Student name:NeemaMsami

Student number:1328712

Project supervisor:Joanne Meredith

Degree BSc Single Honours Psychology

Perceptions of utility and acceptability of the use of e-Mental health interventions in Tanzania
Abstract

Objective: The objective of the current study was to assess the perceptions of utility and acceptability

of the use of e-Mental health services in the Tanzania population.

Design: A qualitative online survey with 10 open-ended questions regarding the use of e-mental

health applications was developed. The data was analyses using Thematic Analysis.

Setting and participants:A volunteer sample of twelveparticipants, who lived in Tanzania, and who

spoke English as their second language, were recruited through Social media advertising.

Results: Three major themes were identified form the data: 1) the purposes and potential positive

contributions of an e-mental health application; 2) Suggested content for an e-mental health

application; and 3) barriers and challenges to the use and utility of an e-mental health intervention

application. Overall, results suggest a favourable perception of e-mental health applications for the

Tanzanian population, as it would address issues such as circumventing social stigma when

‘physically’ seeking help for mental health problems; but also raised issues, such as the availability of

not only the internet but sufficient mobile data and the ambiguous nature of wanting privacy.

Conclusion: Perceptions of utility and use of e-mental health interventions were largely positive,

suggesting the introduction of e-Mental health services in Tanzania may be perceived as positive due

to the potential of making positive contributions in addressing mental health issues in Tanzania.

However, there are challenges before the implementation of such intervention.

Introduction

The World Health Organisation identifies mental health as an integral part of holistic health and

wellbeing. As per its constitution, health is a state of any individual, in which he/she is free from any

physical, mental, emotional and social complications or pressure and health does not only implies a

disease-free human body. Hence, it is identified that mental health is an essential component for the

collective ability of an individual to think, express, emote and healthily interact with one another.

With increasing technological advancements and global competition, mental illness has emerged as

one of the primary concerns of humanity, affecting every component of a holistic healthy body.

Characterised by increasing level of distress, disability, lack of constructive thought and increasing

chances of self-harm or violence, the American Psychiatric Association (2018) also identifies that

mental health issues affect an individual’s social, personal and professional life drastically. While

discussing the mental health illness, it is considered that the World Health Organisation (2018) has

mentioned that more than 264 million people worldwide are currently suffering from it. Depression is

also one of the primary reasons for disability around the world, increasing the burden of disease for

people. Hence, societies must be able to continue the investigation, and developing therapies and

interventions for people affected with mental health complications.

Tanzania: Population Statistics and Health Care System

While discussing about the mental health complications and its effect upon the population of
Tanzania, the paper of Jenkins et al. (2010) should be discussed. In this study, it was found that 31 out
of 1000 people in Tanzania are suffering from critical mental health complications (Jenkins et al.,
2010). It was also found that the rate of women being affected by complications of mental health is
higher than that of men in Tanzania. Besides this, the report about the mental health status of United
Republic of Tanzania published by World Health Organisation (2011) mentioned that for mental
health complications of 100000 populations, only 0.04% patients get beds, a number of mental
healthcare hospitals are 0.002% and there is no outpatient facility or residential care facility for
mental health illnesses. Therefore, it could be identified that the existing mental health primary care
facility is poor in this country (World Health Organisation, 2011). It was also identified in this report
that Tanzania has no mental health nurses per 100,000 individuals and the number of occupational
therapists and psychiatrists are 0.009% and 0.04% respectively. Furthermore, there is a high chance
that the number of individuals receiving mental health interventions is too low and does not accurately
reflect the reality, due to stigma, lack of awareness, and lack of mental health services, many people
remain undiagnosed (Allen, 2019).In addition, Tanzania is one of the poorest countries in the world as
mentioned in the research of Howland, Noe and Brockington (2019) and – as most places in Africa –
investment in mental health service provision has been inadequate (Jenkins et al., 2010).

To understand mental health management in Tanzania, it is necessary to first understand the

social context. This is important because culture shapes or influences help-seeking behaviour; and

attitudes and beliefs about mental illness (Chen, Mak & Lam, 2020). It is therefore important to

understand the beliefs of the population in question, to be able to effectively: Seventy percent of the

Tanzanian population lives in rural areas; which are associated with low provision of (mental) health

services and low levels of (health) literacy and lack (Adams et al., 2020). Past researchhas suggested

that people from rural areas have no understanding of where to seek professional help when

experiencing a crisis (Barlett et al., 2006); thus, this links with low health literacy (i.e. inability to

seek professional/medical help) ( Kelly, Jorm & Wright, 2020).Furthermore, low health literacy has

been related to poorer health outcomes (Sorensen et al, 2015).Here, it is important to note that this

research has been conducted outside of Tanzania, namely in Australia and Europe, and may therefore

not generalize completely to Tanzania; however, it is likely to assume that similarities occur.

Moreover, rural Tanzanian people are notably more conservative in their values and attitudes.

There is a significant negative connotation to openly sharing feelings and experiences. In rural

communities around the world, for example in Australia, individuals and their families are expected to

solve their problems in private and not talk about them publicly (Judd et al., 2006); thus, when

someone is experiencing negative affect, they are expected to keep this private. This is also true for

African countries, where emotional expression and openness are not cultural values (Inglehart, 2018).

