and mental well-being challenges (29). Additionally, they state that, as the demand of mental health services had been growing in Hong Kong, online counselling will be a new alternative to meeting mental health needs in the future (29).

Previous studies have shown that online counselling, particularly videoconference counselling, can be similar to face-to-face counselling as it can improve the motivation of the counselees to continue the sessions by providing real-time communication with the psychological counsellor (30). In addition, therapeutic alliance can also be established in the online setting (20, 31). Generally, previous studies in developed countries show that there was an increase in the use of video conferences, computers, and telephones/smartphones. This was almost the case for our study as majority of therapists were first time users on the online service provision domain. The primary use of computers and smartphones in this study is in line with the findings from previous research, although psychologists in our study used mostly video conference and telephone calls, whereas email was the most widely used tool in a previous study (32).

Other previous studies found that online counselling also had some disadvantages such as technological limitations (19, 20, 25, 33). Similarly another study enumerated the reasons for dropouts (missing sessions in context of the current study) as being very busy with academic tasks work or having long studying hours, lack of motivation, and the disbelief about the efficacy of the methods used in the group (34). It has also been previously reported that the counselees who dropped out early particularly after the first or second session had a negative attitude towards counselling in general. The study found that despite the unexpected and challenging transition to online psychotherapy resulting from the pandemic, mental health professionals reported a relatively positive experience with remote treatment. During the initial stages of the pandemic, many of the initial relational and practical issues were effectively addressed (35). The decrease in reported challenges may be due to the therapists' ability to adapt to the new therapy format over time and find ways to address the initially experienced challenges. This adaptive process, which leads to the development of resilience, can be understood as reflecting the therapists' capacity for ongoing growth and improvement (36, 37).

A notable exception was the level of distraction experienced by therapists and patients, which seemed to increase over time. Research in other contexts has demonstrated that individuals are more likely to become distracted when using video conferencing compared to in-person settings (38). The study's subjects' reported distractions may have been brought on by therapists losing focus as they became accustomed to the online platform. We may surmise that the rise in distraction may signify a number of problems. Many elements of our life moved online during the pandemic, which meant both patients and therapists may have been sidetracked during an online therapy session by messages, calls, and notifications that appeared on their device, reminding them of other obligations outside of treatment. Self-view in video conferencing, which draws attention to one's looks, may also be distracting, according to anecdotal evidence. Additionally, because there is no need to travel to therapy appointments, waiting in a waiting area, or physically separate therapy from the rest of daily life, there is frequently no opportunity to adjust one's mindset between therapy and other aspects of life (such as work, household chores, responding to emails, etc.). It's also likely that when the novelty of the online therapy platform wears off, distraction worsens and requires less concentration and attention. The common occurrence of "Zoom fatigue" is probably what caused a build-up of tiredness that made it difficult to concentrate (39). These are only conjectures as participants weren't questioned about the precise kind of distractions they encountered at each timepoint. In order to better comprehend the nature of these diversions for patients and therapists over time, more qualitative studies are required in the future.

Challenges limiting the efficaciousness of the study for clients included: multiplicity of media/applications used in service delivery stemming from poor network connectivity, insufficient funds for bundles especially for the most perceived efficacious media - video conferencing. Clients also complained about not having an established platform for the services and the insecurity over confidentiality of information they share with a total stranger they only meet virtually. Similarly,, researchers indicated that although college students in Turkey reported positive attitudes towards online counselling, they also state some concerns and doubts related to online counselling such as technical limitations and privacy issues (40). Contrary to the views found in this study concerning clients expressing themselves with a total stranger, Egbochuku challenges the fact that the absence of face to face contact can also prompt clients to communicate more openly without concerns for bias of race, gender, age, size or physical appearance (41). This may lead to an increased level of honesty and therefore higher validity in the case of self-disclosure. He further adds that the internet clearly offers a level of anonymity that is perceived by many users as non-threatening through allowing an 'invisibility' that can be disinhibiting.

The study found that in the perspective of clients and therapists, online counselling was inefficient during the pandemic and required improvement. Statistically, 89% of respondents were not impressed with the service being provided online. On the contrary (28) found that most psychotherapists identified a somewhat positive attitude toward online psychotherapy, suggesting they were likely to use online psychotherapy in the future. On the part of clients, a similar study found that although clients in Turkey reported positive attitudes towards online counseling, they also state some concerns and doubts related to online counseling such as technical limitations and privacy issues (40).

Similar to the views held by therapists in this study although in the minority, Dores, et al., (32) found that despite the challenges identified, they described the experience with the use of ICTs as positive, meeting clients' adherence, and yielding positive results. Psychologists with the most years of professional experience maintained their traditional services the most, but those with average experience showed the most favourable attitudes toward the use of technologies and web-based interventions. Similarly, a study which focused on the attitudes of psychotherapists towards online therapy during the COVID-19 pandemic also found a positive attitude of the professionals with regard to this therapy modality (28). Although accumulating evidence shows that the treatment efficacy is similar in online and in-person therapies (42, 43). At the beginning of the pandemic, therapists often did not have experience with the online therapy format, and lacked training and knowledge of its efficacy. This might have led to more negative initial views. Over time and with gaining more experience of practicing online therapy, these views became more positive (35).

