Personal characteristics.

The research team members are all psychiatrists at different levels of experience and practice. The lead author (SKK) was a PhD student at the time the study and was based at the methadone clinic where the study was conducted. SKK has training and prior experience in qualitative research.

Relationship with participants.

The lead author, a female psychiatrist, had an established relationship with the participants as she was providing clinical services at the clinic at the time of the study. Participants were aware that the study was part of a PhD research that was assessing use of mobile phones in providing psychosocial treatment for individuals with OUD. This information was provided to study participants prior to enrolling in the study as part of the informed consent document.

1. Gain of CBT skills.

This theme discusses how participants reported to have gained CBT skills from the intervention. This helped them improve substance use behaviour and other areas in their daily lives. Several subthemes were identified as follows:

Understanding and changing thoughts and patterns of substance use: The participants reported getting information about substance use and the effects of substances. This was based on psychoeducation which was a component of the intervention. This facilitated their understanding on substance use and were able to change their patterns of substance use.

“It helped me a lot to shape my problem in my drug addiction. To know the bad part about it and how I should avoid drugs…. The advice that I got is really helpful to me and has helped my life. It gave me advice I have not received from anywhere else.” (Male, 37 years)

“The most basic and helpful thing I learnt is how to cope with drug use. In case you are in a delicate situation and there are drugs in your surrounding how to stop your thoughts and not use.” (Male, 42 years)

Participants reported that they had gained information on triggers and high-risk situations. Having the ability to identify the triggers such as friends and negative emotions, helped them avoid using substances. This was attributed to the information provided through the text messages and perception that the program kept them busy hence were able to avoid using substances.

“Most of the messages were about triggers. For triggers you know, it is mostly friends, the messages gave advise to avoid such friends who are using drugs.” (Male, 37 years)

“Actually, the program was good because the things we discussed about substance use gave advice and motivation to stop using drugs. It was good and it helped to keep me busy…. For example, there was a time my things were not going well and I was feeling stressed. Previously this is what made me use drugs but this program kept me busy and made me to feel less stressed about my problems.” (Male, 51 years)

Coping with craving: Participants reported to have gained information about craving and developed skills to deal with the craving which consequently resulted in reduced substance use. Also, the flexibility of the intervention whereby information on how to deal with cravings was available during the time of experiencing it without having to come to the clinic was reported as beneficial.

“The program was fantastic. One because of the concept of time, it takes place at different times, you can read the text in the morning or evening. You don’t have to be here to see a counsellor. Maybe you could be going through a challenge, let’s say craving, and then you get a message about craving or maybe it could be withdrawal, then you are able to deal with the issue at hand during that time. I think it is a good program. I prefer it that way.” (Male, 27 years)

Drug refusal skills: Participants discussed gaining skills on how to refuse drug offers, which were mainly from friends. They were able to identify the friends who offered substances to them and by keeping away from these friends, it was easy for the participants to stay without using substances.

“For me I would say that the text-message program helped me a lot because you gave advise on how to avoid friends because they are the ones that lead me to use substances. I got help on what to do to stay away from those friends.” (Female, 33 years)

Problem-solving skills: In addition to reduction or stopping substance use, participants reported that the intervention had benefits in other areas of their life such as being able to plan daily life, developing a financial plan, anger management, dealing with peer influence and improved relationships.

“I found the program to help me in areas like planning my finances and how to approach my day to day routines…..started selling things like earrings slowly it picked up… Some of those things we are not taught here at the methadone program, how you can have financial planning and growth.” (Male, 34 years)

“I learnt about anger management, overcoming peer pressure. I really enjoyed the program of which it has created a positive impact to me and also to my husband.” (Female, 29 years)

Improved decision- making skills: Participants found they gained information on improving decision making to avoid using drugs based on the information shared in the text messages.

“Regarding substance use, I learnt very many good things. The messages gave morale and a sense of direction. There was advise on things to do to forget about substance use. For example, it would say this will not help but this will help. I found that useful.” (Male, 42 years)

Self-efficacy: Participants expressed self-efficacy and confidence to be able to stay away from substances. They felt that they were well equipped to continue with their change in substance use behaviour even after the intervention period. Participants also observed that the effect of the intervention also depended on their motivation and effort of the individual in applying the information provided.

“Thank you for the advice. I am positive I can stop using drugs with the support given.” (Female, 23 years)

“The program was helpful in advising someone on how to stop using heroin. When you were asked the questions, and you responded and followed the advice, it was helpful, but if you don’t follow the advice then you don’t benefit.” (Male, 36 years)

2. Therapeutic alliance.

Participants expressed developing a therapeutic alliance during the intervention. First there were comments that showed a bond between the therapist and the participants who felt that the feedback provided enhanced the interactive nature of the intervention which is important for a therapeutic alliance. Although not able to interact physically with the person sending the messages, participants felt connected with the therapist.