Furthermore, there is significant social stigma attached to mental illness, which affects both mentally

ill individuals and their caregivers/families (Patel, 2007; Collins et al., 2010). This stigma is

especially prevalent in rural areas and has a wide-ranging psychosocial impact on caregivers and

family life, to the extent that sometimes caregivers are forced to hide the patient in order to avoid

being discriminated against (Phekoet al.,2013).

 When confronted with a mental illness, most families, in private, consult traditional healers

and spiritual leaders in the search for a cure (Hewson, 1998; Jahoda, 1979; Ofori-Atta & Linden,

1995; Tanner, 1999). This is a by-product of a notable view in Tanzania, along most countries in

Africa that psychiatric illness is not a disease; but rather a curse, a product of both witchcraft and evil

spirits (Mbatia&Kilonzo, 1996; Njenga, 2002). In a special report of the World Health Organisation

(2020), the representative of the United Republic of Tanzania Ms Abdallah has discussed this aspect

of Tanzanian society and their take upon mental health illnesses. As 85% of the population of

Tanzania lives primarily in rural areas, mental health complications are handled by spiritual leaders

and traditional healer and for them; mental health is a complication which occurs due to multiple

supernatural reasons or curses upon an individual (World Health Organisation, 2020). Despite

multiple healthcare and especially mental health care guidelines established by the government, its

integration into mental healthcare as well as modern medication is still a major loophole in the system

(Nkuba, 2017). In this report, the representative of Tanzania mentioned that among multiple severe

stressors that lead a large section of the society in depression or other mental health complication is

their poverty; lack of psychological support system in society and lack of awareness about proper

healthcare guidelines are significant (World Health Organisation, 2020). Besides this, an increasing

number of refugees, subsequently a higher degree of crimes and insecurities of the indigenous

population of this country increases the incidents of depression and mental illness (Amdahl, 2020).

One of the primary reasons for the increasing implementation of traditional healing method for

psychiatric or mental health complications is lack of awareness due to illiteracy in the population

(World Health Organisation, 2020). As per the report of UNESCO (2012), more than 60% of male

and female students’ drop out of their primary education and only 31% and 24% of boys and girls join

secondary education, leading to an average literacy ratio as 73%. Hence, due to lack of education and

awareness, traditional healing and treatment of curse or supernatural aspects are utilised more than

modern medication facilities (Spittel, Maier & Kraus, 2019).

 In Tanzania, traditional healers and faith healers are the primary contact of a personwith a

mental illness, especially in terms of providing psycho-social support to both patients and their

families. The consultation of non-clinical healers, instead of psychological services, can be harmful to

the patient for a number of reasons: firstly, there is however a considerable lack of evidence in terms

of the efficacy of this type of management, and these people usually do not have the necessary

qualifications in psychosocial support care (Ensink & Robertson, 1999; Vinorkor, 2004; WHO, 2002).

Secondly, undergoing non evidence-based “treatment” can worsen the patient’s mental statue as some

mental illnesses can worsen over time if left untreated. Therefore, worsening patient health. Thirdly,

due to this, many patients will never see appropriate psychological care for their illness.

Potential Utility of Technology to Address Inadequate MH Services in Tanzania

One resource that could be extremely useful in terms of addressing these issues is technology

(Greene et al., 2019). Computers, laptops and particularly sophisticated mobile phones are widelyused

in Tanzania; and there is global provision of access to the internet.Just in the past decade there has

been a sharp rise in the use of technology in Tanzania and now 63% of Tanzanians have their own

mobile phones (Financial Sector Deepening Trust Sector (FSDT) 2017). This accessibility to the

internet as well as internet-enabled devices is anticipated to address the shortage of mental health care

services (Piatti-Fünfkirchen & Schneider, 2018).

This modern technology has significantly changed the landscape for the delivery of healthcare

services. It is now possible to treat both mental health as well as some physical conditions without

physically travelling to see a practitioner or attend a health care centre (Lustgarten & Elhai, 2018).

This provision of online services could address a number of the issues raised above: firstly, it could

overcome the shortage of mental health services in Tanzania, especially in remote and rural areas.

Secondly, it could help address the lack of evidence-based treatment seeking, e.g. if more people had

access to psychological care online, they would be less likely to visit a ‘spiritual leader’. Thirdly, it

could help a persona void the stigma attached to mental illness, as e-mental health services might also

offer the possibility to seek help for mental health illnesses anonymously.
 Tanzania, just like any other African country, has a limited mental health care system (Mbatia

et al., 2009). Under-funding caused by poverty and lack of priorities from the government means that

the management of mental illnesses is inadequate, contributing to 5.3% of the global burden of

disease (World Health Organisation, 2017). In addition, there are 0.04 psychiatrists working for every

100,000 people in the population (WHO, 2011); this is significantly lower than, for example,

compared to the UK where 17.65 psychiatrists are working for mental health affected population in

this country (World Health Organisation, 2011). With a population of 56 million and 3% population

growth rate, the mental health-care system is overstretched. This situation means that new approaches

to identify and treat mental health are desperately needed in Tanzania. Such approaches must of

necessity be cost-effective and deliver sustainable solutions. The management of mental health care

must be based on a foundation of awareness and understanding of mental health problems. From this

understanding strategies can be developed.

