i UNIVERSITY OF GHANA DEPARTMENT OF PSYCHOLOGY AN EVALUATION OF A TELEHEALTH INTERVENTION FOR A CHRONIC CARE GROUP IN ACCRA, GHANA BY WILMA KETEKU-ATIEMO (10531280) THIS THESIS IS SUBMITTED TO UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MPHIL IN CLINICAL PSCYHOLOGY DEGREE APRIL, 2022 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I hereby declare that this thesis is an outcome of my own research work and that no part of it has been presented for any academic award in this university or any other university. 29th April, 2022 ……………………………. ………………………………….. WILMA KETEKU-ATIEMO DATE (10531280) This thesis was supervised and submitted for examination with the approval of: 29th April, 2022 ……………………………………….. ……………………… DR. ADOTE ANUM DATE (Principal Supervisor) 29th April, 2022 ……………………………………….. ………………………… DR. ANNABELLA OSEI-TUTU DATE (Co. Supervisor) University of Ghana http://ugspace.ug.edu.gh iii DEDICATION (Psalm 37:4) Delight yourself in the Lord, and he will give you the desires of your heart. To God We discussed, you agreed, and you delivered beyond my imagination. To my family My parents, Mr. William & Mrs. Emma Keteku-Atiemo, for continuously supporting my dreams and believing in me. My siblings, Charlotte, Emmanuel & Michael Keteku-Atiemo, for all the laughs when all I wanted to do was cry. To SMA We make one great team. I love you all University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT I would like to express my utmost gratitude to the following people, who supported me in diverse ways during my studies, and without whom I would not have made it through my master’s degree. I thank my supervisors, Dr. Adote Anum and Dr. Annabella Osei-Tutu for their support, dedication and encouragement. Thank you for the guidance and the sacrifices you made for me. I learnt a lot under your supervision. Nobody has been more important to me in the pursuit of this project than the members of my family. I would like to thank my parents; whose love and guidance are with me in whatever I pursue. They are the ultimate role models. Most importantly, I wish to thank my loving and supportive siblings, Charlotte, Owuraku and Kobby, who provide unending inspiration. The continuous encouragement, advice and prayers means so much to me. I am also grateful to all of those with whom I have had the pleasure to work during this and other related projects. To my friends Rose, Mary, Thelma, Maame Afua, Xolali and Rhoda. Thank you for all the calls just to check in with me and encourage me, especially on days where all I did was cry. Your comforting words always kept me going. Finally, I thank God for providing me with the opportunity to pursue a Master's degree and for providing me with the strength, endurance, and perseverance necessary to complete this work. I am grateful for the opportunity to study at the University of Ghana's Department of Psychology. While studying and conducting research, I have gained a tremendous deal of knowledge and skill. I am departing with a lot of new skills and information. It's been a fantastic adventure with a lot of lessons learnt. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENT DECLARATION......................................................................................................................................... ii DEDICATION............................................................................................................................................ iii ACKNOWLEDGEMENT ......................................................................................................................... iv LIST OF TABLES .................................................................................................................................... vii ABSTRACT .............................................................................................................................................. viii CHAPTER ONE ......................................................................................................................................... 1 INTRODUCTION ................................................................................................................................... 1 Problem statement .................................................................................................................................... 6 Rationale for the study ............................................................................................................................. 7 Aim of the study........................................................................................................................................ 7 Objectives .................................................................................................................................................. 8 Research questions ................................................................................................................................... 8 Significance of the study .......................................................................................................................... 8 Structure of the thesis .............................................................................................................................. 9 CHAPTER TWO ...................................................................................................................................... 10 LITERATURE REVIEW .................................................................................................................... 10 Theoretical framework ....................................................................................................................... 10 Related Studies ................................................................................................................................... 13 Criticisms of Telehealth Service. ..................................................................................................... 15 Competence. ...................................................................................................................................... 16 Telehealth Modules. .......................................................................................................................... 17 User Experiences. .............................................................................................................................. 19 CHAPTER THREE .................................................................................................................................. 21 STUDY 1: SERVICE RECIPIENTS................................................................................................... 21 University of Ghana http://ugspace.ug.edu.gh vi Methodology ....................................................................................................................................... 21 RESULTS .............................................................................................................................................. 27 DISCUSSION ........................................................................................................................................ 50 CHAPTER FOUR ..................................................................................................................................... 54 STUDY 2: TELEHEALTH TRAINEES ............................................................................................. 54 Methodology ....................................................................................................................................... 54 RESULTS .......................................................................................................................................... 59 DISCUSSION .................................................................................................................................... 72 CHAPTER FIVE ...................................................................................................................................... 77 General Discussion ................................................................................................................................ 77 Conclusion ............................................................................................................................................. 82 Limitations and Recommendations for Future Research ................................................................. 85 Implications for Training, Policy and Practice .................................................................................. 86 REFERENCES .......................................................................................................................................... 87 APPENDIX ................................................................................................................................................ 99 Interview Guide (Service Recipients) .................................................................................................. 99 Interview Guide (Telehealth Trainees) ............................................................................................. 101 Informed Consent Document ............................................................................................................. 103 University of Ghana http://ugspace.ug.edu.gh vii LIST OF TABLES Table 1: RE-AIM Dimensions and Related Questions Table 2: Demographic Details of Service recipients Table 3: Summary of main and subthemes from the User Interviews Table 4: Demographic Details of Telehealth trainees Table 5: Summary of main and subthemes from the Trainee Interviews LIST OF FIGURES Figure 1: Competency cube (Rodolfa et al., 2005) LIST OF APPENDICES Appendix 1: Interview Guide (Service recipient) Appendix 2: Interview Guide (Telehealth trainees) Appendix 3: Informed Consent Document University of Ghana http://ugspace.ug.edu.gh viii ABSTRACT The use of technology to deliver psychological interventions has garnered considerable attention. This is especially so during the global COVID-19 pandemic which has compelled experts to explore different ways to provide mental health and psychosocial support. The Chronic Care Group developed a telehealth intervention as part of efforts to improve knowledge on COVID-19 and provide psychosocial support and care to selected vulnerable communities in Accra, Ghana for coping with the pandemic. The aim of this study was to evaluate the Chronic Care Group telehealth intervention program from the perspectives of trainees (n=8) and service recipients (n=17). Two studies were conducted using a qualitative research design. Both studies employed a qualitative approach to explore the experiences of both service users and telehealth trainees. The results were analyzed using thematic analysis. The analysis of data of the telehealth Service Recipients revealed five themes: (1) Life before and during COVID-19; (2) Knowledge about COVID-19; (3) Psychosocial support; (4) Behavior change; and (5) Acceptability of the intervention. Results from the Telehealth Trainees highlighted three themes including: (1) Impact of COVID-19 on psychology training; 2) Competence of trainees; and 3) Challenges with the intervention. From the findings of these studies, the shift to telehealth offers new ways of thinking about and providing psychosocial support or addressing mental health needs as well as psychology training. This, together with the possibility of enhanced accessibility, suggests that telehealth has potential as a new and beneficial realm of practice within mental health services in settings in Accra and Ghana as a whole. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION The digital world, particularly the internet, has tremendously influenced every facet of life and mental health is no exception (Amichai-Hamburger et al., 2014). The use of computer-mediated communication such as electronic mail, video conferencing, open virtual discussion rooms, etc. has formed a normal and accustomed part of everyday activities in business, education and even pleasure seeking. Psychology joined this wave unassumingly, towards the end of the 1980s (Barak, 1999). The provision of mental health services is beginning to experience a cardinal change which is being driven by digital technology (Fairburn & Patel, 2017). Many therapeutic aspects of psychotherapy rely on both verbal and nonverbal interpersonal interaction, that might reflect why clinical psychologists have been reticent to incorporate technology into their practice in the past (Castelnuovo et al., 2001). Though face-to-face therapy will never be replaced due to its significance in psychological practice, technology now provides new ways for clients and therapists to communicate. For mental health practitioners, the internet can serve as an alternative for face-to-face treatments. Mental health professionals have recognized the potential of this medium and have used it to drive improvements in the delivery of mental health treatments, thereby facilitating social change (Amichai-Hamburger et al., 2014). Problems with mental health, neuropsychology, and substance abuse have a significant impact on global health and well-being. These ailments are the largest cause of disability in the world and the tenth major cause of mortality (World Health Organization [WHO], 2008). Despite the high disease burden, there are severe resource constraints in the areas of prevention, diagnosis, and treatment (Forum on Neuroscience and Nervous System Disorders, Board on Health Sciences Policy, Board University of Ghana http://ugspace.ug.edu.gh 2 on Global Health, Institute of Medicine, & National Academies of Sciences, Engineering, and Medicine, 2016). Even though treatment is accessible, over two-thirds of persons with a mental illness never seek help (WHO, 2001). According to WHO (2011), four out of every five people living with mental disorders live in middle or low-income countries and do not have access to the necessary health care. In Sub-Saharan Africa, the discrepancy is most pronounced. There is a shortage of qualified mental health practitioners in Sub-Saharan African countries, as well as a scarcity of mental health facilities and a low concern for mental conditions in public funding. In Africa, one psychiatrist is assigned to every 2 million people, whereas in European countries, one psychiatrist is assigned to every 12,000 people, averagely (Forum on Neuroscience and Nervous System Disorders et al., 2016). Individuals with mental health challenges do not seek any form of therapeutic treatment due to cultural and educational restrictions, difficulties accessing health care and structural limitations in the healthcare system (Kofmehl, 2017). With such a high disease burden, treatment gaps, and treatment costs, it is critical to transition to treatment methods that are quick, easy to access, and the advancement of health-care systems, both in terms of satisfying the requirements of people with mental illnesses and enhancing the efficiency and cost-effectiveness in treatment delivery (Glueckauf et al., 2018). Telehealth (i.e., telecare, telemedicine, telepsychology) has been classified as “the provision of medical care services utilizing technology modalities in lieu of, or in addition to, traditional face-to- face methods” (American Psychological Association [APA], 2020). They are professional client relationship methods that do not include direct face-to-face connection. It encompasses a wide range of options, including everything from phone conversations to video conferencing. It also has advanced features including the ability to attach documents, audio files, or videos, as well as the University of Ghana http://ugspace.ug.edu.gh 3 ability to use podcasts to allow patients to download valuable apps (such as a relaxation system, guided self-instructions, or a therapy program) (Pénate, 2012). The term telehealth is usually used to refer to a specific field of research and development: Internet- based psychological treatment programs (Internet-and computer-based treatments (ICTs); computer- assisted therapy (CAT); and computer-mediated Cognitive-Behavioral Therapy, to name a few (cCBT) (Pénate, 2012). These technological advancements are intended to work in the same way as manual-based therapies, assisting in the treatment of a variety of psychological diseases and difficulties via the internet. Psychological assessment, psychoeducation, training programs, and psychological treatment are just a few of the things that telehealth may help with. Counseling, mentoring, and providing references are among the other responsibilities (Pénate, 2012). It has potential as a treatment delivery strategy that can both enhance access to services and remove barriers to treatment accessibility (Varker et al., 2018). The Chronic Care Group Telehealth intervention was designed to improve knowledge about the coronavirus pandemic and COVID-19, the disease that arises from viral infection and provide psychosocial support and care to selected vulnerable communities in Ghana for coping with the pandemic. A manual was developed to aid the execution of this intervention. The manual had six key areas, overview of the intervention, what you need to know about COVID – 19, protective measures for everyone, protective measures for extremely vulnerable groups, basic communication skills for telehealth interactions, supervision and self-care and important referral numbers. The intervention was in three phases. Phase one involved training telehealth volunteers to execute the aims of the intervention. After which they were assigned specific cases to contact via telephone. The volunteers were to provide basic psychoeducation and psychosocial support as outlined in the manual. For phase two, the telehealth volunteers contacted the assigned cases considered as University of Ghana http://ugspace.ug.edu.gh 4 extremely vulnerable (e.g., people living with hypertension, diabetes, stroke, living in slums and crowded areas where risk of spread was high) and provided information about protecting themselves from the corona virus infection and coping with the psychological and mental health impact of adopting prevention strategies. (Volunteers were also to liaise with the Chronic Care group if there was a need for testing for and treatment of COVID-19). In phase three which was the final stage, recipients of the support may refer others in their communities for support sessions. Phone session appointments were created to respond to referrals. The general role of trained volunteers was to provide basic psychoeducation on COVID-19 to extremely vulnerable groups and their caregivers, model empathy and provide a listening ear and facilitate conversations around stress, anxiety and distress associated with coronavirus and COVID-19 and lastly, help people use problem solving skills to develop informed contingency plans should they become infected (Osei-Tutu & de-Graft Aikins, 2022). The Chronic Care Team is a team of researchers and practitioners with backgrounds in health psychology, social psychology, counseling psychology, and clinical psychology, as well as two decades of experience working with individuals, families, schools, and communities in Ghana. To address complex difficulties originating from chronic illness, debility, and stress, the group employs psychological theories and evidence-based interventions that have been tested in Ghanaian settings. The training manual was created to equip trainees with the necessary skills to provide psychological support for Coronavirus preparedness, treatment, and care in Ghana's most vulnerable populations. (See Osei-Tutu & de-Graft Aikins, 2022). Coronavirus disease (COVID-19) is “a disease caused by the newly discovered coronavirus. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes. Most individuals infected by the virus experience University of Ghana http://ugspace.ug.edu.gh 5 mild to moderate respiratory illness that does not require special treatment” (WHO, 2020). However, persons believed to be at high risk of severe infection and symptoms are older adults (65 and older) and people of any age who have underlying chronic health conditions such as lung disease, heart disease, diabetes, obesity, cancer and certain blood disorders, weakened immune systems and chronic kidney and liver disease (Centers for Disease Control & Prevention [CDC], 2022). The coronavirus has had a large global impact. In addition to the high infection and fatality rates, it has had a huge psychosocial impact, causing public uproar, economic burden, and financial loss. People from many walks of life have experienced a variety of mental health manifestations as a result of the epidemic (Dubey et al., 2020). Several governments around the world were forced to deploy quarantine and isolation measures as quickly as feasible, as a key control method. Quarantine has a wide range of implications on mental health and well- being at both the individual and population levels, in addition to physical suffering. Due to feelings of being cornered and powerless, quarantine imposed by governments and regulatory agencies can cause mass hysteria, anxiety, and agony. These sentiments are amplified when families are separated for an extended period of time due to uncertainty about the disease's prognosis, a lack of basic necessities, lost revenue, and a perception of elevated risk, all of which are aggravated by ambiguous information and poor mass communication in the initial stages of a pandemic (Maunder et al., 2003). Irritability, fear of infection and spread to family members, anger, perplexity, frustration, loneliness, denial, worry, sadness, insomnia, and despair, as well as extremes such as suicide, have been reported in previous epidemics (Brooks et al., 2020). Infectious diseases and chronic physical and mental disorders, have a negative impact on the world's poorest communities. This has serious health and developmental University of Ghana http://ugspace.ug.edu.gh 6 ramifications. Chronic non-communicable diseases (NCDs) and injuries (NCDIs) account for more than a third of the sickness burden in the poorest areas, disproportionately impacting those under the age of 40. (de-Graft Aikins et al., 2020). A telehealth intervention is required to reach and give some form of education and psychosocial support to such populations. A telehealth intervention was established to provide such service since such persons are believed to be at a high risk of Coronavirus consequences. Following the virus's breakout, events around the world led to changes in rules, legislation, and policies governing the use of telehealth, as well as the creation of guidelines and modules for telehealth service delivery (McCord et al., 2020a). Problem statement Evidence suggests that telehealth or telepsychology is effective in providing psychotherapeutic support for different populations (Robinson & Serfaty, 2001; Singh & Severn, 2018; Stasiak et al., 2016; Thompson, 2016). However, a scarcity of research and application in Ghana still remains. The impact of the pandemic resulted in the adoption of changes in healthcare delivery to minimize staff- patient contact and the impact of patient outpourings on health facilities (CDC, 2020). Mental health practice equally experienced significant changes. The events surrounding the coronavirus had a significant impact on mental health practice, compelling mental health professionals to seek other options that do not require face-to-face contact and resulted in a shift toward providing telehealth services to clients and managing their caseloads remotely (McCord et al., 2020a). The widespread misinformation, social distancing policies, and concurrent work-related stressors associated with such a highly contagious disease have long-term effects on mental health, leading to a variety