Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): protocol for a stepped wedge cluster randomized trial

Abstract

Background: The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low-and middle-income countries. Task-shifting has been used to address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery. Methods: BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Traumafocused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors. Discussion: The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts.

Barriers and facilitators of child and guardian attendance in task-shifted mental health services in schools in western Kenya

“…Similarly, the increased cost of transport during heavy rains was a barrier to attendance. A cost analysis conducted as part of the parent study (Dorsey et al, 2020a(Dorsey et al, , 2020b will calculate all costs associated with PT delivery, which may aid policymakers as they consider integrating services into their budget. Though funding transportation may not be a funding priority, the return on investment will be greater for governments if participants can attend services.…”

“…The parent study, BASIC, is a NIMH-funded study of TF-CBT delivered by teachers in the education sector and community health volunteers (CHVs) in the health sector in Western Kenya (see Dorsey et al, 2020aDorsey et al, , 2020b. BASIC is a stepped wedge cluster randomized trial that includes seven sequences.…”

“…Study findings were used to assist stakeholders in selecting strategies to improve attendance in subsequent sites implementing PT, with emphasis on addressing modifiable barriers without using additional resources. Stakeholders engaged in a method for developing tailored strategy plans (Lewis et al, 2018) that were used to coach future sites in supporting attendance and PT implementation (Dorsey et al, 2020a(Dorsey et al, , 2020b. Some aimed to directly impact attendance, such as developing procedures for regular attendance reminders and using the first session to thoroughly sensitize participants about PT benefits and expectations to motivate attendance.…”

“…Studies utilizing a version of TF-CBT adapted to fit the local context demonstrate TF-CBT can be feasibly delivered using task-shifting and results in mental health symptoms improvements for youth in sub-Saharan Africa (Murray et al, 2013a(Murray et al, , 2013bO'Donnell et al, 2014). To enhance sustainability of these efforts, current research is examining the scale-up of task-shifted TF-CBT in schools (Dorsey et al, 2020a(Dorsey et al, , 2020b.…”

Lay Counselor Perspectives of Providing a Child-Focused Mental Health Intervention for Children: Task-Shifting in the Education and Health Sectors in Kenya

“…Data for this study come from a large NIMH-funded hybrid effectiveness-implementation study of TF-CBT delivered through both the Education (via teachers) and Health (via CHVs) sectors in Western Kenya: Building and Sustaining Interventions for Children (BASIC; NIMH-funded R01MH112633) conducted as a collaboration between Duke University, the University of Washington, and Ace Africa, in Bungoma, Kenya (33). This study builds on a pilot of TF-CBT in East Africa (31) and a large randomized controlled trial (RCT) in Kenya and Tanzania (30) that demonstrate the effectiveness of lay counselor-delivered TF-CBT in Kenya.…”