“The messages were good. The person sending was also kind, used good language and treated us well. It was easy to understand…. the approach and confidentiality was good.” (Male, 37 years)

“I liked the fact that one could get counselling services at any time of the day without having to appear physically at the clinic…. the intervention was diverse, it touched on different topics, it was well explained and you could get feedback.” (Male, 27 years)

Another aspect of therapeutic alliance is agreement on tasks and goals. Participants expressed to have understood the expectations during the intervention and were able to follow through the tasks as expected.

“Because it was like a class or lecture, first you got two messages explaining and then a question for homework. This helped me to think around the topic and question. The language used was also positive, English was easier for me.” (Male, 51 years)

“The information in the messages was great. It encouraged you to stick to your goals what you decided to do or what you have been doing. For example, you don’t go back to your past, what you have been doing. For, example if tomorrow you get angry about something, you do not go to use drugs like in the past.” (Male, 25 years)

The element of flexibility and being allowed time to respond also enhanced the therapeutic alliance as the participants did not feel rushed hence could work on the homework at their own pace. Having a chance to choose the language they were more comfortable with further enhanced the alliance.

“The program was good because the things we discussed about substance use, it gave advise and motivation to stop using drugs. Even when you did not respond to the questions immediately, you were given time to respond later.” (Male, 51 years)

“I liked getting information on how to reduce using substances and being given an option to choose between English and Kiswahili languages.” (Male, 25 years)

A challenge that was reported as a possible barrier to optimal therapeutic alliance was the lack of face to face sessions with the therapist. Participants felt that including some level of in-person interaction with the therapist in addition to the messages, would improve the intervention.

“Message alone is not enough. There is need for someone to have a session with counsellor for more detailed discussion. You see, the message can give advice, but it may be difficult to do follow the instructions in the message. But when someone meets with counsellor, the counsellor can help to guide more in order to follow the advice given in messages more easily.” (Male, 37 years)

3. Feedback on intervention component and delivery.

This theme discusses the perception of participants on the delivery of the intervention such as the duration and frequency of the messages.

Frequency of message and intervention duration: There were mixed feelings about the frequency of the messages. Some participants were content with the frequency of the messages while others felt that the messages needed to be more frequent.

“For me I think the frequency of messages- getting the messages once a week- was not enough. I would prefer a minimum of 2–3 times in a week, like Monday, Wednesday and Friday.” (Male, 34 years)

On the other hand, one participant reported that the six weeks duration was long and suggested shorter duration such as four weeks.

“However, something I would add, is that instead of the 6 weeks I would say maybe to go for 4 weeks because 6 weeks is too long.” (Male, 34 years)

Homework questions: Participants were receptive of the homework questions and reported them as appropriate, easy to follow and a tool that helped them to understand the information better.

“The questions were not bad by the way. The questions helped me to evaluate myself. It gave an idea on the things that I can do or the things to avoid, to get myself from using drugs. I would say it really helped.” (Male, 37 years).

Ability to share information with others: Participants reported that they shared messages from the intervention with their friends to influence their substance use behaviour.

“The homework questions were good. I liked it and it helped me. It also helped my friends because since I would not want them to continue the way they were, I shared with them the messages and advice from the program.” (Male, 34 years)

4. Challenges experienced.

In this theme participants identified challenges related with the intervention which were related to phone damage or loss and some components of intervention delivery.

Problems with phone: Some participants reported problems with their phones which prevented them from completing all the homework questions or made them unable to go back to read the messages to remind themselves on what they had learned. Participants indicated that having a chance to come to the clinic for an in-person session would help during the times when they experienced challenges with the phones.

“I have changed my phone recently. This is a new phone. Therefore, I did not answer all the homework questions. I may have missed 1 or 2 when I changed phones. Sometimes if you missed or delayed responding to one, you find another message came requiring you to respond so you end up not responding to all homework questions… since the screen broke I wasn’t able to go back to the messages.” (Male, 25 years)

“Sometimes I had a challenge with my phone being off. In that case, having an option to come to the clinic would be good. Maybe to discuss as a group.” (Male, 42 years)

For some participants the challenge was having airtime to respond to the questions. Despite them being provided with weekly airtime reimbursement during the study period, some said that the airtime got spent in other ways.

“The challenge was the airtime was not enough and was being used up by (the telephone company) due to somethings I may have subscribed to unknowingly hence I ended up using my money.” (Male, 34 years)

Frequent phone loss was expressed as a challenge that can hinder one from participating. One participant was glad that he did not lose his phone during the intervention period. There are those who missed some weekly messages due to problems with phone.