of emotional disorders (e.g., irrational fear and anxiety) and problematic behaviors (e.g., maladaptive coping). As a result, there is an urgent need for adequate methods to reduce psychological stress and encourage positive COVID-19 behaviors. Telehealth services aid in University of Ghana http://ugspace.ug.edu.gh 7 providing needed care to patients while reducing the danger of coronavirus transmission to healthcare staff and patients (CDC, 2020). The Chronic Care Group telehealth intervention was created to train telehealth volunteers to provide psychosocial support for individuals of vulnerable communities in Ghana, severely affected by the coronavirus pandemic in order to minimize the disease's terrible impact. It has not been determined whether this intervention was useful or beneficial. As a result, this thesis explores trainees' and users' experiences in providing and receiving psychoeducation and psychological support respectively via telehealth during the COVID-19 epidemic, with the goal of using the findings to aid future crisis planning and the integration of telehealth into service delivery. Rationale for the study Emerging technologies are commonly utilized to improve and augment the delivery of psychological and behavioral interventions across a wide range of platforms, from universal smartphone apps to cutting-edge telehealth therapies. The COVID-19 pandemic offers a unique opportunity to investigate the deployment and evaluation of these digital health treatments in the context of a public health crisis. This Telehealth intervention, though designed to improve knowledge and provide psychosocial support, can be used as a template to develop a telehealth structure to provide mental health services for other groups, as well as for crisis intervention. This may also influence how psychologists are trained in Ghana to provide mental health services and expand the use of telehealth in health service provision. Aim of the study The aim of the study was to evaluate the Chronic Care Group Telehealth intervention program from trainees’ and service recipients’ perspectives. University of Ghana http://ugspace.ug.edu.gh 8 Objectives 1. Assess the utility of the telehealth intervention in improving knowledge about COVID-19 and provide psychosocial support. 2. Assess the acceptability of the service by users. 3. Examine the experiences and clinical competencies of telehealth trainees. 4. Assess whether telehealth trainees are still using the acquired competencies in their current practice. Research questions 1. To what extent was the telehealth intervention effective in improving knowledge about COVID-19, and providing psychosocial support? 2. How acceptable was this intervention to service users? 3. What experiences and clinical competencies did service providers (telehealth trainees) acquire through the training and implementation of the intervention? 4. To what extent are telehealth trainees applying the competencies acquired in their current practice? 5. What were the challenges with training and implementation? Significance of the study As psychological practice evolves, it is essential to find accessible and cost-effective ways of mental health service provision. The expansion of telehealth particularly in Ghana and on the African continent would assist in addressing several barriers to seeking mental health services. It has the potential to increase access to specialized mental health care that would otherwise be inaccessible, assist in the integration of behavioral health and primary care, resulting in improved results, eliminate care delays, and reduce stigma, among other things. As telehealth University of Ghana http://ugspace.ug.edu.gh 9 becomes a more common convenience, there is a growing amount of support and assistance for it. As a result, regulatory authorities for psychological research and practice must set recommendations for telehealth practice that are careful and based on research data. The findings of this study could help improve telehealth practice. Due to the ethical and therapeutic effectiveness problems presented, telehealth practice demands substantial training. Our findings may be relevant to graduate programs aiming to implement telehealth training experiences in order to improve students' telepsychology and telehealth competencies in general. The best techniques to define, measure, and promote competency growth in this new specialty would be the focus of efforts to improve telepsychology training. It would also help to improve the way psychologists are trained in Ghana. The findings of this study can inform the modification and improvement of this telehealth intervention, as well as the development and implementation of future mental health crisis interventions, in the event of a future public health crisis. Structure of the thesis Two studies were conducted to achieve the aim and objectives of the thesis. The studies evaluated the intervention based on the experiences of the service recipients (participants for whom the intervention was developed and implemented) and the telehealth trainees (graduate students who received training to provide services). Three chapters of the thesis, namely, methodology, results and discussion were written in two sections for the respective studies. University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO LITERATURE REVIEW Theoretical frameworks The theories that guided this study are the RE-AIM framework (Glasgow et al., 1999) and the cube model of competency development (Rodolfa et al., 2005). The RE-AIM Framework. The RE-AIM framework as proposed by Glasgow et al. (1999) is a planning and evaluation model that addresses five aspects of individual and setting-level outcomes crucial to program impact and sustainability. It was created to address the issue of lethargic and inequitable translation of scientific advancements into practice, particularly in terms of public health impact and policy. The RE-AIM dimensions include reach (R), effectiveness (E), and maintenance (M)–which operate at the individual- level (i.e., those who are intended to benefit), and adoption (A), implementation (I), and maintenance (M), which focus on the staff and setting levels (Glasgow et al., 2019). These dimensions highlight the importance of evaluating not only a traditional clinical outcome (i.e., effectiveness), but also implementation outcomes, which are less commonly examined yet critical to achieving broad influence (Holtrop et al., 2018). In terms of access, awareness, appropriateness, and potential generalizability, the RE-AIM studies increased understanding of recruiting strategies and intervention approaches. Physiologic outcomes were once the primary focus of clinical effectiveness research. RE-AIM expanded its scope to incorporate a wide range of factors that influence public health. This method of measuring broader impacts helps in gaining a better understanding of a program's overall effects on quality of life, including unexpected consequences. This framework was adapted to examine the utility of the telehealth intervention in improving knowledge about COVID-19, providing psychosocial support University of Ghana http://ugspace.ug.edu.gh 11 services for the telehealth service recipients, its acceptability to service recipients, competencies acquired for executing the intervention, challenges faced during the process and the competencies maintained by trainees. Effectiveness, adoption, implementation and maintenance are the four dimensions that this study focused on. Table 1: RE-AIM Dimensions and Related Questions RE-AIM Dimension Addresses Reach Effectiveness Is the telehealth intervention useful in improving knowledge on COVID-19 and providing psychosocial support? Adoption Is the intervention acceptable to service users? Implementation What competencies did trainees acquire to implement the intervention? What were the challenges with training and implementation? Maintenance Are telehealth trainees applying acquired competencies in their current practice? The Cube model of Competency development. The cube model is a conceptual model of core skill categories used in psychology. It includes of functional competency domains as well as the intellectual and interpersonal foundations on which they are based, all of which are important components in the professional development of a psychologist (Rodolfa et al., 2005). The cube model has been utilized as a theoretical framework for assessing competency in a variety of subfields of psychology, and it is now widely employed in professional psychology. Rodolfa et al. (2005) identified 12 competencies that can be divided into two categories: foundational and functional. Foundational competences (on the x-axis) are the knowledge, skills, attitudes, and beliefs that underpin the functions that a psychologist is supposed to perform (e.g., understanding of ethics, awareness and understanding of individual and cultural University of Ghana http://ugspace.ug.edu.gh 12 diversity issues, and knowledge of the scientific foundations of psychology). The foundational domains provide the knowledge and skills that psychologists need to gain functional competency later. The primary applied functions that a psychologist is expected to do on a daily basis (on the y-axis) were represented by functional competencies (on the x-axis), each of which demanded the reflective integration of fundamental competencies in issue identification (e.g., assessment, intervention, consultation, and research). Beginning with graduate school, internships, postdoctoral experiences, employment, and concluding with advanced and lifetime learning, the z-axis represented the progression of training or phases of professional advancement. From a conceptual approach, the cube model assumes that the acquisition of competences overlaps throughout developmental phases. To put it another way, the development of one skill is reliant on and aided by the development of others. Students can learn how to practice psychology by using a competency framework (Madan- Swain et al., 2012). University of Ghana http://ugspace.ug.edu.gh 13 Figure 1: Competency cube (Rodolfa et al., 2005) Trainees were expected to have basic competencies following the training. This study, based on the competency model assessed the foundational and functional competencies acquired by trainees based on the training received for implementation of the intervention. Related Studies Research has shown that therapy improves mental health irrespective of the medium through which it is delivered. The use of telehealth has resulted in substantial changes in the structure and delivery of mental health treatment (Adjorlolo, 2015) as it has broken down barriers to mental health care such as accessibility, cost, and convenience of use (Hilty et al., 2007). Online interventions are progressively gaining acceptance as a viable option for meeting the growing need for mental health care. These interventions should be supported by empirical research in order to be effective (Dowling & Rickwood, 2013). Telehealth has been shown to be an effective tool in the treatment of a variety of psychological disorders, including anxiety, depression, stress, phobias, obsessive compulsive University of Ghana http://ugspace.ug.edu.gh 14 disorder, body dysmorphic disorder, post-traumatic stress disorder, bipolar disorder (Andersson, 2018; Hodges, 2013; Varker et al., 2018), and many others. In a meta-analysis of randomized control trials (RCTs) reporting the effects of psychological interventions delivered through smartphones in the management of anxiety, Firth et al. (2017) found a significant reduction in total anxiety scores from smartphone interventions when compared to the control condition. Stasiak et al. (2016) have identified and described computer-based and online therapies that are used to prevent and treat depression and anxiety in children and adolescents. These programs use software to give therapy