Delivering Trauma-focused Cognitive-Behavioral Therapy in Kenya: Exploring Determinants and Impacts of Organizational Implementation Constructs

Abstract

Implementation research presents opportunities to study methods that facilitate successful uptake of evidence-based treatments (EBTs) in low-resource mental health settings. Exploring determinants that facilitate EBT implementation success and how successful implementation leads to improved clinical outcomes would help us develop implementation strategies that achieve favorable implementation and clinical outcomes. Using data from a randomized controlled trial evaluating the lay-counselor delivery of a culturally adapted group-based Trauma-focused Cognitive Behavioral Therapy (TF-CBT) to orphaned youth in Western Kenya, the overarching aims of this project are two-fold. The first aim was to identify individual- and organizational-level factors that predict implementation climate in the Education sector — the extent to which TF-CBT delivery is expected, supported, and rewarded — through coincidence analysis (CNA). Teacher-counselors' self-report measures of organizational characteristics, implementation leadership, implementation climate, burnout, and job satisfaction were included in our analyses. The second aim was to explore the relationships between organizational readiness for change, TF-CBT fidelity (i.e., adherence and competence), and clinical outcomes in both the Education and Health sectors using multilevel path analyses. Lay counselors completed self-report measures on organizational readiness for change, whereas their supervisors completed adherence and competence ratings based on live observations of child- and guardian-groups. Children completed baseline- and post-treatment post-traumatic stress symptoms (PTSS) self-report measures. Results from aim 1 highlighted different combinations of individual- and organizational-level conditions that are minimally necessary or sufficient to achieve moderate and high levels of implementation climate. These findings can help inform context-specific, efficient implementation strategies that can promote higher levels of implementation climate, and ultimately successful EBT implementation. Results from aim 2 demonstrated the importance of organizational readiness for change in improving adherence to TF-CBT elements in the Education sector. Further, our findings revealed that TF-CBT adherence and competence, mainly in guardian-group sessions, can improve post-treatment child PTSS. Taken together, this project underscores the utility of harnessing community partnerships and statistical approaches, which identified critical relationships between organizational characteristics, implementation outcomes, and clinical outcomes. Researchers must carefully consider the multifaceted nature of clinical contexts and design low-cost, practical implementation strategies that map onto the contexts' needs to optimize implementation and clinical outcomes.