Efficacy of e-MH Interventions

One possible approach that has already been used in developed countries is the use of internet

resources through the medium of apps, websites and social media. Collectively known as e-mental

health services (Lal& Adair,2014). This use of internet and related technologies has shown to be

effective in the management of mental illness such as depression and anxiety(Andrews

&Wiliams,2014). Studies in other populations, for example Canadian e-mental health have been

demonstrated to be efficient especially in the use of e-CBT in management of mild to moderate

depression and/or anxiety(Shaliniet al., 2019).E-MH interventions can significantly reduce the burden

on the inadequate health-care system (Griffiths, Farrer, & Christen, 2007).

E-MH interventions can also be used to create awareness and provide education regarding

mental health issues. It is also considered to be an invaluable tool especially for those people who

lives in remote/rural areas and who prefer to seek help anonymously. This is by giving them

information on how to identify or assess the state of their mental disorders, find local health centres

options etc (Dreier et al., 2019)

 In Tanzania 46% of Tanzanians are internet users (Statista.com, 2020). Internet interventions

could address the gap in delivering mental health care and could overcome barriers to accessing

treatment, in terms of stigma, lack of awareness and support.

Much research has been done on the effectiveness of e-mental health interventions, however,

Tanzania as a population has not been included in any studies. Before developing such e-mental

health interventions for Tanzania, it is important to assess the perceptions of utility as well as

acceptability of this intervention, to ensure that (future) interventions cover the important aspects and

are effective for the people they are aimed at. Therefore, as a first step to developing e-mental health

interventions in Tanzania, it is important to first identify current perceptions (utility, acceptability) of

such services as this would guide implementation in the future.

Issues addressed in the questionnaire include:

1) What are the perceptions of participants of e- mental health issues in general? This question is

also hoped to tap into the social context and social stigma.

2) What are the perceptions of participants of the provision of e-mental health services?

3) What are the issues that participants felt were important in the provision of e-mental health

services?

Method

Ethical approval. Ethical approval was obtained from ethics committee of Wolverhampton

University.

Design. A questionnaire of ten open- ended questions was used to collect qualitative data. A

qualitative approach was considered appropriate to the purpose of the study which was a wide-ranging

study of people’s general understanding and perception of mental illness and ways in which it might

be treated.
Sampling. Opportunity sampling was used, in that 12participants were recruited from the Tanzanian

online population that use social media and were known to the researcher. Inclusion criteria were that

they were citizens of Tanzania, speak English and were 18 years or older. Exclusion criteria were

those who have had or have a mental health condition, as it would have been unethical to ask people

about perceptions of e-mental health services if they had experiences problems with their mental

health and expressed this in the questionnaire as nothing could be done to help these participants,

from the UK.

Data collection. An online survey of ten open-ended questions was developed and used to collect

data. The use of an online survey was practical and facilitated the participation of participants in

geographically distant locations. Two examples of questions ere “What do you perceive will be

advantages of e-MH?” and “Under what circumstances one will use e-MH?” A copy of the ten

questions used is included in Appendix A. The questions were developed by the researcher, in a

manner to comprehensively address the research questions.

After ethical approval, the survey was imported to SurveyMonkey platform. The study was shared via

social media: Participants were recruited though Facebook with requests for volunteers to take part in

the study. Participants who volunteered were emailed a consent form and information sheet. Upon

receipt of a signed consent form participants were given a URL link to the study questionnaire in

SurveyMonkey.

Analysis. Thematic analysis was used to identify patterns of meaning across the data set pertaining to

perception of utility and acceptability. Analysis followed the steps outlined by Braun & Clark (2006);

1) Data preparation; 2) Familiarisation of data; 3) Coding; 4) Searching for themes; 5) Reviewing

themes; 6) Naming themes; and 7) Final write up.

After data collection, the data was prepared for analysis by copying it into a Word document

(Step 1), the data was then read several times by the researcher to familiarise themselves with the data

(2), after the data was read several times, the researcher stared coding (3). Coding was done by adding
informative pieces of information to parts of text. This process was repeated several times, until the

researcher was confident that all salient aspects of the data were captured, and nothing was missed.

Then, codes were organised into themes (4); these developed themes were then compared to the data,

and whether they describe the data well. Then, themes were named (5) and the final write-up of the

results was conducted (6).

Alternatives to Thematic Analysis that were considered for this project included Content

Analysis, Interpretative Phenomenological Analysis and Discourse Analysis. However, content

analysis was deemed too simplistic for potentially complex answers and material (Hsieh &Shannon,

2005). Interpretative Phenomenological Analysis was not deemed suitable due to the emphasis on

subjective experience, which was not the aim of this study (Smith, 2011). Finally, discourse analysis

was also not suitable due its focus on the use of language, rather than opinions and beliefs

(Fairclough, 2013).

Results

Three major themes were identified: 1) Purposes and potential positive contribution of e-mental health

intervention, 2) Suggested content for utility of e-mental health interventions and 3) Barriers and

challenges to the use and utility of e-mental health interventions.

