Shannon Dorsey, Leah Lucid, Prerna Martin, Kevin M. King, Karen O’Donnell, Laura K. Murray, Augustine I. Wasonga, Dafrosa K. Itemba, Judith A. Cohen, Rachel Manongi, Kathryn Whetten
University of Washington affiliated authors are displayed in bold.
Published: January 2020
Shannon Dorsey, Christine L. Gray, Augustine I. Wasonga, Cyrilla Amanya, Bryan J. Weiner, C. Micha Belden, Prerna Martin, Rosemary D. Meza, Andrew K. Weinhold, Caroline Soi, Laura K. Murray, Leah Lucid, Elizabeth L. Turner, Robyn Mildon & Kathryn Whetten
University of Washington affiliated authors are displayed in bold.
Published: January 2020
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.
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 Trauma-focused 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.
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.
ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017
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Shannon Dorsey, Rosemary D. Meza, Prerna Martin, Christine L. Gray, Noah S. Triplett, Caroline Soi, Grace S. Woodard, Leah Lucid, Cyrilla Amanya, Augustine Wasonga and Kathryn Whetten
University of Washington affiliated authors are displayed in bold.
Published: December 2019
The global mental health treatment gap has increasingly been addressed using task-shifting; however, very little research has focused on lay counselors’ perspectives on the acceptability, feasibility, and appropriateness of mental health interventions in specific government-supported sectors that might scale up and sustain mental health care for children and adolescents. In western Kenya, these sectors include Education and Health.
Data come from a large hybrid effectiveness-implementation study examining implementation practices and policies in either or both sectors that support successful implementation of a child-focused intervention, Trauma-focused Cognitive Behavioral Therapy (TF-CBT), for children and adolescents who had experienced parental death. We examined lay counselors’ self-report of acceptability, feasibility, and appropriateness of TF-CBT. Lay counselors were teachers (n = 30) from the Education sector and Community Health Volunteers (CHVs; n = 30) from the Health sector, who were part of Sequence 1 of a large stepped-wedge, cluster randomized trial.
Lay counselor self-report surveys included reflective and formative measurement of acceptability, feasibility, and appropriateness administered after lay counselors in both sectors had experience delivering the locally-adapted, group-based TF-CBT intervention. Descriptive statistics (means, standard deviations) were used to understand counselors’ perspectives stratified by sector.
Both teachers and CHVs endorsed high acceptability, feasibility, and appropriateness of TF-CBT, with lay counselors’ responses on items from the formative measures providing some insight into specific aspects of acceptability, feasibility, and appropriateness that may be important to consider when planning for implementation support.
These early findings suggest that both sectors may hold promise for task-shifting of mental health care for children and adolescents but also underline the importance of considering the multiple facets of these three implementation outcomes as well as lay counselor context (Education vs. Health).
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Michael D. Pullmann, Leah Lucid, Julie P. Harrison, Prerna Martin, Esther Deblinger, Katherine S. Benjamin and Shannon Dorsey
University of Washington affiliated authors are displayed in bold.
Published: October 2018
Children infrequently receive evidence-based treatments (EBTs) for mental health problems due to a science-to-practice implementation gap. Workplace-based clinical supervision, in which supervisors provide oversight, feedback, and training on clinical practice, may be a method to support EBT implementation. Our prior research suggests that the intensity of supervisory focus on EBT (i.e., thoroughness of coverage) during workplace-based supervision varies. This study explores predictors of supervisory EBT intensity.
Participants were twenty-eight supervisors and 70 clinician supervisees. They completed a baseline survey, and audio recorded supervision sessions over 1 year. Four hundred and thirty eight recordings were coded for supervision content. We chose to explore predictors of two EBT content elements due to their strong evidence for effectiveness and sufficient variance to permit testing. These included a treatment technique (“exposure”) and a method to structure treatment (“assessment”). We also explored predictors of non-EBT content (“other topics”). Mixed-effects models explored predictors at organizational/supervisor, clinician, and session levels.
