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

Three-Year Change in the Wellbeing of Orphaned and Separated Children in Institutional and Family-Based Care Settings in Five Low- and Middle-Income Countries

Background With more than 2 million children living in group homes, or “institutions”, worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers. Methods A two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6–12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites. Findings At 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11–27% of total variation) or care settings within sites (8–14%), with most variation attributable to differences between children within settings (60–75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0–4% at baseline, 0–3% at 36-month follow-up, and 0–4% for changes between baseline and 36 months. Interpretation These findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting

Factors affecting the psychosocial well-being of orphan and separated children in five low- and middle-income countries: Which is more important, quality of care or care setting?

As millions of children continue to live without parental care in under-resourced societies in low- and middle-income countries (LMICs), it is important for policymakers and practitioners to understand the specific characteristics within different care settings and the extent to which they are associated with outcomes of orphan and separated children (OSC). This study was designed to (1) examine if the psychosocial well-being of OSC in under-resourced societies in LMICs is more dependent on the availability of certain components of quality of care rather than the care setting itself (i.e. the residential care-based or community family-based setting), and (2) identify the relative significance of certain components of quality of care that are associated with a child's psychosocial well-being across different OSC care settings. This study drew from 36-month follow-up data from the Positive Outcomes for Orphans (POFO) Study and used a sample population of 2,013 (923 institution- and 1,090 community-based) OSC among six diverse study sites across five LMICs: Cambodia, India (Hyderabad and Nagaland), Kenya, Tanzania, and Ethiopia. Analyses showed that all four components of quality of care significantly predicted child psychosocial well-being. Child psychosocial well-being across "high" and "low" levels of quality of care showed negligible differences between residential- and community-based care settings, suggesting the important factor in child well-being is quality of care rather than setting of care. Practical and policy implications and future research are discussed

Variation in wellbeing attributable to the site, setting, and individual levels.

1<p>From a linear mixed model adjusted for age and gender and including random effects for sites and care settings.</p>2<p>Institutions or community clusters sampled within sites.</p>3<p>Percent reduction in overall variance upon introduction of dichotomous variable and random site-level slopes for setting type, conditional on site, age, and gender.</p><p>Variation in wellbeing attributable to the site, setting, and individual levels.</p

Sample characteristics at baseline, among those retained at 36 months and those lost to follow-up.

1<p>Means (standard deviations; sd) and frequencies (percentages; %) at baseline among those retained at 36 months.</p>2<p>Means (standard deviations; sd) and frequencies (percentages; %) at baseline among those lost to follow-up at 36 months.</p>3<p>Frequencies (percentages; %) of institution-based and family-based children, respectively.</p><p>Sample characteristics at baseline, among those retained at 36 months and those lost to follow-up.</p

Changes in wellbeing of orphaned and separated children over 3 years, at the individual level and the institution or community cluster level.

<p>Sample size: Height for age – 252 community clusters, 1231 children; 73 institutions, 916 children. BMI for age – 247 community clusters, 1215 children; 73 institutions, 928 children. Total difficulties score, caregiver report – 245 community clusters, 1210 children; 69 institutions, 866 children. Total difficulties score, self-report – 38 community clusters, 326 children; 36 institutions, 221 children. Cognition (K-ABC II) – 256 community clusters, 1284 children; 73 institutions, 958 children. California Verbal Learning Test – 253 community clusters, 1268 children; 73 institutions, 944 children. The number of observations for self-reported total difficulties score is lower because only children at least 11 years old were asked for self-report. Numbers of observations vary across outcomes because of missing baseline or follow-up data (children) and because mean changes were only calculated for community clusters and institutions with at least 3 children with a change measure.</p

Child outcomes in institution and community-based care settings at baseline and after 36 months.

1<p>Baseline values include only those children who were not later lost to follow-up.</p>2<p>Difference represents child-level changes between baseline and follow-up.</p>3<p>Weighted difference accounts for age and sex differences in the distribution of children across study sites and differential rates of attrition between baseline and follow-up.</p><p>CVLT: California Verbal Learning Test. SDQ-CG: Strengths and Difficulties Questionnaire, Caregiver Report. SDQ-SR: SDQ, Self Report.</p><p>Child outcomes in institution and community-based care settings at baseline and after 36 months.</p