This study assessed the acceptability and fidelity of the PROACTIVE psychosocial intervention for treating older adults with depression in basic health units in Brazil using qualitative research methods. The main findings indicated that (1) task-shifting in this context was acceptable (i.e., older adult participants accepted having the intervention delivered by non-mental health specialists, and health workers were able of delivering it as defined in the protocol), (2) collaborative care and stepped-care ensured adequate treatment, and (3) technology was crucial for fidelity to the protocol and motivating participants.
Overall, the training and supervision provided to the health workers before and after the psychosocial intervention achieved its goals . The intervention protocol was applied properly by the health workers with minor possible improvements to be addressed, and they did not have difficulties using the PROACTIVE app during the home sessions. Although most health workers complained about the extra work associated with their participation in the programme, they valued the experience and felt the programme was needed for treating older adults with depression.
Since collaborative care is already part of the FHTs work, it was not something completely new to health professionals at primary care. However, with PROACTIVE, non-specialized health workers had more space to talk at meetings and could contribute to the teams’ discussions when dealing with depression cases, which was seen as empowering for them. Thus, the programme adapts well to the existing FHS, which functions similarly across Brazil in that staff cooperate with each other when dealing with patients in their coverage area. Hence, the pilot study suggests that the PROACTIVE programme is likely to be acceptable and feasible all around the country. Sometimes, patients may need more or less care depending on symptoms or other reasons , for that reason stepped-care was another component in this intervention. Accordingly, patients who did not improve were referred to the family doctor and when needed, to a specialist, but they were only identified with the help of continuous depression assessments during weekly sessions and the automated notifications to the FHT.
As regards task-shifting, prior to the study three main concerns were identified: 1. whether non-mental health specialists would be able to deliver the intervention; 2. whether the intervention would burden care workers with extra tasks; and 3. whether older adult participants would accept this kind of intervention and its delivery by non-mental health specialists. Some studies in Africa using lay providers in primary care have shown that the lack of competence in specific tasks was a great challenge resulting in risks to patients [16, 17]; however, these studies included procedures that needed more specific training and supervision and were not related to counselling or mental health. Another study, also in Africa, used task-shifting in mental health and proved to be effective when there is enough training and support throughout the intervention . PROACTIVE showed that non-mental health specialists (health workers) felt capable of delivering the intervention with the assistance of the information contained in the tablets, and enough training and supervision to be compliant to the protocol. It is interesting that the health workers observed in the last sessions were more secure of themselves when delivering the protocol and were able to have a natural conversation instead of simply reading the script on the tablet.
A challenge known in task-shifting is that lay providers may be overwhelmed with competing tasks [17, 20], which is consistent with our findings. Health workers assumed a new role, but their other duties were not adjusted, and they did not feel supported by their teams. Although, this is an issue in a study context, outside that context they would be allowed to manage their own schedules, choosing the quantity of patients they can see at a time to avoid overlapping tasks.
In spite of older adult participants’ adherence to the intervention and its materials, their high attendance and satisfaction with the intervention, the dropout rate was around 29%. Some of the reported reasons for dropping out were not thinking treatment was needed (lack of information about depression and difficulty in perceiving themselves depressed), lack of time, and doubting the competence of the CHW to deliver a psychosocial intervention targeting depression. It will be important to develop strategies, such as more training and psychoeducation to reduce mental health stigma and increase awareness of the importance of treatment in order to reduce the dropout rate. Notwithstanding for the participants who completed the psychosocial intervention the fact that it was delivered by a non-mental health specialist was not an issue in terms of trust, bonding, or acceptability of the intervention, some participants did indicate that this represented a barrier for their adherence. This finding is in contrast with previous studies, which showed that having non-specialists delivering an intervention is usually well accepted and even preferred by patients. In spite of that, this finding should be taken into consideration for the development of the future trial in terms of discussing strategies that can decrease the resistance of having non-specialists in this role . Issues related to privacy may have played a role in not accepting the non-specialists’ care. CHWs live in the same neighbourhood and NAs are health workers with whom the older adult participants have close contact in the UBS. At the same time, that close contact was also referred by other participants as a positive point when bonding with CHW during the intervention, they feel more comfortable with them. Another crucial point was face-to-face sessions possibly impacting positively on participants’ adherence to the PROACTIVE psychosocial intervention. CASPER study, another collaborative care intervention in the United Kingdom , in which psychologists and nurses delivered sessions by telephone showed that although results in the improvement of depressive symptoms were positive, patients reported preferring face-to-face sessions instead of telephone sessions [18, 19].