Positive implementation climate predicted greater intensity of EBT content coverage for assessment (coefficient = 0.82, p = 0.004) and exposure (coefficient = 0.87, p = 0.001). Intensity of exposure coverage was also predicted by more time spent discussing each case (coefficient = 0.04, p < 0.001). Predictors of greater non-EBT content coverage included longer duration of supervision sessions (coefficient = 0.05, p < 0.001) and lower levels of supervisor EBT knowledge (coefficient = −0.17, p = 0.013). No other supervisor- or clinician-level variables were significant predictors in the mixed effects models.
This was the first study to explore multi-level predictors of objectively coded workplace-based supervision content. Results suggest that organizations that expect, support and reward EBT are more likely to have greater intensity of EBT supervision coverage, which in turn may positively impact clinician EBT fidelity and client outcomes. There was evidence that supervisor knowledge of the EBT contributes to greater coverage, although robust supervisor and clinician factors that drive supervision are yet to be identified. Findings highlight the potential effectiveness of implementation strategies that simultaneously address organizational implementation climate and supervisor practices. More research is needed to identify mechanisms that support integration of EBT into supervision.
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Leah Lucid, Rosemary Meza, Michael D. Pullmann, Nathaniel Jungbluth, Esther Deblinger, & Shannon Dorsey
University of Washington affiliated authors are displayed in bold.
Published: July 2018
L. K. Murray, B. J. Hall, S. Dorsey, A. M. Ugueto, E. S. Puffer, A. Sim, A. Ismael, J. Bass, C. Akiba, L. Lucid, J. Harrison, A. Erikson, and P. A. Bolton
University of Washington affiliated authors are displayed in bold.
Published: April 2018
Children, defined as any boy or girl under 18 years, make up almost half of the world’s refugee population (United Nations High Commissioner for Refugees, 2016) and are exposed to challenges, traumas and stressors at the individual, family, and community levels that increase their risk for mental health problems (Barenbaum et al., 2004; Betancourt & Khan, 2008; Reed et al., 2012). These may include forced migration, forced labor, witnessing of murder and mass killings, lack of food and shelter, rape, torture, loss and separation from family, recruitment and use by armed forces, physical abuse, and family and sexual violence (Lustig et al., 2004; Office of the Special Representative of the Secretary-General for Children & Armed Conflict et al., 2009). Overlaid on potentially traumatic events are the daily, chronic stressors caused by displacement and associated with living in the camp environment – lack of basic needs, crowded and unsafe living conditions, and interpersonal conflict, among others (Layne et al., 2010; Miller & Rasmussen, 2010).
Children affected by these types of traumas and stressors present with a wide range of mental health symptoms, including those associated with posttraumatic stress (PTS), depression, anxiety, conduct problems, risk behaviors (e.g., alcohol or drug use), and distress associated with grief reactions (Barenbaum et al., 2004; Lustig et al., 2004; Sagi-Schwartz, 2008; Attanayake et al., 2009; Okello et al., 2013[for review], Morgos et al., 2008; Fernando et al., 2010; Miller & Rasmussen, 2010; Reed et al., 2012; Meyer et al., 2013; Newnham et al., 2015). Prevalence is difficult to study in these contexts; however, most studies find higher rates of mental health problems among displaced children compared with non-displaced populations (Goldstein et al., 1997; Paardekooper et al., 1999; Tousignant et al., 1999; Morgos et al., 2008; Bronstein & Montgomery, 2011; Reed et al., 2012).