and target symptoms of sadness and/or anxiety. Various programs were found to be successful in treating these disorders, according to the findings. In a study of ten randomized control studies, Singh and Severn (2018) found that all of them incorporated therapist-guided e-therapy therapies for generalized anxiety disorder, panic disorder, or social anxiety disorder. These studies found that therapist-assisted e-therapy interventions were more effective than waitlist and active controls in treating these problems. It may, however, have the same outcomes as face-to-face Cognitive Behavioral Therapy (CBT). Robinson & Serfaty (2001) recruited 23 females via e-mails to provide them with treatment for bulimia nervosa who appeared to meet the full Diagnostic Statistical Manual (DSM) diagnostic criteria. These women were provided online therapy by one of two clinicians experienced in such treatment. A follow-up revealed a reduction in outcome scores. There were also significant correlations between word count, engagement with treatment and outcomes. From the study, it was evident that, the internet is a useful way to recruit and treat those with eating disorders. Lin et al. (2019) concluded that delivering treatment interventions for drug use disorders via video conferencing was beneficial in a review of randomized control trials. These studies looked at how University of Ghana http://ugspace.ug.edu.gh 15 psychotherapy and pharmacological treatments are delivered and found that they are connected with higher patient satisfaction and are a viable alternative, especially in circumstances when treatment access is limited. Postel, et al. (2010) used a pre-post design to examine weekly alcohol use, alcohol-related health problems, and weekly motivation in a study of an e-therapy program including therapists for 527 Dutch-speaking patients. Despite a high dropout rate, patients demonstrated a considerable reduction in alcohol use and health concerns associated to alcohol. The program was also feasible, because it drew patients who would not have sought assistance otherwise. Stewart et al. (2020) found that 96.8% of participants who completed the treatment no longer met the diagnostic criteria for a trauma-related disorder at posttreatment, in a pilot study that examined the feasibility and effectiveness of Trauma-focused Cognitive Behavioral therapy in childhood post- traumatic disorder; delivered via tele-psychotherapy in community-based locations of either schools or patient homes. Both youth and caregiver-reported reductions in posttraumatic stress disorder symptoms indicated clinically meaningful decreases in symptoms, with substantial effect sizes. Criticisms of Telehealth Service. For a variety of reasons, several specialists have resisted the use of telehealth. It has been chastised for its lack of face-to-face visibility, which makes it impossible to detect and convey nonverbal communication cues from clients and the therapist's body language on the one hand (Kanani & Regehr, 2003). These are regarded as critical components of the therapeutic interaction. Several ethical concerns have been raised about the use of technology in therapy, including secrecy and confidentiality, client and therapist identity, impersonation, emergency response, and many others (Satalkar et al., 2015). Another issue is the inadequacy of laws and regulations to address the various scenarios that internet treatment creates, such as license requirements, legal jurisdictions, University of Ghana http://ugspace.ug.edu.gh 16 professional liability insurance, and so on, resulting in unresolved legal concerns (Manhal-baugus et al., 2001). Practical and technical issues about online therapist training, electricity dependence, and the usage of complex and fragile technologies have also been raised (Barak et al., 2008). Though these objections persist, many of them have been addressed to a large extent as the discipline has progressed. In addition, these criticisms existed mainly at a time where technology was less advanced. People have therefore, become more accepting of online therapy as a result of advances in technology, changes in ethical rules, and the introduction of training courses and workshops (Chester & Glass, 2006; Grohol, 2004; Mahtta et al., 2021; Gajarawala & Pelkowski, 2021 ). Competence. Competence, like every other profession, is germane to the use of telehealth in providing psychological services. Psychologists must be capable of dealing with psychopathology of varied degrees of severity in both remote and in-person sessions. Individuals with more serious problems may be readier to seek treatment online rather than in person (Yuen et al., 2010). Rodolfa et al. (2005) define competency as having knowledge or skills in a specific area, as well as being qualified, capable, and able to understand and act appropriately and effectively. "The habitual and prudent application of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in everyday practice for the benefit of the individual and community served," according to Epstein and Hundert (2002, p.226). Different elements, including as discrete information, skills, and attitudes, are included into competencies; some areas of competency are highlighted to demonstrate the integrated knowledge, abilities, and attitude used in psychology professional practice (Kaslow, 2004). Research on competence in telehealth in Ghana remains almost limited. Professional competence is relevant in telehealth or telepsychology just as it is in face-to-face therapy. Though its use has the University of Ghana http://ugspace.ug.edu.gh 17 capacity to reduce human error, errors in the usage of such devices can have significant consequences (Adjorlolo, 2015). The professional is required to have some competencies such as service provision, cultural competency, self-awareness, ethics and laws governing its use, telepsychology technical skills, etc. (McCord et al., 2015). Equipping professionals with such competencies through training better places them to provides quality services. de-Graft Aikins et al. (2019) investigated the competencies of professional psychologists in active clinical health practice in Ghana, finding that training prepared them primarily for research and teaching, but not for clinical practice. Due to a lack of reflective practice, serious issues in emotional and cultural competences arose. There was a lack of structural support for ongoing professional development. The conclusion is that psychologists should have the necessary skills to deliver treatments in remote locations, including to clients with severe psychopathologies, and to deal with the challenges and crises that may develop as a result (Yuen et al., 2012). Telehealth Modules. In the literature, there are multiple reports of telehealth modules and intervention programs that were successful in attaining their goals. Tarlow et al. (2020) found that the hub and spoke model of telehealth service delivery was an acceptable model for improving access to mental health care services in rural and underserved communities, even for clients who lived relatively far from access points, in a study to determine if service utilization behaviors varied with the remoteness of clients served by a telepsychology clinic in a predominantly rural health professional shortage area (HPSA) in Texas. In a similar study, McCord et al. (2020b) constructed a model of core practice domains relevant to a number of telepsychology practice applications. The research found that telepsychology had the potential to address present challenges with mental health care availability, accessibility, University of Ghana http://ugspace.ug.edu.gh 18 acceptability, anonymity, and affordability. Furthermore, the applications of this model might be communicated in many situations and through various channels, and this practice model could inform future competency development. Kilbourne et al. (2008) discuss the conceptualization, implementation, and tolerability findings of a manual-based medical care model (BCM) modified from the Bipolar Disorder Collaborative Chronic Care Model (Bauer et al., 2006; Simon et al., 2006). The concept was created to help older persons with bipolar disorder improve their medical results. It comprises of self-management sessions focusing on bipolar disorder symptom control, healthy habits, and provider engagement, (ii) telephone care management to coordinate care and reinforce self-management goals, and (iii) guideline distribution focused on bipolar disorder medical issues. BCM feasibility testing demonstrated high overall patient satisfaction, high fidelity (e.g., the majority of self-management sessions and follow-up contacts were completed), and good tolerability (dropout rate of 5%). Telephone communications may have helped to overcome hurdles to medical care (e.g., transportation). Hodges (2013) also created a psychotherapy model (BIB model) that included technological resources to improve treatment aspects and enable successful psychotherapeutic interventions that result in long-term recovery for people with bipolar disorders. The paradigm allows persons with bipolar disorder to obtain long-term, comprehensive, and tailored psychotherapy treatment, according to the findings. Dent et al. (2018) provided Cognitive Behavior Therapy (CBT) through phone or video using a technology-enabled, standardized, and evidence-based behavioral health approach. The program had a nationwide reach, high patient satisfaction, and significant reductions in depression, anxiety, and stress symptoms, according to a retrospective before-and-after study. University of Ghana http://ugspace.ug.edu.gh 19 User Experiences. In health services research, the relevance of incorporating user perspectives into intervention design is becoming widely recognized, and it is at the heart of broad policy goals to deliver patient-centered therapy that is sensitive to patients' perspectives. Despite the critical importance of such synthesis in providing a rigorous and complete foundation for driving evidence-based clinical practice, several qualitative studies addressing user perspectives have yet to be synthesized systematically (Knowles et al., 2014), despite the fact that many service users prefer remote consultations (Juan et al., 2021), which they find as satisfactory as face-to-face alternatives (Dorstyn et al., 2013; Salmoiraghi et al., 2015; Christensen et al., 2020). Juan et al. (2021) sought to determine how service users felt about tele-mental health treatment and what factors influenced their desire to interact and accept it. Participants' perceptions and experiences were dynamic and varied across time, situations, and individuals, according to the findings. The reasons for contacting services, their relationship with care providers, both sides' access to technology and their unique preferences all influenced their impressions and experiences. Despite the fact that face-to-face care was preferred, participants nonetheless emphasized the benefits of tele-mental health and called attention to the need to address some of the obstacles that could limit access to help and aggravate inequality. Venville et al. (2021) also found that telehealth is well accepted by service users, but that this is contingent on them continuing to receive the help they needed in a secure and comfortable manner. While certain service users' access concerns should not be neglected, the majority of service users and workers were able to transition to telehealth by focusing on maintaining connections and using choice and flexibility to maintain service delivery. University of Ghana http://ugspace.ug.edu.gh 20 Knowles et al. (2014) found two major themes in a meta-analysis to identify factors that facilitate or impede engagement for computerized therapies: the need for therapies to be tailored to the individual, and the dialectical nature of user experience, with varying degrees of support and anonymity