Consumer perspectives on acceptability of trauma-focused cognitive behavioral therapy in Tanzania and Kenya: A mixed methods study

Background There is a substantial mental health treatment gap globally. Increasingly, mental health treatments with evidence of effectiveness in western countries have been adapted and tested in culturally and contextually distinct countries. Findings from these studies have been promising, but to better understand treatment outcome results and consider broader scale up, treatment acceptability needs to be assessed and better understood. This mixed methods study aimed to examine child and guardian acceptability of trauma-focused cognitive behavioral therapy (TF-CBT) in two regions in Tanzania and Kenya and to better understand how TF-CBT was perceived as helpful for children and guardians. Methods Participants were 315 children (7–13), who experienced the death of one or both parents and 315 guardians, both of whom participated in TF-CBT as part of a randomized controlled trial conducted in Tanzania and Kenya. The study used mixed methods, with quantitative evaluation from guardian perspective (N=315) using the Treatment Acceptability Questionnaire (TAQ) and the Client Satisfaction Questionnaire-8 (CSQ-8). Acceptability was assessed qualitatively from both guardian and child perspectives. Qualitative evaluation involved analysis using stratified selection to identify 160 child and 160 guardian interviews, to allow exploration of potential differences in acceptability by country, setting (urban/rural), and youth age (younger/older). Results Guardians reported high acceptability on the TAQ and, using an interpretation guide from U.S.-based work, medium acceptability on the CSQ-8. Guardians and children noted high acceptability in the qualitative analysis, noting benefits that correspond to TF-CBT’s therapeutic goals. Analyses exploring differences in acceptability yielded few differences by setting or child age but suggested some potential differences by country. Conclusion Quantitative and qualitative data converged to suggest high acceptability of TF-CBT from guardian and child perspectives in Tanzania and Kenya. Findings add to accumulating evidence of high TF-CBT acceptability from Zambia and other countries (United States, Norway, Australia). Plain Language Summary: Evidence-based treatments have been shown to be effective in countries and regions that are contextually and culturally distinct from where they were developed. But, perspectives of consumers on these treatments have not been assessed regularly or thoroughly. We used open-ended questions and rating scales to assess guardian and youth perspectives on a group-based, cognitive behavioral treatment for children impacted by parental death, in regions within Tanzania and Kenya. Our findings indicate that both guardians and youth found the treatment to be very acceptable. Nearly all guardians talked about specific benefits for the child, followed by benefits for the family and themselves. Eighty percent of youth mentioned benefits for themselves and all youth said they would recommend the program to others. Benefits mentioned by guardians and youth corresponded to treatment goals (improved mood/feelings or behavior, less distress when thinking about the parent/s’ death). Both guardians and children named specific aspects of the treatment that they liked and found useful. Dislikes and challenges of the treatment were less frequently mentioned, but point to areas where acceptability could be further improved. Recommendations from participants also offer areas where acceptability could be improved, namely guardians’ recommendation that the treatment also address non-mental health needs and offer some follow-up or opportunity to participate in the program again. Our study provides an example of how to assess acceptability and identify places to further enhance acceptability

Co-developed implementation guidelines to maximize acceptability, feasibility, and usability of mobile phone supervision in Kenya

Opportunities exist to leverage mobile phones to replace or supplement in-person supervision of lay counselors. However, contextual variables, such as network connectivity and provider preferences, must be considered. Using an iterative and mixed methods approach, we co-developed implementation guidelines to support the implementation of mobile phone supervision with lay counselors and supervisors delivering a culturally adapted trauma-focused cognitive behavioral therapy in Western Kenya. Guidelines were shared and discussed with lay counselors in educational outreach visits led by supervisors. We evaluated the impact of guidelines and outreach on the acceptability, feasibility, and usability of mobile phone supervision. Guidelines were associated with significant improvements in acceptability and usability of mobile phone supervision. There was no evidence of a significant difference in feasibility. Qualitative interviews with lay counselors and supervisors contextualized how guidelines impacted acceptability and feasibility – by setting expectations for mobile phone supervision, emphasizing importance, increasing comfort, and sharing strategies to improve mobile phone supervision. Introducing and discussing co-developed implementation guidelines significantly improved the acceptability and usability of mobile phone supervision. This approach may provide a flexible and scalable model to address challenges with implementing evidence-based practices and implementation strategies in lower-resourced areas

Supervisory alliance as a moderator of the effects of behavioral rehearsal on TF-CBT fidelity: results from a randomized trial of supervision strategies