Theme 1: Purposes and potential positive contribution of e- mental health intervention

 To help people (stay
safe)

To help tackle
Purpose
inadequate provision

Theme 1: Purpose & Solution-oriented

potential positive
contributions of e-MH
interventions
Increased education
and awareness of MH
conditions & help
Potential positive
contributions

Tackling stigma

Figure 1. Purposes and potential positive contribution of e-mental health interventions

This first theme was titled “Purposes and potential positive contributions of e-MH interventions”, and

consisted of two subthemes, Purposes and Potential positive contributions. Each of these sub-themes,

as can be seen in Figure 1, were broken down into further categories.

Purposes

In this sub-theme, participants discussed what they perceived to be the purpose of e-MH

interventions to be.

Staying safe

Participants emphasized that the purpose of an e-MH intervention should be to help people

stay safe. The fact that two participants emphasizes ‘safety’ as the purpose of e-MH interventions

suggests that their perception of bad or poor mental health might be the opposite of ‘safety’. In the

context of MH, this could be participants’ awareness of potential suicidal thoughts, suicidal ideation
or potential suicide. However, due to the design of the study (i.e. online survey with open-ended

questions), it was not possible to follow-up what participants meant by safety in more detail.

“assurance that the crisis is not the end of the world and it will can be addressed, feeling safe

and supported”

“What he/she can do to stay safe”.

To help tackle inadequate provision

In this sub-subtheme, participants reflected on the current inadequate provision in Tanzania.

Therefore, the provision of e-MH interventions is viewed as positive, as it can meet current unmet

needs in the population.

“Give that there is insufficient services provided by the government”

(Context: Current Provision) “Not good enough”

Solution-oriented

In this subtheme, participants emphasized the need of interventions to be solution oriented.

One participant, for example, emphasizes the role of hope when giving someone a solution to

challenges they face, with the use of e-MH services. The focus on ‘solutions might reflect the

participants’ views that poor mental health, i.e. needing MH interventions, can have positive

outcomes if treated, in other words it can be solved with interventions.

“giving hope that there is a solution for the challenge s/he faces”
“provision of best possible solutions that one can take to address mental problems”
(When asked what barriers might exist for the use of e-MH services) “Not enough solutions
for mental health”
“Possible solutions to overcome this”

Potential positive contributions

The potential positive contributions of e-MH interventions were recognized by the participants in this

subtheme; this theme has two number of further subthemes which are “Increased education and

awareness of MH conditions and help” and “Tackling stigma”

Increased education and awareness of MH conditions and help

 Participants perceived that e-MH interventions could address the lack of awareness of mental

health conditions in Tanzania, as well as act as educating tools to help people understand the

conditions.

“It can be used for multiple services at once, e.g. educational”

“e-mental health services are a range of digitalized service which must include
psychoeducational information”
“I think they can be of great help to create awareness of the disease”

Tackling stigma

Another positive contribution of e-MH services in Tanzania could be tackling stigma. This subtheme

may also with the subtheme above (Education, awareness).

In detail, participants discussed two aspects here: firstly, they discussed the presence of stigma

attached to mental illness.

(When asked about what might encourage someone to use e-MH interventions) “Stigma
around the mental health”
“It can help in reducing stigmatization attached to e-mental health in general”

Secondly, they discussed the perceived benefits of anonymity and confidentiality when accessing e-

MH services; this was perceived as a benefit because participants perceived there would be less

judgement by others and thus avoiding the stigma (if it was unknown that a service was accessed).

“Convenience, avoid stigma”

“The fact that some people are shy and feel that mental health has stigma attached to it, may
feel comfortable using e-mental health services because they feel less likely to be judged”
“Good idea, it means it is private”
“Anonymous service, promoting confidentiality

Theme 2: Suggested content for utility of e-mental health interventions

 Language

Design User-friendly Clarity of design

Responsive to users'
Information
needs
Information &
Theme 2: Suggested education
Content for e-MH
interventions Other

Therapeutic content

Interventions & Signpost further

counselling services
Provision of extra
support, in addition of
e-MH intervention
Availability of face-to-
face professional
contact if required

Figure 2. Suggested content for utility of e-mental health interventions

The second theme that was developed from the data was named “Suggested content for e-MH

interventions”. This theme has three subthemes, called “Design”, “Information & education” and”

Interventions & counselling”; all have further subthemes (see Figure 2). This theme (2) collates

participants’ suggestions as to what they perceived to be important to be included in an e-MH

intervention.

Design

User-friendly

The user-friendliness of the interventions was discussed; and this was an aspect that was

deemed important by participant. Three areas were especially discussed by participants, these are

reflected in the subthemes of this subtheme.

Language
 This subtheme highlights the importance of user-oriented language. Participants advocate for

the use of ‘user-oriented’ language, i.e. no difficult or academic words. This might be motivated by

participants wanting the e-MH intervention to be as accessible and understandable by as many people

as possible.

“Difficult words to use”

What is very interesting is that one participant said that the language “should be easily

understood and not use doctor’s language which requires one to consult a physician”; this might link

the easy language to avoiding stigma/judgement from medical professionals. This then means that this

participant wants the e-MH intervention to be sufficient to use without contacting a medical

professional.

A further comment made by another participant was the following; “the service doesn’t

discriminate”. While no further comments on the type of discrimination were made and no

clarifications on this comment could be sought, it warrants discussion in the context of language (as

well as content). This might reflect the participant touching on the subject of inclusive language, such

as, for example, the use of non-gender specific language or assumptive language (Hsieh & Shannon,

2005).

