Project Title: Improving Outcomes for Orphaned Youth: Implementation of Trauma-focused Cognitive Behavioral Therapy (R01)
PI: Shannon Dorsey, Ph.D., Kathryn Whetten, Ph.D.
Funding: National Institute of Mental Health (NIMH, 2012 – 2017)
The primary goal of this R01 proposal is to study the effectiveness of Trauma-focused Cognitive Behavioral Therapy (TF-CBT) in treating traumatic grief and traumatic stress for orphaned children and young adolescents in two East African sites with high prevalence HIV, Moshi, Tanzania (TZ) and Bungoma, Kenya (KE), through a randomized controlled trial (RCT). The mental health gap in low and middle income countries (LMICs) is substantial, with few individuals in need of treatment receiving even basic care. Orphaned children and adolescents currently number 143 million worldwide, with nearly 50 million in Sub-Saharan Africa alone, 16.6 million due to HIV/AIDS. These are vulnerable children, who often have mental health problems subsequent to parental death as well as high rates of trauma exposure. In our feasibility study of TF-CBT with orphans in Tanzania, we have found a group-based TF-CBT intervention to be feasible and acceptable, with promising clinical outcomes. In the feasibility study, lay counselors with no prior mental health experience delivered the intervention with training and supervision by our team of mental health and TF-CBT experts.
Building on this initial study, we propose a RCT to test the effectiveness of TF-CBT for traumatic grief and traumatic stress compared to receipt of usual care orphan services in TZ and KE. The study extends our prior work in three ways: 1) includes a comparison condition; 2) includes two countries to examine broader applicability and effectiveness; and 3) involves partnering with the experienced lay counselors from the feasibility study to train and supervise lay counselors, in an attempt to build local responsibility and take steps toward sustainability. The proposed study involves collaboration with HIV/AIDS grassroots organizations and local Co-Investigators in TZ and KE, both of whom are longstanding collaborators with our US team and are located in mixed urban and rural areas, allowing examination of effectiveness in two countries and two settings (urban/rural). Using a task-shifting approach, in which lay individuals are trained as counselors, we will train six counselors in each country, who deliver 20 groups in each site (10 rural, 10 urban), resulting in 320 children and adolescents (ages 7-13) who receive TF-CBT and 320 who receive usual care. Outcomes for children are assessed at 12-14 weeks (i.e., corresponding with the end of TF-CBT), 6-months post-treatment, and 12-months post-treatment. TF-CBT experts from our team partner with the lay counselors from the feasibility study (e.g., local trainers) to train the TZ and KE counselors, and these local trainers provide the TF-CBT supervision, while supervised themselves by the US-based TF-CBT and mental health experts. We expect this trial to yield recommendations regarding an effective intervention for orphans that is acceptable, feasible, and includes local responsibility as a means to enhance potential sustainability in LMICs. Findings will inform other efforts to scale up mental health interventions to address the substantial mental health gap.
Pamoja Tunaweza is using the Design, Implementation, Monitoring, and Evaluation(DIME) method developed by researchers at Johns Hopkins University’s Bloomberg School of Public Health, the Applied Mental Health Research Group (AMHR), for cross-cultural mental health and psychosocial assistance programs. In August 2012 we completed the Qualitative module of DIME in Moshi, Tanzania by conducting free listing interviews with orphans, guardians, and key informants to find out what problems orphans in the community are facing, and what tasks are considered locally important to measure functioning1. In January 2013 we will be conducting the Validity (“Developing Quantitative Tools”) module of DIME, and the results will be used to ensure our measures are culturally relevant and comprehensive2.
Project Title: Cognitive Behavioral Therapy for Orphans (R34)
PI: Kathryn Whetten, Ph.D. (Duke University)
Co-Investigator: Shannon Dorsey, Ph.D.
Funding: National Institute of Mental Health (NIMH, 2010 – 2012)
Pamoja Tunaweza is a NIMH-funded project designed to examine the feasibility of providing Trauma-focused Cognitive Behavioral Therapy (TF-CBT), for Childhood Traumatic Grief (CTG) to orphaned youth in Tanzania (Whetten, PI; Duke University School of Medicine). Dr. Shannon Dorsey, faculty at PBHJP, is a Co-Investigator on the project. Among the high number of youth orphaned in sub-Saharan Africa, nearly 11.4 million lost one or both parents to AIDS3. Many of these youth are taken into the homes of relatives. Prior research by our team indicated that one of the primary problems reported by guardians, even rivaling concerns about tangible, concrete needs (e.g., food, shelter, school fees) was a reported lack of skills to support children and adolescents with grief and sadness. In Pamoja Tunaweza, local providers are trained and supervised in TF-CBT for CTG. The intervention is delivered in 12 child, guardian, and conjoint groups (1.5 hours). The goal is to investigate the acceptability and feasibility of delivering TF-CBT for CTG in a low-resource setting, in both an urban and rural environment, and to obtain preliminary child and adolescent outcomes. Findings from Pamoja Tunaweza will inform a larger randomized trial of TF-CBT for CTG in Tanzania.
- Murray, L. K., Dorsey, S., Skavenski, S., Jere, J., Kasoma, M., Imasiku, M., Hupunda, G., Bolton, P., Bass, J., & Cohen, J. (2013). Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: The use of TF-CBT in Zambia. International Journal of Mental Health Systems, 7(1), 1–24.
- Dorsey, S., O’Donnell, K., & Whetten, K. (2012). Implementation of TF-CBT in Tanzania: Task-shifting mental health care for orphaned youth. Annual NIH Conference on the Science of Dissemination and Implementation, Bethesda, Maryland.
- Dorsey, S., O’Donnell, K., Whetten, K., Itemba, Manongi, Chinyanganya, L., & Gong (2012, November). Group-Based Trauma-Focused CBT for Orphaned Children in Tanzania. In S. Dorsey (Chair), Trauma-Focused CBT: Implementation in Three Low-Resource Settings With Distinct Contexts. Symposium conducted at the ISTSS 28th Annual Meeting, Los Angeles, California.
- Dorsey, S., O’Donnell, K., Whetten, K., Gong, W., Itemba, D., & Manongi, R. (2013, May). Scaling up care for orphans in Tanzania: A task-sharing approach to mental health treatment. Seattle Implementation Conference, Seattle, WA.
- Lucid, L., Dorsey, S., Whetten, K., O’Donnell, K., & Koons, A. (2013, November). Task-shifting mental health care in low income countries: TF-CBT in Tanzania and Kenya. Poster presented for the Dissemination and Implementation Science Special Interest Group at the 47th Annual ABCT Convention, Nashville, TN.
1 Bolton, P., & Tang, A. M. (2002). An alternative approach to cross-cultural function assessment. Social Psychiatry & Psychiatric Epidemiology, 37, 537-543.
2 Bolton, P. (2001). Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. The Journal of Nervous and Mental Disease, 189(4), 238-242.
3 UNAIDS (2007). Report on the global AIDS empidemic. Geneva, Switzerland: Author.