being viewed as both beneficial and adverse. Personalization and sensitization of information to individual users could improve the user experience of computerized therapy by acknowledging the need for users to have a feeling of "self" in the treatment, which was previously lacking. Using the shared characteristics of computerized treatment to increase perceived connection and collaboration could help to alleviate tensions produced by the dialectical nature of user experience. University of Ghana http://ugspace.ug.edu.gh 21 CHAPTER THREE STUDY 1: SERVICE RECIPIENTS Methodology This chapter focused on the various techniques used in data collection and analysis for the telehealth service recipients. The research design, population, sample and sampling procedure, method of data collection and procedure for data analysis as well as expected outcomes were discussed in this section. Research design. The qualitative research design was used in this study. The importance of analyzing variables in their natural situation, particularly their interactions with other factors, is emphasized by this design. It provides in-depth information of how people learn to perceive, act, and regulate their daily interactions in specific situations (Institute for Work and Health, 2011). This research took a phenomenological approach. Based on their lived experiences, this method describes a concept's or phenomenon's shared meaning for several people. Phenomenologists focus on articulating what all individuals have in common when explaining a phenomenon (e.g., grief is universally experienced). The basic goal of phenomenology is to reduce individual encounters with phenomena to a description of the phenomenon's universal essence. This is accomplished by qualitative researchers identifying a phenomenon, or "object," of human experience (Creswell & Poth, 2018, p. 121). This method allows the researcher to get a better sense of what the subjects went through and how they went through it (Moustakas, 1994). Research setting. The research was conducted in the Ga Mashi community of Accra, which is part of the Greater Accra region. Ga Mashi is composed of twin towns, Jamestown and Usshertown, which are two of Accra's University of Ghana http://ugspace.ug.edu.gh 22 oldest settlements. Both communities existed before Accra became the nation's capital in 1877, and their current location (along the Atlantic coast) is known as Old Accra (de-Graft Aikins et al., 2020). It has a long and illustrious history of artistic expression, popular culture, and political engagement. The Central Business District, Houses of Parliament, numerous government departments, and Ghana's first and leading teaching hospital, the Korle-Bu Teaching Hospital, are all within proximity. It has received a slew of development grants and support from international and local non- governmental organizations (NGOs), including being earmarked for urban regeneration as part of the millennium cities project (de-Graft Aikins, 2020). Ga Mashi is, however, one of Ghana's poorest and most densely populated non-slum settlements. Ga Mashie, like other African urban poor areas, is plagued by infectious and chronic diseases that have major health and development repercussions (Agyei-Mensah & de-Graft Aikins, 2010). Members of the neighborhood have restricted access to education, work, and formal (biomedical) health services, despite being surrounded by luxury and social amenities. Participants. The prospective participants for this study comprised 36 service recipients of the intervention. This was the total number of participants who received support through the intervention. However, only 17 of these participants were available to participate in the study. Some service recipients had either passed away and others too weak due to ill health. The service recipients were members of the Tsui Anaa group, a self-help group in Ga-Mashi community. They were individuals living with chronic health conditions such as hypertension, diabetes, asthma, chronic kidney disease, among others, who were considered at higher risk of the complications associated with COVID-19. Gender equity could not be ensured in this study as the intervention had already been implemented. To be included in the University of Ghana http://ugspace.ug.edu.gh 23 study, participants should have been members of the Ga-Mashi community who received psychosocial support through the intervention program. Sample and sampling technique. Purposive sampling method was used in the selection of participants. This involves identifying and selecting individuals or groups who are seen to have knowledge about or experience with a phenomenon of interest (Creswell & Plano Clark, 2011). It is a non-random technique that does not require underlying theories or a particular number of informants. Basically, the researcher decides what needs to be known and sets out to find people who can and are willing to provide the information by virtue of knowledge or experience (Bernard, 2002; Lewis & Sheppard, 2006). Purposive sampling was used since the service recipients were believed to have been provided with a service through the intervention program and had the requisite information for the study. A semi structured interview guide (see Appendix A) was developed and used in data collection. A semi structured interview provides the opportunity to ask follow-up questions, reduces the risk of veering off the focus of the study and keeps the interview within a particular structure. Data Collection Instrument. The data collection instrument consisted of two sections that gathered demographic information of the participants and asked questions pertaining to the research questions. A semi-structured interview schedule with open-ended questions was used as a guide for the interviews (see Appendix 1). This guide was developed by identifying questions, a total of 19, that best bring out responses that answer the research questions which mainly focused on knowledge about COVID-19, psychosocial support and the acceptability of the intervention. Some of the questions were: 1) “When the Tsui Anaa group called you, how did they explain COVID-19 to you? 2) Knowing that having a chronic condition placed you at high risk of severe illness, if you contracted COVID-19, how did University of Ghana http://ugspace.ug.edu.gh 24 that make you feel? 3) What coping skills did you learn to help alleviate the psychological distress associated with dealing with COVID-19? 4) How were you taught to cope with isolation? 5) What aspects of the service did you like and why? And, 6) Would you like to utilize such service in the future? The questions were translated into Ga and Twi Language, which were the languages that the participants were fluent in. This was done with the help of a research assistant who was fluent in both languages. The questions were then tested through a pilot and did not require any other modifications. Procedure. Following the intervention from March 2020 to June 2020, the process to evaluate the intervention began in January 2021. After receiving ethical approval from the ethics committee (ECH 107/ 20- 21), an interview guide was developed and translated into both Twi and Ga languages and translated back into English to ensure that the questions conveyed the same meaning. This was done with the help of the researcher’s supervisors and a research assistant using simple forward translation (WHO, 2016). The Research Assistant who is fluent in the target languages assisted the researcher to translate the guide. The researcher’s supervisors reviewed the translated interview guide, conducted a back translation and offered comments to amend the guide. The translated interview guide was shared with colleagues to determine accuracy in conveying the same meaning in both English and the two local dialects in which the interviews would be conducted. Participants were then recruited for the study. Initial pilot interviews were conducted in August 2021. Actual interviews were conducted from September 2021 to October 2021 at the waiting area of the Jamestown Police station. The interviews were conducted with the help of a research assistant since the researcher was part of the team that implemented the intervention. This was to prevent researcher and participant effects. A research University of Ghana http://ugspace.ug.edu.gh 25 assistant was also required because of the language barrier between the researcher and the participants. Majority of the participants spoke Ga which the researcher was not fluent in. The research assistant who already had experience with qualitative research interviewing received further training on how to administer the interviews and also participated in a mock interview. The interviews were conducted individually in either Ga or Twi language and lasted for an average of 30 minutes. A total of 17 out of the 36 participants were approached for the interview and they all accepted to be part of the study. The interviews were recorded using an audio recorder with consent from participants. Data analysis. The data was transcribed with the support of an interview transcriber, a research assistant who was fluent in both English and Ga. An interview transcriber was needed due to the language barrier. The transcriber was to help the researcher translate the interviews into English for easy transcription. The interviews in Ga and Twi were simultaneously translated and transcribed. The transcripts were reviewed by the interviewer, researcher, supervisors and the researcher’s colleagues who were fluent in the Ga language, to determine accuracy. This was done by comparing the transcripts to the audio recordings. The data was analyzed using Thematic Analysis as proposed by Braun & Clarke (2006) which includes: familiarization with all the transcripts, generation of initial codes, organization of codes into themes, review of themes, defining and naming of themes, and production of results. The aim of a thematic analysis is to uncover themes—that is, significant or intriguing patterns in the data—and then utilize those themes to discuss the research or make a point. A strong thematic analysis does more than just summarize the data; it explains and clarifies it. Using the primary University of Ghana http://ugspace.ug.edu.gh 26 interview questions as the themes is a typical error (Clarke & Braun, 2013). This typically indicates that the data have been organized and summarized rather than analyzed. The researcher read the scripts thoroughly to be familiar with the data. It is critical to read and reread the transcript several times during the first stage of the analysis to become as familiar with the narrative as possible. While familiarizing with the data, initial notes or commentary were made Initial codes were identified by reviewing all the transcripts and noting parts of the transcript that communicated information about COVID-19 experiences, knowledge on COVID-19 and psychosocial support. Examples of initial codes include coping with “lockdown,” “financial difficulties,” “feelings of distress,” “prior understanding of COVID- 19,” and “changes made during peak of virus”. The recurrent codes were highlighted, grouped in a table in Microsoft word document. This was shared with fellow graduate students and a qualitative research expert, who reviewed the codes and ensured that they accurately represented the data. Following their corrections and input, the codes were then compared and combined to create preliminary themes and subthemes which were also validated by the same persons. Following this process, some of the themes were modified to best depict the data. University of Ghana http://ugspace.ug.edu.gh 27 RESULTS The study included 17 participants (4 men and 13 women). Sixteen participants were Christians, and one was a traditionalist. Participant details are presented in Table 2 Table 2: Demographic Details of Service recipients Participant No. Age Gender Marital status