Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania

Abstract

IMPORTANCE Approximately 140 million children worldwide have experienced the death of one or both parents. These children, mostly in low-and middle-income countries, have higher rates of mental health problems than those who have not experienced parental death. Cognitive behavioral therapy (CBT) may improve the well-being of these children, but to our knowledge there have been no randomized clinical trials specifically focused on this population.OBJECTIVES To test the effectiveness of trauma-focused CBT (TF-CBT) for improving posttraumatic stress (PTS) in children in Kenya and Tanzania who have experienced parental death, to test the effects of TF-CBT on other mental health symptoms, and to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as trainers and supervisors. DESIGN, SETTING, AND PARTICIPANTSA randomized clinical trial conducted in urban and rural areas of Tanzania and Kenya compared TF-CBT and usual care (UC) for 640 children aged 7 to 13 years who were recruited from February 13, 2013, to July 24, 2015. All children had experienced the death of one or both parents and had elevated PTS and/or prolonged grief. Interviewers were masked to study condition. Participants were followed up for 12 months after the randomized clinical trial. Statistical analysis was performed from February 3, 2017, to August 26, 2019. All analyses were on an intent-to-treat basis. INTERVENTIONSIn the intervention condition, 320 children received 12 weeks of group TF-CBT delivered by lay counselors who were supervised weekly. In the UC condition, 320 children received community services typically offered to this population. MAIN OUTCOMES AND MEASURESThe primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured. RESULTS A total of 640 children (320 girls and 320 boys; mean [SD] age, 10.6 [1.6] years) were included in the study. Trauma-focused CBT was more effective than UC for PTS in 3 of 4 sites after treatment (end of 3-month randomized clinical trial): rural Kenya (Cohen d = 1.04 [95% CI, 0.72-1.36]), urban Kenya (Cohen d = 0.56 [95% CI, 0.29-0.83]), and urban Tanzania (Cohen d = 0.45 [95% CI, 0.10-0.80]). At 12-month follow-up, TF-CBT remained more effective than UC in both rural (Cohen d = 0.86 [95% CI, 0.64-1.07]) and urban (Cohen d = 0.99 [95% CI, 0.75-1.23]) Kenya. At 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement (rural Tanzania, Cohen d = 0.09 [95% CI, −0.08 to 0.26]; urban Tanzania, Cohen d = 0.11 [95% CI, −0.09 to 0.31]).A similar pattern was seen for secondary outcomes, with stronger effects observed in Kenya, where children experienced greater stress and adversity (eg, more food scarcity, poorer guardian health, and greater exposure to traumatic events).CONCLUSIONS AND RELEVANCE This study found that TF-CBT was more effective than UC in reducing PTS among children who experienced parental death in 3 of 4 sites in K...

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

“…"Building and Sustaining Interventions for Children (BASIC): Task Sharing Mental Health Care in Low-Resource Settings" builds on our 15-year history of collaborations with Ace Africa in Kenya, and recent work evaluating the effectiveness of Trauma-focused Cognitive Behavioral Therapy (TF-CBT) [19] ("Pamoja Tunaweza") with children who experienced parental death [20,21] and have mental health impact. Our goal is to identify locally sustainable implementation policies and practices (IPPs) that lead to effective implementation of task-shifted EBT delivery (Pamoja Tunaweza in this study) in 2 governmental sectors in Kenya, identified by our Kenyan partners as potential platforms for scaleup-Education (via teacher delivery) and Health (via community health volunteer [CHV] delivery).…”

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. The goal of BASIC is to learn what makes an enabling context for mental health delivery in both Education and Health, by identifying implementation practices and policies (IPPs) that support successful implementation in the distinct sectors.…”

“…Intervention TF-CBT is an evidence-based treatment protocol which treats psychosocial sequelae from child trauma exposure, with a specific application for maladaptive grief (23). There is substantial evidence of its effectiveness from RCTs in highincome countries (HICs; 35) with evidence of effectiveness from large RCTs in Zambia (15) and Kenya (30) and two small RCTs in the Democratic Republic of Congo (36,37). In our previous collaborative work, we modified TF-CBT for delivery in Eastern Africa, with results from an open trial in Tanzania suggesting that the intervention held promise, given positive clinical outcomes at the end of treatment and maintained gains at a 1-year follow up (31).…”

“…Groupbased delivery was chosen for multiple reasons: a) all youth were receiving treatment for the same primary traumatic event (parental death); b) the group format maximized reach and efficiency (i.e., more children served); and c) early qualitative work suggested that a group-based intervention was perceived as more culturally appropriate, more supportive, and less stigmatizing. Following the open trial, we conducted a large RCT in eastern Tanzania and western Kenya (N = 640), testing Pamoja Tunaweza compared to usual care services at end of treatment and a 1-year follow-up (30). The intervention was delivered by six lay counselors in each country, who were trained and supervised by the experienced lay counselors from the open trial in Tanzania, with support from the first author, following the Apprenticeship Model of training (38).…”

“…The goal of the present study is to assess counselor-perceived acceptability, feasibility, and appropriateness of a trauma-focused intervention for children and adolescents in the context of a task-shifting, implementation science-focused study in western Kenya. We specifically examine these constructs with the first lay counselors from two different sectors, Education and Health, who delivered TF-CBT (23) for children who experienced the death of one or both parents and have related mental health symptoms (30,31). While these first lay counselors represent a sub-group of our final sample (60 of 240), given study design and randomization procedures, they likely are representative of counselors in the full sample.…”