Clarity of design

One participant reported that the content should be clear, and easy to use.

(When asked what makes a good e-MH intervention) “The information is clear and easy to
use”

Responsiveness

The responsiveness of a potential e-MH intervention was also discussed; particularly in

response to two points: firstly, a good e-MH intervention should have professionals available online
when needed; secondly, a good e-MH intervention should be responsive in a timely manner and

thirdly, communication between the professionals and the user should be timely and responsive.

“Availability of online professionals to provide mental related services when it is needed”

“When the service provides timely response/answer and established reliable communication
needs between the user and the service provider”

Information & education

This is the second subtheme of Theme 2 “Suggested content for e-MH interventions”; it has

two subthemes (Information, Other). This theme relates to content that is purely informative or

‘other’, i.e. distraction from mental health; and does not relate to therapeutic content/intervention

content.

Information

Participants discussed what particular content would be useful in an e-mental health

information; and especially emphasized the importance of useful information to be contained in such

interventions. This is especially links with Theme 1 (Purpose & potential positive contribution of e-

MH services).

“e mental health services is a wide range of digitalized services which must include …
informations…”
“Good information for reassurance”
“When it has useful information”
“Availability of useful information concerning mental issue”
“Description of possible illness being diagnosed and treatment”
“Good information for reassurance”

Other

One participant mentioned the addition of cheerful content; the perceived benefit of this was

distraction from their ill mental health.

 “Funny videos to keep them active and happy”

Interventions & Counselling

This is the third subtheme; and has two sub-subthemes (Therapeutic Content, Provision of

extra support). This subtheme therefore relates to the suggestion participants made as to what type of

therapeutic content should be contained in an e-MH intervention.

Therapeutic Content

Within the data, it became obvious that different participants perceived it differently what

should be the content of a e-MH intervention. Some participants maybe thought e-MH services should

be educational only; while others emphasize that e-MH interventions should include other services,

such as self-help, e-learning and enabling user to manage or adjust to their symptoms; and others

perceived that there should be online therapy and counseling. Overall, there did not seem to be a

consensus of what the therapeutic content should be.

“E-mental health services is a wide range of digitalized service which must include
psychoeducation informations, electronic patients record, e-learning, screaning, counselling,
therapy and self-help.”
“Meaning symptoms and adjusting mechanisms of a given mental health condition”
“Patient record kind of therapy and counselling”

Interestingly, two participants mentioned that the e-MH interventions should include patients

record. This in contrast to views expressed by other participants, who emphasized the anonymity and

confidentiality of the service. Having patient records on e-MH interventions would require someone

to upload the data; which would then be in direct contrast to the anonymity some participants

promised themselves to have when accessing these interventions.

Provision of extra support, in addition to e-MH intervention

 In addition to the services directly provided by the e-MH intervention, participants wanted

extra support also. This extra support was Signposting to further services (Subtheme 1) and additional

availability and access face-to-face professional help if needed (Subtheme 2).

Signposting

Participants perceived there to be a utility in having contact numbers for support available on the e-

MH intervention.

“Information about where to seek help el organization that deal with mental health who to
call and what to do if experiencing crisis would be helpful”
“Mental health service accessibility”
“Sign posting pp where they can get help”

Availability of face-to-face professional contact if required

In addition to the content of the e-MH interventions and signposting, participants also wanted

the e-MH intervention to have further things: they wanted further face-to-face consultations, if

required, and suggested using the e-MH interventions together with community-based approaches,

which can be interpreted as face-to-face professional service/contact.

“Availability of online professionals to provide mental related services when it is needed”

“The system needs bot combination of community based and technology-based approaches”

Theme 3: Barriers and challenges to the use and utility of e-mental health interventions
 Technological issues

Type of illness

Lack of awareness of
Barriers
intervention
Thene 1:Barriers &
Challenges to the Use
and Utility of e-MH
interventions
Challenges Design issues

Perceived inefficacy
compared to face-to-
face interventions

Figure 3. Barriers and challenges to the use and utility of e-mental health interventions

The third theme that was developed from the data was named “Barriers & Challenges to the Use

and Utility of e-MH intervention”. This theme has two subthemes, called “Barriers” and

“Challenges”; the subtheme “Barriers” has a further number of subthemes. This theme (3) collates

participants’ accounts of what they perceive to be barriers to the use and utility of e-MH interventions

in Tanzania, as well as perceptions of potential challenges the implementation and use will face.

Barriers (Subtheme)

A number of barriers were identified by the participants to the to the Use and Utility of e-MH

intervention; these included technological issues, type of illness, lack of awareness of possible

interventions, design issues and the perceived efficacy of such interventions.

Technological issues
 The most prominent barrier that was identified in the data was participants’ concerns about

lack of access to the internet among the Tanzanian population. The following quotes illustrate this.

“Internet access being difficult”

“Poor internet connection”
“The use of internet (not everyone has access to internet), not everyone is equipped enough to
use modern technology”

However, one participant also emphasised that there are people who, while they may have

some access to the internet, do not have enough mobile data to continually use the intervention. This

suggest that it is important that interventions are data-effective, i.e. do not use a large data volume,

and it also supports the idea that, while internet should be made available across the larger population,

the data volume has to be considered, i.e. simply giving people access to the internet will not be

sufficient if they cannot use the data (or do not have enough data) to access such interventions.

