Abstract
BackgroundEvidence for the effectiveness of psychological treatments in low- and middle-income countries is increasing. However, there is a lack of systematic approaches to guide implementation in government health systems. The objective of this study was to address this gap by employing the Replicating Effective Programs (REP) framework to guide contextualization of a psychological treatment in the Uganda public health system for caregivers of children affected by nodding syndrome, a neuropsychiatric disorder endemic to Sub-Saharan Africa associated with high morbidity and disability.MethodsTo contextualize a psychological treatment, we followed the four components of the REP framework: pre-conditions, pre-implementation, implementation, and maintenance and evolution. A three-step process involved reviewing health services available for nodding syndrome-affected families and current evidence for psychological treatments, qualitative formative research, and analysis and documentation of implementation activities. Stakeholders included members of affected communities, health care workers, therapists, local government leaders, and Ministry of Health officials. Detailed written, audio, and video documentation of the implementation activities was used for content analysis.ResultsDuring the pre-condition component of REP, we selected group interpersonal therapy (IPT-G) because of its feasibility, acceptability, effectiveness in the local setting, and availability of locally developed training materials. During the pre-implementation component, we adapted the training, logistics, and technical assistance strategies in conjunction with government and stakeholder working groups. Adaptations included content modification based on qualitative research with caregivers of children with nodding syndrome. During the implementation component, training was shortened for feasibility with government health workers. Peer-to-peer supervision was selected as a sustainable quality assurance method. IPT-G delivered by community health workers was evaluated for fidelity, patient outcomes, and other process-level variables. More than 90% of beneficiaries completed the treatment program, which was effective in reducing caregiver and child mental health problems. With the Ministry of Health, we conducted preparatory activities for the maintenance and evolution component for scale-up throughout the country.ConclusionsThe REP framework provides a systematic approach to guide contextualization of psychological treatments for delivery in low-resource public health systems. Specific recommendations are provided for REP’s application in global mental health.Trial registrationISRCTN11382067; 08/06/2016; retrospectively registered
Highlights
Evidence for the effectiveness of psychological treatments in low- and middle-income countries is increasing
Adaptations included content modification based on qualitative research with caregivers of children with nodding syndrome
Interpersonal psychotherapy (IPT)-G delivered by community health workers was evaluated for fidelity, patient outcomes, and other process-level variables
Summary
Evidence for the effectiveness of psychological treatments in low- and middle-income countries is increasing. There is a lack of systematic approaches to guide implementation in government health systems. There is increasing attention to the need for systematic approaches to cultural adaptation of evidence-based treatments (EBTs) [2, 3], the process of contextualization has received limited attention. Cultures vary widely around the world, there are common contextualization challenges faced by government health systems in low- and middle-income countries (LMIC) and in other low-resource settings. There are increasing attempts to integrate EBTs into government settings, with limited publications to date on how the process is done and a lack of specific implementation strategies to guide it [4]. There is a global need to develop common guidance principles for contextualization of EBTs
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