Scaling Up Care for Orphans in Tanzania: A Task-sharing Approach to Mental Health Treatment Shannon Dorsey 1 , Karen O’Donnell 2 , Kate Whetten 2 ; Wenfeng Gong 3; Dafrosa Itemba 4 , & Rachel Manongi 5 1 University of Washington, ; 2 Duke University; 3 Johns Hopkins University; 4 Tanzania Women Research Foundation; 5 Kilimanjaro Christian Medical Centre NIMH R34 MH081764; 2009-2012 NIMH R01 MH96633; 2012-2017
Acknowledgements NIMH USAID Victims of Torture Fund (funded training development) Lui Mfangavo (coordinator, interviewer) Simon Chudy (lay counselor) Suzan Kitomari (lay counselor) Bibiana Gali (lay counselor) Leonia Rugalabamu (lay counselor) Karthik Balasubramanian Lillian Chinganyana Wenfeng Gong
Acknowledgements Implementation Research Institute Dr. Dorsey is an investigator with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI).
Orphans in Low and Middle Income Countries Estimated 143 million 16.6 million of these to HIV/AIDS “More than the loss of a parent 1 …” High rates of exposure to potentially traumatic events Higher rate trauma exposure associated with mental health problems 1 Whetten, Ostermann, Whetten, O’Donnell & Thielman, 2011; Cluver, Fincham & Seedat, 2009
Problems of Orphans: Sadness and Grief During development: “need help with children’s sadness”
Low and Middle Income Countries Significant mental health treatment gap (over 75%) 1 Scarcity: Few MH professionals 2 Inequity: MH services within and across countries 2 Lower Middle Income Low Income 1 Kohn, Saxena, Levav, & Saraceno, 2004; 2 Saraceno et al., 2007; WHO, 2008; WHO, 2009
Treatment Gap: Children For each child with need… .16% receive treatment Saraceno et al., 2007
LMIC: Addressing Treatment Gap Implementation Mental Strategy: “Task health Shifting/Sharing professionals Approach” Lay Counselors— Little or No Mental Health Training Patel, 2009
Randomized Trials: Evidence for Evidence-based MH Interventions in LMIC Pakistan 2 Uganda 1 Perinatal women with Adults depression Adolescents Internally displaced persons Iraq, Thailand (displaced Burmese) 4 India 3 Adults Adults Torture, systematic violence Depression/Anxiety 1 Bolton et al., 2003, 2007; 2 Rahman, Malik, Sikander, Roberts, & Creed, 2008; 3 Patel et al., 2010 ; 4 Bolton et al., results forthcoming (Dorsey, involved)
Modifications: Not to Core Components HOW training is conducted Local idioms and stories Simplifying terms, avoiding “clinical” terms: depression Supervision Situating within local context Patel, Chowdhary, Rahman, & Verdeli, 2011
Pa Pamoja Tuna naweza TF-CBT Intervention Trauma-focused Cognitive Behavioral Therapy (TF-CBT) Moshi, Tanzania
TF-CBT Randomized Trial (NIMH; Duke & UW; Dorsey & Whetten) Orphans: Traumatic Stress and Grief-focused Murray, Consultant TF-CBT Randomized Trial (DCOF; Johns Hopkins; Murray & Bolton) TF-CBT Feasibility Study (NIMH; Duke & UW; Whetten; Dorsey, Co-I) TF-CBT Feasibility Study Orphans: (NIMH; Johns Hopkins; Traumatic Stress and Murray) Grief-focused Sexual abuse TF-CBT Randomized Trial (NICHD; Johns Hopkins) Murray & Bolton HIV-prevention focus Dorsey: Faculty
Trauma-focused Cognitive Behavioral Therapy Entire Process is Desensitization/Exposure Baseline Assessment Sessions 1-4 5-8 9-12 P sychoeducation T rauma Narrative C onjoint Parent P arenting Skills Development and Child Sessions Processing R elaxation E nhancing I n-vivo Gradual Safety and A ffective Exposure Future Expression and Development Regulation C ognitive Coping
http://tfcbt.musc.edu/
TF-CBT Internationally TF-CBT Web registrants from over 70 countries Cohen, Mannarino & Deblinger (2006) translated into Dutch, Korean, Mandarin, & German Currently being translated into Japanese and Polish China, Japan, Singapore Norway, Germany, Sweden, the Netherlands Zambia, Tanzania, Cambodia, Indonesia South Korea (Introduction)
http://ctg.musc.edu/
Qualitative Study (DIME Procedures 1 ): Orphan Problems in Tanzania Qualitative Study with Orphans and Guardians Many needs related to education, food, clothing, and shelter Mental health problems still in the running: mentioned by guardians AND children JHU Applied Mental Health Research group; Bolton, 2001
