35.4 LAY-COUNSELOR DELIVERED TRAUMA-FOCUSED CBT (TF-CBT) FOR BEREAVED AFRICAN CHILDREN: OUTCOMES AND ACCEPTABILITY

Abstract

The majority of the world’s children reside in low- and middle-income countries, yet few treatments have been tested in these settings. We present data from an NIMH-funded randomized controlled trial testing the effectiveness and acceptability of lay-counselor–delivered trauma-focused CBT (TF-CBT) in a sample of 640 youth who experienced death of 1 or both parents in Tanzania and Kenya. Child clinical outcomes were assessed at the end of treatment and at 12 months posttreatment. Acceptability was assessed via qualitative interviews 1 year after treatment with children and guardians, with 160 interviews randomly selected for qualitative coding, following a grounded theory approach. In the completed randomized controlled trial, at posttreatment, TF-CBT was more effective than usual care (UC) in reducing posttraumatic stress (PTS) among children who experienced parental death in 3 of 4 sites: rural Kenya (Cohen d = 1.04), urban Kenya (d = 0.56), and urban Tanzania (d = 0.45). At the 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural (d = 0.86) and urban (d = 0.99) Kenya. At the 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement. The intervention was highly acceptable. Child-level benefits were mentioned by almost all guardians (149/160), including improvements in child behavior, mood, feelings, and/or thinking. Children also frequently cited improvements (128/160), including fewer loss-related bad memories, thoughts, and/or feelings, and general improvements in mood or feelings. Few guardians or children mentioned challenges or dislikes, other than the program being viewed as too short. Tanzanian guardians were more likely to mention community-level benefits from sharing knowledge in their communities. Other qualitative coding work, focused on counselor session notes, also suggests that Tanzanian guardians were more likely to share learned skills and lessons from TF-CBT in their communities. TF-CBT demonstrated the greatest effectiveness in Kenya and high acceptability in both Kenya and Tanzania. The qualitative results provide some context for treatment outcomes and inform next directions.