Employment Status Health Condition No of Sessions in the intervention SR001 64 Female Widow Unemployed Hypertension 4 SR002 72 Male Single Unemployed Hypertension 3 SR003 74 Female Single Retired Hypertension 3 SR004 64 Male Married Employed Hypertension, mild stroke 4 SR005 65 Female Single Retired Hypertension 4 SR006 42 Female Married Employed Hypertension 3 SR007 72 Female Single Retired Hypertension 4 SR008 63 Female Single Retired Hypertension 3 SR009 63 Female Widowed Retired Hypertension, Diabetes 3 SR010 66 Female Single Retired Hypertension 3 SR011 70 Female Widowed Retired Hypertension, Asthma 3 SR012 65 Male Widowed Retired Mild stroke 3 SR013 66 Female Married Retired Hypertension 3 SR014 59 Female Widow Unemployed Hypertension, Diabetes 3 SR015 60 Female Single Employed Diabetes 3 SR016 50 Female Divorced Unemployed Hypertension 4 SR017 66 Female Married Retired Hypertension 3 University of Ghana http://ugspace.ug.edu.gh 28 Major Themes The analysis of the telehealth service recipients’ transcripts generated five main themes: (1) Life before and during COVID-19; (2) Knowledge about COVID-19; (3) Psychosocial support; (4) Behavior Change; and (5) Acceptability of the intervention. Table 3 includes summary of themes and subthemes. Table 3: Summary of main themes and subthemes from the User Interviews Themes Subthemes Life before and during COVID-19 COVID-19 induced life changes Lockdown experience Knowledge about COVID-19 Prior knowledge Improved knowledge Vulnerability due to chronic condition Psychosocial support Nature of support Coping with isolation Behavior changes Observation of preventive measures Continuous adherence Acceptability of the intervention Prior relationships Positive feelings and perceptions about the intervention University of Ghana http://ugspace.ug.edu.gh 29 Theme 1: Life Before and During COVID-19 Many have experienced significant changes in their living experiences since the onset of COVID-19 as measures to manage this public health crisis led to the implementation of many restrictions. This resulted in extended time in isolation and loneliness and equally affected social interactions. Participants highlight the COVID-19 induced life changes and lockdown experience which together, describe the living experiences of the participants since the onset of COVID-19. COVID-19 Induced Life Changes. In describing their lives prior to the onset of COVID-19, the living experiences of some participants involved free movement, high engagement in social activity and the ability to go about daily economic activities. This however, changed completely as a result of the outbreak of COVID-19. Service Recipient 1 described how he could initially go for walks around the neighborhood with other members of the community but had to abide by expert advice as a safety precaution and restrict himself to exercising around his home. I was doing nothing. Before, I was going for a walk around, err, City engineers, [oh ok] at dawn with Nii and a couple of others because majority of the people did not want to go. We had to stop the walk at a point when [a telehealth trainee] and his people told us not to go out of our homes but rather exercise around our homes; to protect ourselves from the disease. (Service Recipient 1). According to Service recipient 4, there has been a reduction in economic activity, as sales and patronage of goods or products have been low as compared to before the onset of COVID-19 which for him has resulted in low income and made life difficult: Life has not been easy at all. There’s no money. At least before, we could go out and sell one or two animals to get money for the family. But since this disease came, we could not go out to sell much and people don’t buy as they used to because there is no money. You also have to provide for the family. (Service Recipient 4). University of Ghana http://ugspace.ug.edu.gh 30 Service Recipient 6 also recounted how life during COVID-19 has been different from their prior experiences. She narrated that: What I have seen is that, now, life is not going on too well like before. In terms of trading and in our finances, it has become a bit of a challenge. I see it as a consequence of the pandemic we are experiencing. This virus that we are experiencing, ruined a lot of things in the beginning. We experienced the lockdown, we were not allowed to sell, go to town or do a lot of things. It messed up things a bit but I believe that as time goes on, everything will be fine. (Service Recipient 6). While some service recipients highlighted the significant changes, they had experienced in their lives, others reported no change. Service Recipient 11 narrates that, “I wasn’t doing anything and I have been alright. The only thing is that, now, people are not as free as they used to be to go out and meet people.” Lockdown Experience. The lockdown in the hotspots of the country required many to stay at home for a period. This was one of the many measures taken to reduce the outbreak of the virus. COVID-19 restrictions caused financial hardships immediately after its outbreak. Both the formal and informal work sector were affected immensely which affected many individuals and families. Participants reported their financial struggles as follows: The lockdown worried us. We were home all the time and things were very expensive, but we don’t have the money. We even noticed that the things provided by the government were being shared in town but when it gets to our place then they pass somewhere else, they don’t give us. The last time, they brought us plantain which wasn’t good and fried fishes we don’t like. They didn’t give us anything during the lockdown. They pass through our place with the food or give those before us and when they get to our place they don’t share. So, it was God who stayed with us during the lockdown, thinking killed a lot of us too. (Service Recipient 19). University of Ghana http://ugspace.ug.edu.gh 31 “They” refers to people designated by the government to make relief items available to various communities”. She also added that; If you go to buy something, they give too many complaints. If you must cook too, you have to cook plenty so that it can last for a week. The second lockdown was worse than the first we couldn’t buy anything. There were no tomatoes, you can’t buy onion Gh2 from ‘Kotoko’ so we suffered where we are. The fish too we don’t know where they get it. It was just by the grace of God. (Service Recipient 19). Social isolation, unforeseeable circumstances, changes in daily routine and reduced physical activity, can potentially lead to increasing levels of stress, loneliness and anxiety (Wilkialis et al., 2021). There are numerous coping strategies adopted by different people in dealing with situations that result in distress. This includes self-distraction, active coping, denial, substance use, use of emotional support, use of informational support, and behavioral changes. Participants adopted various coping mechanisms such as observing hygiene protocols, adopting healthier lifestyles, engaging in social activity or seeking social support from family and friends, watching television or listening to the radio and engaging in economic and religious activities to help them deal with the impact of COVID- 19. Below are narrations from participants: Service Recipient 2 narrated that, “I was home doing nothing in particular, just seeing to chieftaincy issues”. Service Recipient 3 admits to making behavioral changes and ensured that members of her household who were equally vulnerable, protected themselves during the lockdown to cope better: I was home and when I needed to go somewhere, I used my nose cover. In addition, I was washing my hands frequently. Anytime I go out, I wash my hands frequently. I ensure my grandchildren wash their hands when they come back from outside before they eat. We do not go out. I cook for them at home, I did not buy food for them from outside during the lockdown. I exercise a lot too. I wake them up at dawn and we walk from here to Palladium and back to the house. (Service Recipient 3). University of Ghana http://ugspace.ug.edu.gh 32 I either watch television or listen to the radio. On Crystal TV, I watch Ghanaian and Nigerian movies. On Sundays, I listen to Mensah Otabil’s church service. I then find something to eat and relax on my bed. (Service Recipient 5). My sister and I would discuss world issues as to how to live. Yes, err, but she is no more. We would sit here and receive all that was given during the lockdown. We used our time together to make ourselves happy. (Service Recipient 7). My children and I have been having discussions because they also can’t go anywhere. They are my friends and partner. They gave me strength during the lockdown. The elderly daughter’s husband is a doctor so we do exercise in the morning, especially me. We always exercise and he talks with me and other things so I didn’t have a problem. (Service Recipient 9). Participants engaged in religious coping as a way of dealing with the various restrictions imposed during the peak of COVID-19. Nobody goes anywhere but during the lockdown, we were going for church activities. A lot of people did not come, but the few people that came, we did whatever we were supposed to do. At home, you can’t go out unless something has happened. At home, I sit and watch TV. I like watching the newspaper review. So, I watch and when I am done watching the newspaper review and eat something, I rest. (Service Recipient 11). We thought about it for some time and pray to God to let it pass. We have not seen something like this before Ghana. We pray about it with our children anytime we wake up in the morning in our room. (Service Recipient 18). The outbreak of infectious diseases such as COVID-19 can result in significant emotional distress such as depression, anxiety and fear of contracting the disease. (Zhou et al., 2020). Due to the restrictive measures imposed in many countries, many had to stay at home which often led to being alone or having very little social interaction, coupled with all the uncertainties of the outcome of the pandemic and an overload of devastating information about COVID-19. These narrations highlight the distress experienced: University of Ghana http://ugspace.ug.edu.gh 33 During that, time people who do not have anybody around to have a chat with ended up being sad. [oh] Yes oh. I told you I like watching television. I could not control myself when I saw what was happening in America. I felt uneasy watching. My child warned me not to watch. The television remote was hidden for some time from me and my in-law called to ask me not to watch. I was devastated seeing people in body bags and coffins. (Service Recipient 1). As for the fear, it is normal to feel that way. But with prayers and… if you do what they have told us to do, you won’t be afraid. (Service Recipient 11). Yes of course I was afraid, because it was all happening too fast… I always keep a distance when I am sitting and someone else is sitting next to me. (Service Recipient 14). COVID-19, since its inception, though it has caused significant challenges in healthcare and healthcare seeking behavior, it has equally offered opportunities for its improvement and more efficient ways of providing or seeking healthcare and healthcare promotion (Saah et al., 2021). Participants describe differences in their experiences with their health and health seeking behavior during the peak of COVID-19. Whilst some completely shied away from the usage of health facilities due to the fear of either contracting the disease or being tagged as an infected person, others continued to visit as and when they needed to. What are you going to do in the hospital? Because, you will be asked many questions. They will think that you have COVID and that’s why you have come to the hospital. We have been told that you only visit the hospital when you have a serious illness. Therefore, you