Thesis (Master's)--University of Washington, 2020The present study examined relations between supervisory alliance and fidelity to the trauma narrative component of Trauma-Focused Cognitive Behavioral Therapy, as well as how supervisory alliance might moderate the effect of behavioral rehearsals (i.e., role plays) on fidelity. Forty-two supervisors and 124 clinicians from 28 different community-based mental health offices across Washington State participated. Clinicians were randomized to receive one of two supervision conditions—symptom and fidelity monitoring or symptom and fidelity monitoring with behavioral rehearsal. Supervisory alliance alone did not predict adherence or extensiveness of the trauma narrative. One aspect of alliance, client focus, significantly altered the effect of supervision condition on adherence (p=0.05); however, this effect was only seen in 43.5% of clinicians. A second aspect of alliance, rapport, altered the effect of condition on trauma narrative extensiveness with moderate significance (p=0.09). Future research should investigate strategies to improve supervisory alliance or match supervision strategies to specific supervisor-clinician dyads

How Engaged are Stakeholders in Evidence-Based Treatment Implementation Projects? Results From a Scoping Review of Children’s Mental Health Treatment Projects

Engaging stakeholders in child mental health evidence-based treatment (EBT) implementation projects may increase the likelihood of successful implementation; However, little is known about the extent of stakeholder engagement to inform the implementation of EBTs. We conducted a scoping review to characterize stakeholder engagement in child mental health EBT implementation projects. We performed data extraction and synthesis to describe key study and stakeholder characteristics, stakeholder engagement methods and rationales, reported impacts of stakeholder engagement, and quality of reporting on stakeholder engagement. We identified a total of 103 unique child mental health EBT implementation projects. The largest number of projects were in the United States and conducted in community mental health settings. Most projects engaged EBT providers during the active implementation phase and with limited depth, often gathering information from stakeholders about barriers and facilitators without sharing decision-making power. Across projects, impacts of stakeholder engagement spanned all implementation outcomes. Given that stakeholder engagement is often shallow and follows initial implementation efforts, additional effort should be made to increase engagement to preempt challenges to EBT implementation and ensure implementation success. Such efforts may ensure the just distribution of power in EBT implementation efforts and could be essential in addressing mental health disparities

Future Directions for Community-Engaged Research in Clinical Psychological Science with Youth

Despite advances in clinical science, the burden of mental health problems among youth is not improving. To tackle this burden, clinical science with youth needs methods that include youth and family perspectives on context and public health. In this paper, we illustrate how community-engaged research (CEnR) methods center these perspectives. Although CEnR methods are well-established in other disciplines (e.g., social work, community psychology), they are underutilized in clinical science with youth. This is due in part to misperceptions of CEnR as resource-intensive, overly contextualized, incompatible with experimentally controlled modes of inquiry, or irrelevant to understanding youth mental health. By contrast, CEnR methods can provide real-world impact, contextualized clinical solutions, and sustainable outcomes. A key advantage of CEnR strategies is their flexibility––they fall across a continuum that centers community engagement as a core principle, and thus can be infused in a variety of research efforts, even those that center experimental control (e.g., randomized controlled trials). This paper provides a brief overview of this continuum of strategies and its application to youth-focused clinical science. We then discuss future directions of CEnR in clinical science with youth, as well as structural changes needed to advance this work. The goals of this paper are to help demystify CEnR and encourage clinical scientists to consider adopting methods that better consider context and intentionally engage the communities that our work seeks to serve

Recommendations for Writing a National Institutes of Health Individual Predoctoral Fellowship (F31) Training Grant in Dissemination and Implementation Science

Early career training is an essential component of building the future of dissemination and implementation (D&I) science. The United States National Institutes of Health Ruth L. Kirschstein National Research Service Award (NRSA) Individual Predoctoral Fellowship (F31) award offers a mechanism for doctoral students to acquire specialized D&I training and mentorship, to pursue independent research in D&I science, and to receive financial support for their graduate studies. Due to scarce resources on preparing early career grant proposals focused on D&I science, this commentary offers guidance to doctoral students on developing a successful application for a specific type of early career proposal - the NIH F31 mechanism. We offer strategies for the research and training components based on themes identified across six funded F31 grant applications and on our experiences in the application process (grants funded from 2019-2020). We are from diverse fields (clinical psychology, school psychology, public health, and epidemiology) with varied research foci (global health, mental health, and infectious diseases). Applications were funded on both the F31 and F31-Diversity mechanisms. Funded F31 research projects included dissemination strategies, treatment adaptions, piloting new methods, and pre-implementation inquiry. Common training goals included developing content expertise in D&I science, understanding specific D&I science methodologies, learning strategies for working with community partners, and enhancing knowledge of analytic methods. D&I training activities included journal clubs, meeting with consultants, attending D&I science trainings, and attending conferences. Mentored research training is essential for learning D&I science methods and developing research-practice partnerships as students