In addition, some participants mentioned the group of elderly people and those with a lack of

technological “know-how”, who would not be able to access and use those e-MH interventions. This

might mean that e-MH interventions for those people are not perceived as helpful due to no access.

“not everyone is equipped enough to use modern technology especially the elderly”

Type of illness

Within this subtheme, there are two different, yet interlinked, views represented: some

participants said that people might be too sick to access online help (suggesting that these people

might need face-to-face or hospital help); while some participants argued that other people might not

feel ‘ill’ enough to access those online services.

“its not appropriate with those with serious psychiatric”

“Might think it only helps those who are not in critical conditions”

This means that the barriers to use are in relation to the target group. This suggests that, in

practice, the limitations of what an e-MH intervention can offer have to be clear, i.e. who it is aimed
at and who it is designed for. This may also link with awareness of MH conditions in general (Theme

1), and the need to make the purpose of an intervention clear.

Lack of awareness

This subtheme reflects participants’ concerns that there is not enough awareness of the e-mental

health interventions among the Tanzanian population; therefore, this is a barrier to the use and utility.

This means therefore that more awareness is needed for e-MH interventions to be used effectively.

“Lack of knowledge and information of e-mental health services”

“Many people in the country still not aware of using e-services”

Design issues

This is a small subtheme; and – to some degree – links with the subtheme “technological

issues”. One participant raised the concern that if the e-MH interventions is not designed well, it

might discourage people from using it. Therefore, e-MH interventions should be designed in a way

that is easy and user-friendly.

“When the ads are not well presented”

Perceived inefficacy compared to face-to-face interventions

This subtheme describes participants’ worries and perceptions of the efficacy of e-MH

interventions. Above all, participants were concerned about the lack of evidence for the efficacy of e-

MH services, and were worried whether it would be as effective as “face-to-face service”.

Specifically, it seemed that participants were worried about the lack of “direct consultation” with

specialist. This suggests that if, for example, e-MH interventions should include face-to-face

components (e.g. over Skype) and emphasised the evidence-base of the interventions, should increase

the likelihood of people using them. In addition, linking with the subtheme of ‘lack of awareness’, it
could be suggested that when raising awareness, the evidence-base of the interventions need to also be

mentioned.

“Lack of evidence of being more effective compared to face to face services”

“Lack of evidence for e-MH apps”
“No direct consultation to mental health specialists”

Challenges

“It’s good although there some challenges”

The second subtheme of the theme “Barriers and challenges to the Use and Utility of e-MH

intervention” was Challenges. Challenges that were mentioned primarily concerned challenges for the

implementation of e-MH services, such as a lack of funding in the country. In addition, two

participants voiced their concern for the cost of such intervention, if not government funded as people

might not be able to afford it. These concerns suggest that the challenges for successful e-MH

interventions include being either free (funded by the government) or affordable at a low cost.

“Cost if at all has to pay for the service”

“The cost of mental health treatment”
“need to get funding to set it up”
“Best practices will depend on the availability of resources and context”

Discussion

This study sought to assess perceptions of acceptability and utility of e-MH interventions in
Tanzania. Using a qualitative design, an online survey was conducted and analysed using Thematic
Analysis. Three themes were identified, these were identification of purpose and significance of the e-
MH services while treating for a number of mental health complications, identifications of
interventions for mental health complications in Tanzania and the third theme was identifying the
barriers and loopholes identified in the process.
Overall, results indicate that the perceived acceptability and utility of e-MH services was
good; but that participants worried about potential barriers and challenges in, and for, implementation.
 The first theme discussed in this section identified that participants perceived e-MH services
to have a number of very different from identifying the role of e-MH system in creating awareness in
the population of Tanzania to leading the population to a point, where they can start utilising these
healthcare processes in modern care system and have the potential to make positive contributions to
the mental health care in Tanzania (Vis et al., 2018). For example, participants emphasised the current
inadequate provision and that e-MH interventions could substitute this inadequate provision. This is
echoed by the literature, where it has been found and reported that internet application might
significantly lessen the burden on an already inadequate health care system (Griffiths, Farrer, &
Christen, 2007); this thus suggests that there is both a market for e-MH intervention in Tanzania as
well as the need to supplement an inadequate health care system in the most effective way. Further
aspects discussed in this theme were the presence of stigma and education; two subthemes that are
intrinsically linked. The aspect of social stigma is addressed in the literature in (Patel, 2007; Collins et
al., 2010) and has been discussed in this paper; social stigma in Tanzania in regard to mental illness is
prevalent and will only be tackled if people are educated about mental illness. Therefore, participants
perceived those to be two very important purposes of e-MH interventions (education, tackling
stigma). In recent research conducted by Srivastava, Chatterjee and Bhat (2016), awareness and
education were used as primary variables to identify the impact of awareness strategies and
educational guidelines for the population in increasing their understanding of mental health
complications. With continuous and effective awareness campaigns, research participants were able to
modify their thought process effectively. Similar results conducted by Dimoff, Kelloway and
Burnstein (2016) were also identified in another research wherein the implementation of MHAT or
mental health awareness training was used for the awareness for the mental health of individuals. This
research also identified that awareness affects the mental health of people positively as they
understand the impact of this upon their health (Dimoff, Kelloway & Burnstein, 2016). Hence, the
importance of mental health awareness in populations to increase implementation of mental health
modern medicinal interventions was found to be effective.