“Most times I lose my phone and would not have benefited but it was good during this time of program I had a phone.” (Male, 51 years)

Challenges with delivery of intervention: Some participants reported challenges with understanding some message based on the structure, with certain messages being described as long necessitating need to get help so as to comprehend.

“In terms of length, I would suggest using short messages that are easy to understand. There are a few times, I found some messages to be hard, and I would go look for someone, with more education to explain to me…. I answered all the questions but I would prefer if the message was shorter and easier to understand.” (Male, 36 years)

“The content was okay although sometimes it was very long and tiresome to read. Especially if the message is sent in the evening when the mind is tired. I prefer they send the message in the morning for those long messages.” (Male, 27 years)

Another concern expressed by participants was getting the same message more than once which occurred occasionally. This was reported to make the intervention boring.

“Sometimes you got the same message within even more than two times this makes you get bored.” (Male, 26 years)

5. Recommendations for improvement.

This theme discusses the various suggestions from participants on how they felt the intervention can be changed to be more useful and benefit more individuals at the clinic.

Include a variety of homework questions and chance to choose topic: Participant suggested that to improve on intervention delivery, there was need to make the content easy and provide options of homework questions. This would give a person an opportunity to choose a question that they understand and feel equipped to respond well.

“The two messages and homework were okay but for homework questions I would prefer it was made easier. For example, have questions ‘a’ and ‘b’ with options for someone to choose the one that is easier to them. This would help even those with low education to respond. There was a day I was with a friend, I shared the question with him and told him to answer but it was a challenge for him.” (Male, 51 years)

Participants also suggested allowing them to choose the topic of discussion so that the person and the therapist can focus in area that the individuals felt they needed more support.

“I think it is better to have the messages sent at random. But then it is better to tell someone to say the topics they have challenges in. We were never given that chance to do that. For example, one may be asked if there something that they don’t like and then from there the counsellor goes through the list to address the issues.” (Male, 27 years)

In addition, participants expressed need for more content to be included in the program such as more information on methadone treatment. This would enhance their knowledge on substance use disorders treatment which can help improve other treatment outcomes such as retention in treatment.

“For example, in addiction, you know even methadone treatment is about addiction, the message can be used to help people understand how methadone works.” (Male, 42 years)

Increase duration and/ frequency of message: Participants suggested increase in frequency of message delivery, with message delivery several times a week instead of once. They also felt a longer duration of intervention would help in improving the treatment outcomes over time and that more frequent messages would allow them to discuss more topics and enable the intervention to be delivered over shorter period.

“I feel it is better if the message was given more days, maybe daily Monday to Friday so that every day you discuss something different.” (Male, 36 years)

“If the messages are given daily, Monday to Friday, 3 weeks to one month would be enough instead of the six weeks.” (Male, 37 years)

Participants noted that the longer duration would benefit those who may need more time to recover.

“To increase the time of the intervention to be more efficient to those who need more time or take time to heal.” (Male, 30 years)

Provide additional support: For some participants the intervention was sufficient as delivered. However, some participants gave suggestion on adding elements to improve the intervention. This included addition of phone calls and face-to face visit with the psychologist for individual and group therapy

1. Phone calls: both audio calls and video calls were cited as beneficial if included in the intervention.

“Messages were okay. But maybe for those with smartphones we can do video calls or something like that.” (Male, 27 years)

1. Face to face visit: Participants recommended visits to the clinic either for individual sessions with the counsellor or group therapy. They felt that the visit with the counsellor would help clarify any difficulty experienced and provide a platform for what should be included in subsequent messages.

“I feel that the messages alone are okay. However, having a chance to see a counsellor would be better. For example, since the messages are once a week, it can be planned that after receiving the message, someone then gets a session with the counsellor. Then the counselor would review the topic with you and see if your understanding is okay or not.” (Male, 42 years)

Participants suggested including group sessions as part of the intervention. This included virtual meetings with an option of meeting physically at the clinic.

“I can advise we should form a group therapy in which a client come to share with their counselor about most difficult time in recovery and also introduce one-on-one session with the client and friendship with like-minded people who are trying to recover. How to guide the client in the journey of recovery.” (Male, 42 years)

1. Include family members: Participants cited the role of including family or an individual’s support system in the intervention so that they can be aware of what is happening. They further mentioned that this could help in improving accountability to the patient even if the family member does not actively participate in the discussion.

“Sometimes it would be good to communicate with someone’s family and tell them this and this is happening. It can even be conference call, maybe with a parent, client and counsellor. The family therapy can also be a WhatsApp chat, so that the message I get, my mother or someone else also gets them. The other person may not respond but at least they are able to see the conversations that are going on in the chat. That is something I would like to be added, a group chat with the family.” (Male, 27 years)