Judy Bass

A qualitative study of georgian youth who are on the street or institutionalized.

Street children, or children who live and/or spend time on the streets, are a vulnerable group of considerable concern to the global public health community. This paper describes the results of two linked qualitative studies conducted with children living or spending time on the street and in orphanages in and around urban areas in the Republic of Georgia between 2005 and 2006. The studies examined perceived causes of children going to the street, as well as indicators of healthy functioning and psychosocial problems among these children. Results on causes indicated a range of “push” factors leading children to the street and “pull” factors that keep children living on the street. Findings also showed a range of internalizing and externalizing mental health symptoms among children on the street and within orphanages. Some differences in responses were found between children living on the street and in institutions. It is important to understand the perspectives of these vulnerable populations to guide decisions on appropriate interventions that address their primary problems.

Caregiver mental health and HIV-infected child wellness: perspectives from Ugandan caregivers

ABSTRACT Prior studies indicate a substantial link between maternal depression and early child health but give limited consideration to the direction of this relationship or the context in which it occurs. We sought to create a contextually informed conceptual framework of this relationship through semi-structured interviews with women that had lived experience of caring for an HIV-infected child while coping with depression and anxiety symptoms. Caregivers explained their role in raising healthy children as complex and complicated by poverty, stigma, and isolation. Caregivers discussed the effects of their own mental health on child well-being as primarily emotional and behavioral, and explained how looking after a child could bring distress, particularly when unable to provide desired care for sick children. Our findings suggest the need for investigation of the reciprocal effects of child sickness on caregiver wellness and for integrated programs that holistically address the needs of HIV-affected families.

Local perceptions of the impact of group interpersonal psychotherapy in rural Uganda

Background. This study investigated local perceptions of changes stemming from a long-standing Group Interpersonal Psychotherapy (IPT-G) program for the treatment of depression in rural Uganda. The study was conducted in a low-income, severely HIV/AIDS-affected area where in 2001 the prevalence of depression was estimated at 21% among adults. Method. Data were collected using free-listing and key informant qualitative interviews. A convenience sample of 60 free-list respondents was selected from among IPT-G participants, their families, and other community members from 10 Ugandan villages. Twenty-two key informants and six IPT-G facilitators were also interviewed. Results. Content analysis yielded five primary categories of change in the community related to the IPT-G program: (1) improved school attendance for children; (2) improved productivity; (3) improved sanitation in communities; (4) greater cohesion among community members; and (5) reduced conflict in families. Community members and IPT-G facilitators suggested that as depression remitted, IPT-G participants became more hopeful, motivated and productive. Conclusion. Results suggest that providing treatment for depression in communities with high depression prevalence rates may lead to positive changes in a range of non-mental health outcomes.

The impact of Cognitive Processing Therapy on stigma among survivors of sexual violence in eastern Democratic Republic of Congo: results from a cluster randomized controlled trial

BackgroundSexual violence is associated with a multitude of poor physical, emotional, and social outcomes. Despite reports of stigma by sexual violence survivors, limited evidence exists on effective strategies to reduce stigma, particularly in conflict-affected settings. We sought to assess the effect of group Cognitive Processing Therapy (CPT) on stigma and the extent to which stigma might moderate the effectiveness of CPT in treating mental health problems among survivors of sexual violence in the Democratic Republic of Congo.MethodsData were drawn from 405 adult female survivors of sexual violence reporting mental distress and poor functioning in North and South Kivu. Women were recruited through organizations providing psychosocial support and then cluster randomized to group CPT or individual support. Women were assessed at baseline, the end of treatment, and again six months later. Assessors were masked to women’s treatment assignment. Linear mixed-effect regression models were used to estimate (1) the effect of CPT on feelings of perceived and internalized (felt) stigma, and (2) whether felt stigma and discrimination (enacted stigma) moderated the effects of CPT on combined depression and anxiety symptoms, posttraumatic stress, and functional impairment.ResultsParticipants receiving CPT experienced moderate reductions in felt stigma relative to those in individual support (Cohen’s D = 0.44, p = value = 0.02) following the end of treatment, though this difference was no longer significant six-months later (Cohen’s D = 0.45, p = value = 0.12). Neither felt nor enacted stigma significantly moderated the effect of CPT on mental health symptoms or functional impairment.ConclusionsGroup cognitive-behavioral based therapies may be an effective stigma reduction tool for survivors of sexual violence. Experiences and perceptions of stigma did not hinder therapeutic effects of group psychotherapy on survivors’ mental health.Trial registrationClinicalTrials.gov NCT01385163.

Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq

Background. Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Bolton et al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq. Methods. This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Bolton et al. 2014a), informed by the Assessment–Decision–Administration-Production–Topical experts–Integration–Training–Testing (ADAPT–ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting. Results. Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT–ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility. Conclusions. BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.

Stigma modifies the association between social support and mental health among sexual violence survivors in the Democratic Republic of Congo: implications for practice

ABSTRACT Background and Objectives: The aim of this study was to further understanding of the relationship between social support, internalized and perceived stigma, and mental health among women who experienced sexual violence in the eastern Democratic Republic of Congo (DRC). Methods: Drawing from baseline survey data collected in eastern DRC, researchers conducted a secondary cross-sectional analysis using data from 744 participants. Regression and moderation analyses were conducted to examine associations between social support variables, felt stigma, and depression, anxiety and posttraumatic stress disorder (PTSD). Results: Emotional support seeking and felt stigma were positively associated with increased symptom severity across all three mental health variables. Stigma modified associations between emotional support seeking and depression (t = −2.49, p = .013), anxiety (t = −3.08, p = .002), and PTSD (t = −2.94, p = .003). Increased frequency of emotional support seeking was associated with higher mental health symptoms of anxiety and PTSD among women experiencing all levels of stigma. Conclusions: Enhancing understanding of social support and stigma may inform research and intervention among Congolese forced migrant populations across circumstances and geographic locations. Implications for practice and research are discussed.

Local Perceptions of the Impact of Group Interpersonal Psychotherapy inRural Uganda

This study investigated local perceptions of changes stemming from a long-standing Group Interpersonal Psychotherapy (IPT-G) program for the treatment of depression in rural Uganda. The study was conducted in a lowincome, severely HIV/AIDS affected area where in 2001 the prevalence of depression was estimated at 21% among adults. Data were collected between May 10 and May 31, 2010, using free-listing and key informant qualitative interviewing techniques. A convenience sample of sixty free-list respondents was selected from among adults who had participated in IPT-G, their family members, and other community members, from 10 villages representing a range of sizes and geographical locations. Twenty-two key informants were also selected from these villages, based on their knowledge about changes reported by free-list respondents. Interviews were analyzed using content analysis and response frequency tallied. IPT-G facilitators were also interviewed about the reported changes. Free-list respondents identified 5 primary categories of change in the community related to the IPT-G program: 1) Improved school attendance for children; 2) Improved productivity; 3) Improved sanitation in communities; 4) Greater cohesion among community members; and 5) Reduced conflict in families. Key informant interviews with community members and IPT-G facilitators suggested that as depression remitted, IPT-G participants became more hopeful and motivated and resumed productive pursuits. Greater cohesion between group members and other affected community members led to increases in collaborative farming and building efforts, and to ongoing mutual emotional support and peer counseling. Changes reported in this study cannot uniquely be attributed to the IPT-G program as other development programs in the area, related to farming, sanitation, and education, may also have contributed. Nevertheless, results suggest that providing treatment for depression in communities where it is prevalent may lead to positive changes in a range of non-mental health areas that are perceived to be connected the depression services.

An evaluation of a common elements treatment approach for youth in Somali refugee camps

Background. This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, 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 from the perspective of staff, lay providers, and families who engaged in the intervention. Methods. This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors. Results. Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d = 1.37), externalizing (d = 0.85), and posttraumatic stress (d = 1.71), and improvements in well-being (d = 0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility. Conclusions. This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.