There remains limited evidence on the effectiveness of interventions to treat mental health problems of children in refugee settings in low- and middle-income countries (LMICs). Some studies suggest that cognitive–behavioral-based treatments can be effective for reducing mental health symptoms in refugee children (Bolton et al., 2007; Layne et al., 2010). Relatedly, some eclectic psychosocial programs have been tested with conflict-affected populations, and show an impact on outcomes such as self-esteem or hope, but not mental health (Tol et al., 2014). Studies have generally utilized focal disorder treatments – or treatments focused on one disorder or cluster of symptoms. For example, Layne and colleagues used a treatment developed for posttraumatic stress disorder (PTSD) and grief (Layne et al., unpublished treatment manual) and Bolton and team (2007) used a treatment developed for depression (Interpersonal Therapy for depression; IPT). In contrast to this focal disorder treatment model where everyone receives the same elements in the same order, in common elements approaches providers learn elements that can be combined in different ways (elements used, order, dose) to treat a range of common mental health symptoms, and how to handle comorbidity (e.g., depression, trauma, anxiety co-occurrence) (Chorpita et al., 2005; Weisz et al., 2011; Weisz et al., 2012; Murray et al., 2014a). This approach is potentially more efficient and sustainable in both high-income countries (Mansell et al., 2008; Weisz et al., 2011; Weisz et al., 2012) and in LMICs (Bolton et al., 2014; Murray et al., 2014a; Ventevogel, 2015; Weisz et al., 2015) because it does not require providers to learn multiple interventions. Additionally, in settings with high rates of disorder comorbidity, such as in refugee populations, a model that can address multiple disorders may also be more appropriate (Murray & Jordans, 2016).
This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) (Bolton et al., 2007; Bolton et al., 2014; Murray et al., 2014a; Weisz et al., 2015) developed for comorbid presentations of depression, anxiety, post traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border; and (2) an evaluation of implementation factors including acceptability, applicability/fit, feasibility and treatment facilitators, and barriers from the perspective of staff of the implementing partner organization, lay providers, and families who engaged in…
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Shannon Dorsey, Suzanne E. U. Kerns, Leah Lucid, Michael D. Pullmann, Julie P. Harrison, Lucy Berliner, Kelly Thompson, and Esther Deblinger
University of Washington affiliated authors are displayed in bold.
Published: January 2018
Workplace-based clinical supervision as an implementation strategy to support evidence-based treatment (EBT) in public mental health has received limited research attention. A commonly provided infrastructure support, it may offer a relatively cost-neutral implementation strategy for organizations. However, research has not objectively examined workplace-based supervision of EBT and specifically how it might differ from EBT supervision provided in efficacy and effectiveness trials.
Data come from a descriptive study of supervision in the context of a state-funded EBT implementation effort. Verbal interactions from audio recordings of 438 supervision sessions between 28 supervisors and 70 clinicians from 17 public mental health organizations (in 23 offices) were objectively coded for presence and intensity coverage of 29 supervision strategies (16 content and 13 technique items), duration, and temporal focus. Random effects mixed models estimated proportion of variance in content and techniques attributable to the supervisor and clinician levels.
Interrater reliability among coders was excellent. EBT cases averaged 12.4 min of supervision per session. Intensity of coverage for EBT content varied, with some discussed frequently at medium or high intensity (exposure) and others infrequently discussed or discussed only at low intensity (behavior management; assigning/reviewing client homework). Other than fidelity assessment, supervision techniques common in treatment trials (e.g., reviewing actual practice, behavioral rehearsal) were used rarely or primarily at low intensity. In general, EBT content clustered more at the clinician level; different techniques clustered at either the clinician or supervisor level.
Workplace-based clinical supervision may be a feasible implementation strategy for supporting EBT implementation, yet it differs from supervision in treatment trials. Time allotted per case is limited, compressing time for EBT coverage. Techniques that involve observation of clinician skills are rarely used. Workplace-based supervision content appears to be tailored to individual clinicians and driven to some degree by the individual supervisor. Our findings point to areas for intervention to enhance the potential of workplace-based supervision for implementation effectiveness.
NCT01800266, Clinical Trials, Retrospectively Registered (for this descriptive study; registration prior to any intervention [part of phase II RCT, this manuscript is only phase I descriptive results])
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