need to control yourself. Nothing has happened to me since. I used to take the medication but I stopped at a point in time because according to the leaflet, the medicine can give you infection. When you live a healthy lifestyle, you will be fine. Recently I had to go to the hospital for medicine because I had an issue with someone and I got angry which triggered my blood pressure to go high. The doctor asked if I have run out of medicine and I told him there is nothing wrong with me. He told me that though nothing is wrong with me I should come any time I run out and I told him ok. (Service Recipient 1). University of Ghana http://ugspace.ug.edu.gh 34 I was going to the hospital as usual until the week of the lockdown. I was given medication during my last visit which I was taking but I was not taking it regularly because I did not want my medication to finish since we could not go to the hospital. Even if you go, you will not be allowed to enter unless it is an emergency. And so, if I take it today, I will not take it tomorrow but rather the next day so that I will not run out of the medication. That is how I was taking it. (Service Recipient 6). Yes, I was able to go. Anytime I feel a little discomfort in my body, I go to the hospital. I take them every time. I have taken my medication this morning. I do not joke with my blood pressure (BP) medication because it is killing many people. (Service Recipient 8). Research question 1: To what extent was the telehealth intervention effective in improving knowledge about COVID, and providing psychosocial support? Theme 2: Knowledge About COVID-19 In exploring their knowledge acquired about COVID-19 through the Chronic care group, the narratives given by participants paint a picture about their views, perceptions and beliefs about COVID-19 before (Prior knowledge) and after receiving psychoeducation (Improved Knowledge), as well as knowing about their vulnerability to COVID-19 infection (Vulnerability due to having a chronic condition). Prior Knowledge. Before receiving psychoeducation on COVID-19, participants mainly had limited knowledge about what COVID-19 was, how to identify it, what measures or precautions were required to protect themselves and the outcomes of contracting the disease. There were also a few misconceptions based on the variation and authenticity of information received, which could be attributed to the different presentations of COVID-19 on different media platforms or outlets and how they were understood. This often led to some misconceptions and false theories about the virus. Some misconceptions about COVID-19 include: University of Ghana http://ugspace.ug.edu.gh 35 We the Gas [an ethnic group in Ghana] do not believe there is Covid-19 and are not abiding by the protocols. What we know is that, the leaders in the country are making money out of the pandemic. (Service Recipient 1). The COVID-19 virus is a sickness that really breaks you. When you get it, ‘you really don’t stand a chance’. You will experience coughing, chest pains, it makes you feel cold… There are a lot of sicknesses associated with the COVID-19 sickness. (Service Recipient 13). The term ‘you don’t really stand a chance’ means that a person who contracts COVID-19 has no chance of survival, which may not necessarily be the case and can be classified as a misconception. I didn’t know much about the sickness. When you give your attention to a sickness if you don’t take care, you will get it so I didn’t give my attention to it. I wasn’t feeling well by then too I keep getting boils. (Service Recipient 19). With the misconception that giving a disease too much attention could result in contracting it, this participant decided not to give the COVID-19 virus any attention and so did not have knowledge about it. Analysis of the data also shows that participants had very limited or inaccurate knowledge on COVID-19 prior to receiving psychoeducation from the Chronic Care Group. This is evident in the following narrations: We knew that it is a disease that has affected many people around the world. It is a disease that when you contract it and you are not careful, you can die as a result. Therefore, you need to find the antidote. (Service Recipient 1). I heard it being discussed on the radio and television, but I am yet to see anyone who has contracted the disease. I did not know what disease it was but what I heard is when you contract it, you cannot breathe. (Service Recipient 3). We heard on the television that when stepping out we must wear our nose mask and wash our hands. We have been doing that ever since. (Service Recipient 4). Though this participant was abiding by the hygiene protocols heard on radio, he still lacked the understanding of why such protocols were important. University of Ghana http://ugspace.ug.edu.gh 36 OH. Everyone knows that it was a sickness that came “tsruukaa” (out of the blue) and it is only doctors who know what it is. That it infects you, they are bacterium in the air “neke neke neke” (this and that), hands have to be washed often and you need to do that… and I don’t go out so… I mean I don’t often go in the mist of crowd so I think it can’t infect me, not like it can’t infect me because I’m not God. (Service Recipient 12). According to Service Recipient 12, the COVID-19 was believed to be a disease that came “tsrukaa,” which meant out of the blue. This means that they have no knowledge about what the disease is and how it came about. Prior to the psychoeducation received from the Chronic care group, some participants had some knowledge of the hygiene protocols and safety measures. We heard on the television that when stepping out we must wear our nose mask and wash our hands. We have been doing that ever since. (Service Recipient 4). We already knew we have to use our nose mask, wash our hands and follow the protocols. We were following the protocols before they came to have a chat with us so we do not have any issues. (Service Recipient 8). New Knowledge. Through the psychoeducation received from the Chronic Care Telehealth Manual, most participants showed improved knowledge about COVID-19. Based on the psychoeducation received, participants demonstrated knowledge of what the virus was, symptoms of COVID-19, mode of transmission, the protective measures and consequences of contracting the virus. Based on the education received on the definition of COVID-19, participants explained that: They said it is a disease caused by “mmoawa” (a virus) that is being transmitted from one person to another and so we should be careful. (Service Recipient 2). University of Ghana http://ugspace.ug.edu.gh 37 ‘Mmoawa’ (Twi) literally means small organisms which this participant uses to describe the COVID- 19 virus and is believed to cause the Corona virus disease and further shows how it can be transmitted from person to person. Therefore, one needed to take care. They [the telehealth providers] said it is a disease or virus in the air that people contract. (Service Recipient 6). He [telehealth provider] said they are bacteria so we should protect ourselves, we should be wearing the face mask. (Service Recipient 19). The following are narratives that demonstrate their knowledge retained on the mode of transmission of COVID-19: We were told that it is a disease that can be contracted when you get close to an infected person. We should wear the nose mask and we should not go anywhere. That was the advice given us. (Service Recipient 5). It is transmitted through the air so if an infected person coughs and spit around people can be infected. You must take good care of yourself so you do not contract the disease. (Service Recipient 7). They [telehealth providers] said COVID-19 is a new disease that has been discovered. So, you can get it through the air or when you shake hands with someone or maybe you have contact with someone. (Service Recipient 12). Based on the education received from the Chronic care group, participants describe the symptoms of COVID-19 as follows: We were told that the symptoms are cold, cough, vomiting, pain in the ribs and the entire body together with flu. Aside these symptoms I do not know of any. We have been told of a ‘new one’ (a new variant), which is worse than the first one that came. (Service Recipient 1). They mentioned coughing, headache, difficulty breathing… As for what I saw on the television, I cannot describe it. All I saw was dead bodies going to be buried. (Service Recipient 5). University of Ghana http://ugspace.ug.edu.gh 38 They say that when you see the person coughing and can’t breathe properly, then you will know that the person has some or you take the person for checkup. (Service Recipient 12). Though participants had received education on the symptoms of COVID-19, some participants believed that only a doctor could tell the symptoms of COVID-19. Therefore, they suggested that such tasks should be left for healthcare professionals: I do not know but I think it is only a doctor that can tell whether someone has COVID-19 or not. When you are sick, you go to the hospital and the doctor will determine the disease you are suffering from. You cannot tell what is wrong with the person. You will be asked to do some tests and the results will reveal what is wrong with you. Is that not the case? (Service Recipient 4). These participants defined COVID-19 based on consequences of contracting the virus; They said the sickness that has come, it really kills and we don’t see it. (Service Recipient 7). It is a disease that is killing many people abroad but it seems luck is on our side in this part of the world. (Service Recipient 4). There’s an admission by service recipient 4 to the fact that though the disease has killed many, the participant attributes the outcomes of the disease in Ghana to luck. This means that though others have experienced life-threatening outcomes, Ghanaians have been lucky. Eating green leafy vegetables such as ‘kontomire’ provide nutrients that boost the immune system to fight COVID-19. Participants were encouraged to eat such foods to protect them. The protective measures they learnt from the education received are as follows: We were told not to remove this thing (referring to the nose mask), wash our hands every second with soap and wipe with tissue. The tissue should be put in a dustbin and not on the floor. We were also told to have hand sanitizers on us for ready use; particularly in areas where there is no water. (Service Recipient 1). They said we should avoid getting close to people, we should get water to be washing of hands regularly and also wearing nose mask Hmmm, I am trying to remember. They told us University of Ghana http://ugspace.ug.edu.gh 39 to eat well and exercise. As for that, we have already been doing it because of the bp. (Service Recipient 5). They called and told me that what came is very serious so we should be taking good care of ourselves. And secondly, our hospital attendance, how we have our conversation and sitting among people. We shouldn’t be going to funeral and things before they asked how we are doing. (Service Recipient 9). They said we should wash our hands under running water with liquid soap and when you’re done you need to sanitize your palm, when you use the paper tissue, you put it into the dustbin. There’s a provided dustbin aside. When you’re home too as many times as you can, and you should use the nose mask to cover where you’re supposed to cover because they said your saliva can infect someone so you must use it to cover your mouth. (Service Recipient 11). For some participants, albeit they had received psychoeducation on what COVID-19 was, some admitted that there was an inability to recall. Participants narrate as follows: I do not know what the disease is but what I remember is that, when you contract it, you cannot breathe. I have forgotten. (Service Recipient 3). There was also an inability to demonstrate knowledge about seeking healthcare support during the