In detail, Theme 2 “Suggested Content for an e-MH intervention” collates discussion around
the design, Information and Education, as well as Intervention that should be included and reflected in
an e-MH intervention. This therefore suggests that participants perceive the content of e-MH
interventions to be diverse and to include different aspects, depending on user needs.

Firstly, comments on design ranged from comments on user- friendly design, including
simple language, to responsiveness. Participants, along with past research, trecognize the importance
of e-MH interventions to offer user-friendly, engaging content. In fact, past research has found that
poor design can lead service user to become frustrated or confused with the intervention, and
subsequently leave the course of the treatment (Kuluski et al., 2020). In addition, engagement has
been found to be reduced if content is perceived as challenging or as irrelevant to service users’ needs
(Chiu&Eysenbach, 2010; Lenert et al.,2003). Therefore, the user-friendliness of an e-MH
interventions must be a priority, as past research and the current findings suggest.

In addition, Participants advocated for the use of ‘user-oriented’ language, i.e. no difficult or
academic words. This might be motivated by participants wanting the e-MH intervention to be as
accessible and understandable by as many people as possible (Smith, 2011). One of the participants
said that the words used should not require “one to consult a physician”. This can be understood in
two ways: firstly, it may reflect social stigma as a consideration and a fear of the judgement of
medical professionals, but also just simply indicate that ‘lay’ people should be able to understand the
content without further help (as then the purpose of substituting inadequate provision of e-MH
services would be compromised, if one would still need a physician to explain the content).

‘Responsiveness’ seemed to incorporate a number of ideas in that professionals should be

available online when needed; secondly, also a good e-MH intervention should be responsive in a
timely manner; and thirdly that communication, between the professionals and the user should be
timely and responsive, which also relates to the use of language. It is possible to infer from this some
Tanzanian people would prefer to talk to a mental health professional on-line or by telephone rather
than face-to-face. Again, this raises the ambiguity of not wishing to consult professionals and feeling
the need for them. This issue is further complicated by the lack of medical professionals dealing with
mental health in Tanzania, where there are 0.04 psychiatrists working for every 100,000 people in the
population, (WHO, 2011).The idea of an application imparting information is rather obvious but one
interesting deviation from this central idea is that it might include ‘Funny videos to keep them active
and happy’. Although it might be easy to discount this idea as a participant’s misconception that
being online involves games and cartoons, or there might be a more interesting interpretation that the
nature of the language and the content could be designed in such a way as to be very positive and
cheerful (Smith, 2011).

Secondly, participants indicated the importance of the e-MH intervention containing enough
information and educational material. This may link with the lack of evidence-based information on
mental conditions in Tanzania, and many people being ‘afraid’ or unsure of mental illness
(Fairclough, 2013; Smith, 2011). Being able to access information about these mental illnesses may
enable people to understand this further, especially if they – themselves – have otherwise little access
to health information. It might be suggested that this may especially benefit the rural areas of
Tanzania, where the majority of residents prefer self-help, rather than formal help from mental health
professionals (Kathleen M Grifith, hellencristensen, 2007).

In addition, to information material, participants suggested a good e-MH intervention would

also have an intervention component. Participants mentioned that intervention should always be
proceeded by an awareness process and then the care professional should provide complete detail
about the intervention so that clarity of the complete process could be identified (Patterson, Edwards
& Vakili, 2018). In this situation, the participants also emphasise that there may be cases where the
online intervention (self-completion tasks) may not be enough, therefore signposting and the potential
of including further access to face-to-face professional help when in crisis were discussed. These
suggestions are also in line with past research, emphasising the importance of the ‘physical’ presence
of a mental health professional: for example, research has pointed out that automated programs
without guidance from therapist have shown to be less effective compared with
programmes/interventions that have minimal guidance from a therapist ( Palmqvist, Carlbring and
Andersson, 2007; Spek, Cuijpers et al., 2007). It could therefore be suggested that the minimal
guidance and availability of a therapist makes the interventions more effective; perhaps this does link
to a reassuring feeling for service users that – if the e-MH intervention is not enough – they can get
further help, but can also act as a driving motivation for them to complete the intervention by
themselves first before seeking more help, if they need. Furthermore, online counselling has been
shown to be an effective treatment option, for example, King et al. (2009) demonstrated online
counselling to be effective to treat substance abuse.

In detail, Theme 3 was about barrier and challenges for the uptake of e-MH interventions, this

ranged from type of illness (to be treated) to Perceived inefficacy compared to (physical) face-

interventions; for example, participants perceived e-MH to be efficient for mild conditions such as

Anxiety and Depression but not severe/serious mental illnesses such as schizophrenia (Luthar &

Kumar, 2018). This is following the research Silove, Ventevogel and Rees (2017), it was identified

that multiple challenges and barriers are associated with affected patients, their culture, community

and their educational achievements. In a research of Wainberg et al. (2017), it was identified that

majority of the patients that are affected with mental health complications are illiterate and hence they

do not understand the gravity of their state of health. Unawareness of mental health issues are directly

proportionate to the illiteracy and hence, illiterate society is a major barrier to the mental healthcare

achievement (Luthar & Kumar, 2018; Fairclough, 2013).