The study found a higher and significant association between a positive perception and belonging to the age group 26–37 years (OR 2.9, p < 0.05) compared to the reference group of 18–26 years. However, results show that older therapists (57–64 years) had significantly lower odds of being prepared for the online sessions. Being in Lusaka (the capital) was associated with higher odds of categorising the online counselling as efficacious. There was also a high association between preparedness and profession. Specifically, the analysis showed that Mental Health Nurses and Psychiatrist had high odds ratios, but these were also not statistically significant. The study found a disconnect between most respondents complaining about data bundles costs and connectivity but also agreeing that video conferencing is the best tool they used. In the same line, online psychotherapy entails some initial costs for the therapist, which may make access to online psychotherapy services too expensive for some patients (44). These initial costs could make it difficult to implement online psychotherapy in some low-income and developing countries (45). The use of technology became the only way in many countries to provide psychotherapy, and an overnight transition from in-office to online practice occurred during the Covid-19.

Given that videoconferencing constitutes a similar way of delivering therapy to traditional in-person psychotherapy, it has been rapidly incorporated (46, 47). Fernandez-Alvarez and Fernandez-Alvarez, (2020) noted that although different media started to be incorporated, videoconferencing is undoubtedly the most common way in which therapists are doing therapy these days. Although it was thought that patients were resistant to videoconferencing psychotherapy (VCP) in its early days, research shows that overall patients have a positive attitude toward VCP (Trondsen et al., 2014; Bleyel et al., 2020). Another study which compared connectivity of real-time video counselling versus telephone counselling for smoking cessation in rural and remote areas found that video sessions had significantly greater odds of experiencing connectivity difficulties than telephone sessions in relation to connecting to the participant at the start (odds ratio, OR = 5.13, 95% confidence interval, CI 1.88–14.00), loss of connection during the session (OR = 11.84, 95% CI 4.80–29.22) and hearing the participant (OR = 2.53, 95% CI 1.41–4.55). The results of the current study on Lusaka also supports this connectivity issue.

This study found that a therapist’s level of preparedness affects effectiveness of the session from the client’s view. Further, it was found that older therapists were less likely to be prepared and older clients less likely to see online counselling as effective. Age has been theorized to also have an impact on attitudes toward technology use (48), and younger age is often associated with being more technology savvy. In the context of online psychotherapy, pre-pandemic studies found no relationship between age and attitudes toward online therapy (47, 48); however, therapists of all ages’ sudden and en masse transition to online therapy might have posed specific challenges to therapists based on their age and experience. That is, even though younger generations might have had more preliminary experience with video conferencing, which they might have used more for personal communication purposes, older, clinically more experienced therapists might have had the advantage of having developed more solid and transferable therapy skills that could be more easily adapted to the new online platform. Concerns about being able to connect with patients online appeared to be the most impactful, in that it predicted negative attitudes toward online therapy and its perceived efficacy 3 months later, above and beyond the effect of therapists’ age and clinical experience (35). Despite growing empirical evidence that the therapeutic alliance in online therapies is just as strong as in in-person settings, especially when rated by patients, therapists still feel challenged by the relational aspects of online therapy, and this challenge has a significant and long-term impact on their attitudes and views on online therapy and its efficacy (35).

The study concludes that online counselling services were not efficacious and required improvement. Therapists faced inconsistent attendance of session by clients, network challenges, clients thinking they were scammers and lack of physical assessment. Clients equally cited poor network, and privacy issues as challenges. We therefore recommend that the Ministry of Health, Private Mental Health Institutions and Individual Practitioners to develop a dedicated and interactive platform for mental health similar to the e-learning platforms available in education institutions. Regulation should be made available to only allow those that have a facility or standard and dedicated platform to offer mental services online. Sensitization and educative programs for the community should be implemented to deal with confidentiality concerns. Continuous professional development programs for Mental Health Staff should incorporate this aspect of service provision in this digital age. Further research is needed to assess quality and legal implications of online counseling services among practitioners in Zambia.

Ethical Considerations

All methods were carried out in accordance with relevant guidelines and regulations of the ethics committee. All participants gave informed consent to participate in the study by signing an informed consent form. All protocols for the study were approved by Blessings University of Excellence Research Ethics Committee, Zambia.

Consent for publication of pictures

Not applicable

Data Availability

The data reported and supporting this paper was sourced from the existing literature therefore are available through the detailed reference list.

Competing interests

The authors declare that they have no competing interests.

Funding

This study did not receive any funding as it was part of Masters study

Author’s contributions

CM and KM conceptualized and designed the study. CM prepared the first draft of the study and KM and TM reviewed the manuscript to improve the flow of ideas, and the clarity of the concepts. All authors reviewed draft versions of the manuscript and approved the last version of the manuscript.

Acknowledgements

I would like to acknowledge first God for this opportunity. A special thanks to the counsellors and the clients who were willing to participate in the study.

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No competing interests reported.

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published 08 Mar, 2024

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Editorial decision: Major revision
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Efficacy of Online Counseling During Pandemics in Zambia: A Client and Therapist Perspective

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Abstract

Figures

1. BACKGROUND

2. METHODS

2.1 Participants

2.2 Procedure

2.3 Study Participants

2.4 Research Instruments.

2.5 Data Analysis

3 RESULTS

3.1 Demand for Counselling

3.2 Level of preparedness to offer online counselling services

3.3 ICT Applications Explored for the Provision of Online Counselling During the Pandemic

3.4 Limitations Faced by Clients and Therapists in Using Online Counselling.

3.4.1 Challenges faced by Therapist

3.4.2. Challenges faced by the Clients

3.5 The Efficacy of Online Counselling

3.5.1 Factors Associated with a Positive Perception of Online Counselling

3.6 Views around online counselling during a pandemic outbreak

4 DISCUSSION AND IMPLICATIONS

Conclusions

Declarations

References

Additional Declarations

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