The use of technology is known to be challenging in LMIC  due to professionals or patients’ lack of ability to work with technological devices. In the PROACTIVE programme the older adults do not use tablet computers themselves, but with the support of the health workers, who use the device during sessions. Therefore, from the perspective of the older adults the use of technology was not an issue. In fact, they benefited from the technology, as a large proportion of the older adult participants are illiterate, and the use of videos stored in the tablet allows easy access to information. Another important issue is mental health stigma and patients’ difficulty in accepting the depression diagnosis, therefore not seeking professional help  or withdrawing from the intervention because they did not understand the need for taking part in it [18, 38]. In the PROACTIVE programme the video animations helped with these problems as older adult participants reflected on the characters, learnt from them, and felt motivated in adhering to the treatment. From the health workers’ perspective, technology was of great use to structure the intervention, record and store older adult participant responses and present intervention content, and they did not struggle using it. The results of our study indicate that the training was sufficient to teach them how to manage the tablet computer and work with the app. The scripts on the tablet were of great use for health workers, allowing an adequate session delivery and fidelity to the protocol.
Supervision allowed us to provide ongoing training to the health workers and implement improvements during the pilot intervention. The functionality of the app on the tablet, for instance, was frequently adapted to resolve difficulties the health workers faced, such as problems accessing data on the tablet or accidentally skipping important content. The qualitative findings contributed to suggest improvements for the training and supervision in the main RCT, such as highlighting the importance of older adults to engage in pleasant activities (behavioural intervention) and strengthen their autonomy when dealing with depressive symptoms and choosing their own activities. Also, some minor issues in fidelity must be addressed, such as not entering data in the app, skipping videos or activities and managing time poorly. A way to avoid skipping content or lacking entrance of data is to block the screen in the app and add a reminder. Time management also needs more attention and must be discussed in the training and role played with health workers, raising strategies to keep the focus in the intervention. These issues should also be raised in weekly supervisions to ensure fidelity. Another improvement suggestion would be to have more training meetings with other members of the team (doctors and nurses) from time to time to address the overlap of tasks for non-specialists. As expected, it was confirmed that the psychoeducation texts in the booklet were not useful for illiterate older adult participants, and sometimes health workers forgot to use them, so the booklet will be reconsidered or highlighted in training as a useful tool to plan activities.
Although this qualitative study enhances our understanding of the acceptability and fidelity of the PROACTIVE psychosocial intervention, it does so with some limitations that should be considered when interpreting results.
First, non-participant observations were carried out only once for each session, moreover health worker and the older adult participant (dyad) were observed once in a specific session, not allowing us to assess improvements with gained experience along the intervention. Future qualitative studies should observe the same health worker conducting sessions at different time points to have a better overview of their development over time. We think that the focus group with the health workers conducted at the end of the intervention programme may have helped to reduce this issue though, as they have reported their experience conducting the intervention.
Second, even though during the non-participant observations the observer behaved unobtrusively, we have to concede that the presence of the qualitative researcher during the observations may have influenced the way the health workers behaved. Health workers reported feeling anxious while observed. The fact that based on the narratives of older adult participants the intervention developed well may indicate that the anxiety felt by health workers while delivering the intervention was restricted to the session in which they were observed. Observing sessions at different time points would maybe have mitigated the effect related to the observer’s presence in the session.
Third, the structured interviews could have been recorded, allowing checking back on data during the analysis process. However, participants’ concern for privacy was prioritized and the research team attempted to overcome this issue by registering carefully and in a standardized way all answers and relevant details. Additionally, there were quantitative questions in the structured interview that we have not analysed. We have used a structured questionnaire, which is an approach that has the advantage of being standardized since every participant answers the same questions. Nonetheless, we are aware that this type of approach has limitations for qualitative investigations, offering less opportunity for participants to fully express themselves and for the researchers to explore broad areas of interest in more depth.
Fourth, a de-identified survey could have been conducted in addition to the focus group to capture a greater range of perceptions from the health workers, since some of them may not have spoken-up in the focus group.
Last, the qualitative assessment was conducted in the pilot phase, which means that the sample size was defined by the pilot design, which for pragmatic reasons, included a maximum of three participants per health worker, and 11 health workers. Therefore, we did not use saturation as a criterion to stop data collection. Previous studies emphasized the importance of having a sample that allows identifying meaningful patterns across a dataset. Recommendations on sample size vary though with at least six participants being recommend for thematic analysis, for example. Hence, we believe our sample of 31 older adult participants with depression allowed us to generate meaningful qualitative insights regarding the pilot phase of the PROACTIVE psychosocial intervention .
Despite these limitations, our study provided useful insight on the acceptability and fidelity of the PROACTIVE psychosocial intervention. The qualitative findings attest to the good acceptability of the intervention by the older adult participants and to the fidelity to the intervention protocol by the health workers.