The fact that participants think that only some mental illnesses can be managed via e-mental

health interventions may also link to one of Theme 1’s subtheme, stating that the purpose of an e-

mental health application is to help people stay safe. Participants may think that for more serious

mental health problems, patients should be admitted to psychiatric care, or at least have increased
direct contact with mental health professionals to help keep them safe; participants may believe that a

internet-based application may not be able to fulfil the same purpose for people with more serious

mental illnesses.

The view that e-mental health interventions are less effective compared to face-face-

intervention, is in line with research. For example, Leach, Christensen, Griffiths, Jorm and Mackinnon

(2007) assessed perceptions of = treatments options that are given through a website, the results

showed these online treatments were rated the least favourable option. In addition, many patients

prefer face-to-face consultations rather than online interventions; with one study reporting that the

majority of their participants (77.1%) preferred face-to-face consultations. However, what is

important to bear in mind is that these studies were conducted in Western Countries such as United

States of America or European countries; and thus the stigma attached to mental illness may be very

different compared to the one in Tanzania. Therefore, while individuals in Western countries may see

online interventions as ‘less than’ face-to-face interventions, people in Tanzania may actually prefer

the online versions due to circumventing the need to physically go to a place and be faced with the

stigma (Fairclough, 2013).

Further limitations identified by participants were a lack of awareness of e-mental health

services among people. This barrier has also been identified in past research; for exampleCarper et al

(2011) demonstrated in their study, that e- mental health services were not familiar to many

participants; which consequently meat that engagement in this kind of treatment was low. Therefore,

it is essential that research and practice work together to attempt to overcome these barriers of lack of

awareness and lack of familiarity, to develop successful e-mental health interventions.

In the results, it was also obvious that while participants advocated for privacy (i.e. being

anonymous, to reduce stigma), participants also wanted for their own personal history, for example, to

be accessible and taken into account and for there to be personal contact when needed. This is

therefore a difficult territory to navigate, as the balance between privacy and access to information

would not be a simple matter.

Limitations of the current study& future research

 There are a number of limitations to the current study:

One of the limitations of this study was that it was conducted in theEnglish language;

however, participants’ first language was Swahili. Due to participants answering in their second

language, the clarity of expression may have been compromised, this may have had an adverse effect

on results. Future research may want to conduct the research in Swahili.

Another limitation is that the exclusive criterion that people who are currently, or have in the

past experienced mental health issues, were excluded from participation. It is these people that might

have contributed more meaningfully to this issue due to their own personal experience and the

participants, who have not experienced mental health issues, might not accurately envisage the issues

and implications of treating mental illness. However, due to ethical implications and safeguarding, the

inclusion of participants with mental illnesses from Tanzania was not possible; and future research

may wish to instigate this further. In addition, future studies could also deploy different strategies that

might incorporatethe views of a range of mental health stakeholders,such as psychiatrists, nurses,IT

technicians and caregivers. This may have the advantage that more perspectives are reflected in the

results; thus, making it generalisable between groups.

Thirdly, the study did not collect any demographic information; this a potential loss of

meaningful data. The study should have recorded demographic information since remote/rural areas

are most affected by mental health issues and face mental health services shortages heavily; future

research should be objectively targeting this group of individuals for research.

Conclusion

While concluding this study, the entire paper and its significance should be re-established.

Despite medical technology improvements and globalisation, mental health is still a taboo in majority

of the countries that are still in their developmental phase. While many communities around the world

feel stigmatised while discussing about mental complications in their family, many do not even reach

to mental healthcare facilities for effective treatment and interventions. In this paper, discussion about

one such country, its community and their take upon mental health complications has been discussed.
It was identified that mental health is connected with supernatural aspects, spirits and curse and

majority of the patients are dependent upon traditional spiritual interventions. Hence, in this

condition, this current research process addressed multiple loopholes in all the previously conducted

researches, associated with their perceptions, acceptability, utility and implementation of e-Mental

Health interventions for mental healthcare complications in Tanzania. Results collected from these

former researches identified that e-mental health interventions would be an effective process for the

population of Tanzania and would help them to implement modern medication interventions for their

psychological complications. However, one complication that was also observed in this process was

the potential barriers as well as challenges that could arise in the mental health intervention

implementation in Tanzania. Besides this, these findings collected from the literature review also

distinguishes that it is also important to understand the kind of information and education should be

used for awareness and education of population so that the Tanzanian population, and who the main

target group should be able to address their complication for mental illness and rural education and

urban education could be differentiated. Hence, from this research process, it could be identified and

recommended that rural areas of Tanzania require effective mental interventions, however they are

unable to use it due to their inability to access it. The primary reason for this was associated with lack

of awareness of mental health and e-Mental Health services, technological barriers and stigma within

the Tanzanian community. Hence, this should be addressed in future research prospects so that

barriers that need to be overcome for effective mental health illness could be successful implemented

in Tanzanian healthcare system and community.

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