lockdown. Compared to other aspects of psychoeducation, participants were barely able to define or illustrate the terms, ‘self-isolation’ and ‘quarantine’. Despite the inability of most participants to accurately recall the definition of these terms, due to forgetfulness, a few participants were able to recall; Self-isolation? Err they said that, if you feel like where you went, there is someone there with covid, you’ll have to stay in your room for some time. You will be in your own room for some days, you won’t go anywhere. Before they see if you have some of the sickness or not. (Service Recipient 9). My understanding is when someone contracts the disease; the person will be taken somewhere to be quarantined to find out whether it is covid-19. (Service Recipient 5). University of Ghana http://ugspace.ug.edu.gh 40 The quarantine… when you get the virus, they must put you aside and treat you. (Service Recipient 11). On the other hand, majority of them were able to illustrate ‘social distancing’. When asked to demonstrate knowledge of social distancing, participants comment as follows: Social distancing means there should be a gap between us when we sit. On this bench only three of us can sit. The way you are close to me, it is not allowed. You are to sit on the third seat from me. Our people are not going according to protocols. When I am invited to a funeral and I meet the person who invited me, I give my donation to the person and leave. I do not sit to eat or drink. There are funerals in my locality which I cannot attend because people’s life matter. A member of NDC, our party, has passed but I will not attend the funeral. People’s life matter to me more than going to those events. (Service Recipient 1). We should let a gap be between us. Is that not it? (Service Recipient 4). Vulnerability Due to Chronic Condition. For elderly populations and people living with chronic health conditions such as hypertension, diabetes, cardiovascular diseases, asthma, etc., they have increased risk of infection and a severe course of COVID-19. These populations are excessively impacted and are at higher risk for hospitalizations, morbidity and mortality. Participants were fully aware of their susceptibility to the infection due to having a chronic condition, its severity and the possible consequences of infection. In expressing their feelings about the knowledge of their vulnerability, some participants admitted to being afraid, anxious, panicking, frustrated and living in uncertainty, while others experienced no fear at all: When I heard that when you have hypertension, diabetes and other diseases could suffer more from contracting COVID-19, I was scared. I even told my husband that I heard that if you have hypertension and diabetes, you can have serious problems, he didn’t believe it. He said you can still die from it whether you have such illness or not. So, he asked me to forget about it. (Service Recipient 6). University of Ghana http://ugspace.ug.edu.gh 41 Honestly, it made me feel a little bothered. Those of us who have BP and stuff, we really need to take good care of ourselves. Because if we are unable to abide by the instructions given to us and we get COVID-19, we are the ones that… As we have also grown older, we are the ones it takes away quickly. So, we ought to follow the instructions given to us very well. (Service Recipient 13). I felt so frustrated because I have children and only one is with me, they come and go but since the lockdown they have not been able to come. I stay alone, but they have been calling me and what they say is that, I’m a Muslim and we like washing our hands. When I’m going to clean myself, I go with soap. Our bathroom is for the whole house so when going to bath I spread ‘akesha’ (bleach) there and wait for some time before going to bath. I was going by that practice but now I can’t. I know how to take care of myself, I tell God not to allow any misfortune to happen to me and my children. (Service Recipient 15). I felt it in my heart because I am not well myself. (Service Recipient 20). Hm, initially I was very afraid because they said when we get it, we will die. So, I was very worried. But when Paapa’s (telehealth trainee) people called me, they explained that if I do all the things that they have asked us to do to protect ourselves, we will not die. So, I became alright. I take very good care of myself, and I make sure there is a gap between others and myself when we are talking. When that also happened, I did not joke with my medication. (Service Recipient 7). I felt frustrated and didn’t know what to do. So, we took it into prayers, so it doesn’t come our way. (Service Recipient 18). While some experienced fear and worry over their vulnerability, others had no worries and believed that they would be fine if they continued to adhere to the safety protocols, they had received education on: I never had any fears. I had faith that once I continue to protect myself like Paapa and co told me to, there is no way I can contract the disease. I am not sure I will contract the disease because now I have also taken the vaccine. (Service Recipient 2). University of Ghana http://ugspace.ug.edu.gh 42 Rather than deal with the difficult feelings and thoughts about their perceived vulnerability, some participants decided to engage in avoidant coping by not thinking about it or engaging in other activities to enable them to forget or as a distraction from the real issues: In the beginning I had a little panic and I said no, if you put fear in you, it will get the chance. I watch the television in the morning and laugh watching it, I like to watch film so that I feel happy and release the fear in me, that was what helped me. When they said people with sickness can easily get it, I was a little afraid, but it got to a point where I told myself that I will forget it. When our people called me too, they spoke to me and advised me that I should not be afraid. I should just protect myself and take my medicine and I should also do things that will make me happy and relaxed. (Service Recipient 9). COVID infects people with underling illness and kills them quickly. I was frightened, so I know how I move about, so I don’t get infected. Because as I sit here, I have BP and Diabetes too, so if some comes to add up to it then I will be dying… so I really take care of myself, so I don’t get infected by it… (Service Recipient 14). Theme 3: Psychosocial Support In reviewing the management of the psychosocial difficulties encountered by participants, this theme looks at the experiences of participants with the support received from the chronic care group during the peak of COVID-19. Nature of Support. A considerable amount of support received was counselling, which included talking to them and facilitating conversations about anxiety, fear and stress, its causes and how they could deal with such issues using coping mechanisms and problem-solving skills. Participants also received financial support and other forms of relief such as, groceries, healthcare assistance and hygiene products. They narrate the type of support received as follows: University of Ghana http://ugspace.ug.edu.gh 43 They helped us. As I earlier mentioned, they gave us ‘provisions’ (groceries). They advise us anytime they called. Somebody like Vida will always call to check on me and tell me to always relax so that my bp will not go up. Sometime ago, err, I think last month, she called me. She asked why I had not gone for the vaccine, and I told her I would not go for the vaccine, and I do not know of any vaccination center. Now that there is a more dangerous one around, when I hear the vaccination is going on, I will go and take the vaccine. The group also sent us 1,000,000 (GHS 100) during that time. Recently they sent us some money. I do not quite remember the amount. It was either GHS 250 or GHS 500. They help us a lot. (Service Recipient 1). The term ‘a lot’, depicted the amount of support received while ‘they advise us anytime they called’, referred to the counselling received during the care call. They have been extremely helpful. They taught us proper dieting and exercising. I am a leader of our group, so I call them at 5 am for walks. There are elderly people amongst us. Tsui Anaa gets us doctors for medical screening and registered many of us on national health insurance scheme. Those of us who don’t have money to buy our medications too, they provided funds for us to get our medication. (Service Recipient 2). The statement “They treat us like the hospital does” means that participants’ experience shows no difference between a face-to-face intervention and an online intervention. Coping with Isolation. Based on the manual, participants were equipped with coping skills which enabled them to deal with isolation, loneliness and changes in daily routine. They narrate their experiences as follows: Ahh, they only said that we should exercise ... And that, if we feel like talking to somebody, we can call them on phone. As for the TV, as I already said, I have been watching it always so… (Service Recipient 1). Participants were encouraged to use remote technology such as mobile phone, to keep in touch with family and friends and to exercise regularly. “We should go for walks and exercise so that we do not become dull”. (Service Recipient 2). University of Ghana http://ugspace.ug.edu.gh 44 “Becoming dull” could mean adopting a lifestyle that is more sedentary and has the potential to further exacerbate their chronic health conditions. They taught us to feel free at home, watch TV, play with our children, call our relatives and talk to them and pray. They also said we should not be worried or be afraid. Once we protect ourselves, we will be fine. (Service Recipient 6). Theme 4: Behavior Changes As part of infection control measures for COVID-19, hygiene protocols and safety precautionary measures were implemented which included, social distancing, self-isolation, quarantine, appropriate and frequent hand washing, use of nose masks and sanitizers, etc. This required significant behavior change and continuous adherence to safety protocols. Observation of Preventive Measures. Participants made significant behavioral changes by observing the outlined covid-19 preventive measures and maintained some of these changes due to various reasons which are mainly perceived susceptibility, perceived severity and cues to action: Something like going to visit friends in their homes. You go out and enjoy. Attend funerals to enjoy. People will say ‘we used to drink with you’ but now you say you are drinking no more. As you have seen what is happening, you must change your lifestyle. You also need to be careful with the people you are sitting with because you will not know whether they have the virus or not. I no longer visit my friends. I only watch television in my room. (Service Recipient 1). Service recipient 1 stopped visiting friends and attending funerals which eventually led to potential problems with friends. She however admits that these changes are necessary due to the current times. During that time, I changed. As I said earlier, I was not going anywhere, I am home with my grandchildren most of the time. We go for walk at dawn, come back home wash down and get something to eat. I later go and lie down to rest. (Service Recipient 3). University of Ghana http://ugspace.ug.edu.gh 45 During the COVID-19 period, I was always at home because I didn’t want to get the disease. I wasn’t selling or doing anything of the sort. But now go out often. (Service Recipient 6). I have not been washing my hands as many times and things but since the COVID-19 came, whatever I touch, I must wash my hands. I don’t always wear the facemask at home. We saw how other countries were suffering and their people were dying. (Service Recipient 11). This is an external prompt to trigger behavior change (cue to action) I don’t go to crowded places, even when I must eat, I go into my