Qualitative Study (DIME Procedures): Orphan Problems in Tanzania Tabia Mbaya (Bad Behavior) Unyanyasaji (humiliation/treated badly) Kuathirika kisaikologia (psychological problems) Kutopendwa (not feeling/being loved) Msongo wa mawazo (stress; overthinking)
Feasibility study Can lay counselors deliver the intervention with fidelity? TF-CBT with Orphans in Tanzania Is the model acceptable with children/adolescents, guardians, and counselors? ID any needed modifications for local delivery * guardian support
Partnership with Local CBO Tanzania Women Research Foundation
Study Design N = 64 children (7-13) Half urban; half rural Assessment Pre-treatment Post-treatment 3-month follow-up 12-month follow-up
Focus Group Feedback TF-CBT Intervention Single sex groups Divide by age: 7-10; 11-13 Tea and snacks to start
TF-CBT Intervention 12 groups; Child and guardian TF-CBT components AND four grief-specific components 3 individual visits for individual Imaginal Exposure At home or community location (e.g., school) 12-session agenda: Collaboratively developed with lay counselors post-training Revised iteratively
Adherence Monitoring: Groups
Monitoring Individual Child and Guardian Response
Completed Pilot; 8 groups ( N = 64) Current Study Status All data collected (12 mo. to be analyzed) High satisfaction: guardian exit interviews Completed all 8 groups ( N = 64) Good attendance All end of treatment and 3-months post-treatment data collected One-year follow up data still to be collected for groups 7 & 8 High levels of satisfaction with the group, reported in guardian exit interviews Good attendance
PTSD Outcomes 50 45 40 35 PTSD Symptoms 30 25 Caregiver 20 Child 15 10 5 0 Baseline End of Treatment 3 Month FU Panel Regression: BL-ET: Caregiver β = 11.19, p < .001; Child β = 15.38, p < .001
Traumatic Grief Outcomes 30 25 20 15 Child 10 5 0 Baseline End of Treatment 3-month FU Panel Regression: BL-ET: Child β = 8.46, p < . 001
Summary and Implications TF-CBT: feasible and acceptable Guardians requested additional group meetings Lay Counselors: High fidelity Loved the intervention Outcomes appear promising Limitations Small sample size No control group
TF-CBT: RCT in Eastern Africa Moshi, Tanzania Bungoma, Kenya RCT: TF-CBT compared to usual care (UC) supports Lay Counselors from NIMH R34 assist with training of new providers in both sites Provide supervision, under supervision themselves 12 counselors (6 in each country) 20 groups in each country (320 youth: TF-CBT; 320 UC)
Training Model: Murray, Dorsey et al., 2011
Apprenticeship Model: Lay Counselors Murray, Dorsey, et al., 2011
Apprenticeship Model: Lay Counselors Murray, Dorsey, et al., 2011
R34 Counselors:
Partners
Outcomes of Interest Clinical Outcomes PTSD Symptoms Traumatic Grief Depression Child Functioning Implementation Outcomes Fidelity (BRs; self-reported; via coded audiotapes) Child/Guardian attendance Acceptability Provider Knowledge Supervisory Relationship
Outcomes of Interest Clinical Outcomes PTSD Symptoms Traumatic Grief Depression Child Functioning Implementation Outcomes Fidelity (BRs; self-reported; via coded audiotapes) Child/Guardian attendance Acceptability Provider Knowledge Supervisory Relationship
To Date… October 2012: Training Administered Modified Practice Attitudes Scale Independent ratings of overall counselor fidelity post- training Similar pattern ratings across counselors; with “expert” Knowledge pre and post-test
Possibilities for Broad Scale Up… Remote Behavioral Rehearsal and Supervision
Lay Counselors as Co-Trainers & Supervisors Adherence “Step Sheets” guide practice Adherence =Following the recipe
Lay Counselors as Co-Trainers & Supervisors Competence: List developed collaboratively: “ What do You SAY in feedback ?” Spicing it up: Flexibility within Fidelity
Task-shifting/ Task-sharing “… however, the biggest barrier to scaling up may be the perception held by mental health specialists about the risks of non- specialist health workers delivering [psychological treatments] …” Patel et al., 2011, p. 527
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