Genetic Analyses of Rare ESBL ST628 Klebsiella pneumoniae Detected during a Protracted Nosocomial Outbreak in the United Kingdom.

Klebsiella pneumoniae (K. pneumoniae) cultures from a hospital-wide outbreak in the UK, which lasted for over 12 months, were sequenced. We sought to sequence and genetically characterise the outbreak strain. Antibiotic Susceptibility Testing (AST) was performed on 65 K. pneumoniae isolates saved from the outbreak. All isolates were sequenced using the Oxford Nanopore Technologies (ONT) MinION flowcell: 10 isolates, including the isolate with the earliest collection date in 2017, were additionally sequenced on the NovaSeq 6000 platform to build high-accuracy nanopore-illumina assemblies. Among the sequenced strains, 60 were typed as ST628. 96.6% (n = 58/60) ST628 strains harboured a large ~247-kb FIB(K) plasmid carrying up to 11 antimicrobial resistance genes, including the extended-spectrum beta-lactamase (ESBL) gene, blaCTX-M-15. Clonality between the outbreak isolates was confirmed using single nucleotide polymorphism (SNP) typing. The outbreak strains were phylogenetically related to clinical ST628 strains identified in 2012, 6 years prior to the outbreak. A rare ESBL K. pneumoniae K2 ST628 strain harbouring a multi-drug resistant (MDR) plasmid encoding the ESBL gene blaCTX-M-15 was detected across multiple independent wards during the protracted nosocomial outbreak. Surveillance of this strain is recommended to prevent future nosocomial outbreaks.

A qualitative study of mental health problems among children living in New Delhi slums.

Children living in urban slums in India are exposed to chronic stressors that increase their risk of developing mental disorders, but they remain a neglected group. Effective mental health interventions are needed; however, it is necessary to understand how mental health symptoms and needs are perceived and prioritized locally to tailor interventions for this population. We used an existing rapid ethnographic assessment approach to identify mental health problems from the perspective of children living in Indian slums, including local descriptions, perceived causes, impact, and coping behavior. Local Hindi-speaking interviewers conducted 77 free-list interviews and 33 key informant interviews with children and adults (N = 107) from two slums in New Delhi. Results identified a range of internalizing and externalizing symptoms consistent with depression, anxiety, and conduct problems in children. Findings included both common cross-cultural experiences and symptoms as well as uniquely described symptoms (e.g., "madness or anger," "pain in the heart and mind") not typically included on western standardized measures of psychopathology. Mental health problems appeared to be highly interconnected, with experiences such as harassment and fighting often described as both causes and impacts of mental health symptoms in children. Community perspectives indicated that even in the face of several unmet basic needs, mental health problems were important to the community and counseling interventions were likely to be acceptable. We discuss implications for adapting mental health interventions and assessing their effectiveness to reduce the burden of mental illness among children living in urban slums in India.

Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial.

Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.

Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care.

This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization's Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.

Responding to the impact of COVID-19 on the mental health and well-being of health workers in LMICs.

The COVID-19 pandemic has worsened mental health among health workers around the world. With a projected global shortage of 10.2 million health workers by 2030, further exacerbated by COVID-19, taking action to support health worker mental health needs to be an integral component of investments to overcome this gap and build resiliency of systems for the future. Health workers are functioning in highly stressful environments at great personal risk to provide services that improve quality of life and save lives. To reduce burnout and early exits from the workforce, health workers must be protected and equipped to work in supportive environments, manage stress, and access mental health services when needed. This article explores the impact of COVID-19 on health worker mental health and proposes actions for health systems and workplaces to support health workers which draw on available evidence and examples of USAID-supported partner activities.

Development and Piloting of a Mental Health Prevention and Referral Program for Veterans and Their Families in Ukraine.

BACKGROUND: While growing evidence exists for the effectiveness of mental health interventions in global mental health, the evidence base for psychosocial supports is lacking despite the need for a broader range of supports that span the prevention-treatment continuum and can be integrated into other service systems. Following rigorous evaluation of the Common Elements Treatment Approach (CETA) in Ukraine, this article describes the development and feasibility testing of CETA Psychosocial Support (CPSS), a brief psychosocial prevention and referral program for Ukrainian veterans and their families. CPSS DEVELOPMENT: CPSS development used evidence-based CETA intervention components and was informed by a stakeholder needs analysis incorporating feedback from veterans and their families, literature review, and expert consultations. The program includes psychoeducation, cognitive coping skill development, and a self-assessment tool that identifies participants for potential referral. After initial development of the program, the intervention underwent: (1) initial implementation by skilled providers focused on iterative refinement; (2) additional field-testing of the refined intervention by newly trained providers in real-world conditions; and (3) a formal pilot evaluation with collection of pre-post mental health assessments and implementation ratings using locally validated instruments. RESULTS: Fifteen CPSS providers delivered 14 group sessions to 109 participants (55 veterans, 39 family members, and 15 providers from veterans' service organizations). After incorporating changes related to content, process, and group dynamics, data from the pilot evaluation suggest the refined CPSS program is an acceptable and potentially effective brief psychosocial prevention and promotion program that can be implemented by trained veteran providers. Forty percent of participants required safety or referral follow-ups. CONCLUSION: The iterative, inclusive development process resulted in an appropriate program with content and implementation strategies tailored to Ukrainian veterans and their families. Brief psychosocial programs can fit within a larger multitiered mental health and psychosocial continuum of care that supports further referral.

Psychometric performance of the Mental Health Implementation Science Tools (mhIST) across six low- and middle-income countries.

BACKGROUND: Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups-consumers, providers, organization leaders, and policy makers-with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. METHODS: We compiled secondary data from seven studies across six LMIC-Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia-to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. RESULTS: All but one scale within the Provider and Consumer versions had Cronbach's alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. CONCLUSION: We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.

Comment: silent burden no more: a global call to action to prioritize perinatal mental health.

Common perinatal mental disorders are the most frequent complications of pregnancy, childbirth and the postpartum period, and the prevalence among women in low- and middle-income countries is the highest at nearly 20%. Women are the cornerstone of a healthy and prosperous society and until their mental health is taken as seriously as their physical wellbeing, we will not improve maternal mortality, morbidity and the ability of women to thrive. On the heels of several international efforts to put perinatal mental health on the global agenda, we propose seven urgent actions that the international community, governments, health systems, academia, civil society, and individuals should take to ensure that women everywhere have access to high-quality, respectful care for both their physical and mental wellbeing. Addressing perinatal mental health promotion, prevention, early intervention and treatment of common perinatal mental disorders must be a global priority.

The end of the trial: Perspectives on cognitive processing therapy from community-based providers in the Democratic Republic of Congo.

Despite calls forincreased mental health programming in low-resource and humanitarian contexts and effectiveness trials of psychotherapy in these settings, little research exists on the extent to which providers and recipients continue to practice skills learned during trials of these programs. To understand if and how providers continued to use mental health intervention skills without ongoing institutional support following the completion of randomized controlled trials (RCTs), we analyzed data from semistructured interviews with six of seven providers who participated in an RCT of cognitive processing therapy (CPT) in the Democratic Republic of Congo 7 years prior. Provider interviews revealed continued knowledge of and, in some cases, the practice of core CPT skills as well as efforts to keep meeting with women in the community and a strong desire to learn new skills. Although financial limitations sometimes prohibited providers from formally convening CPT groups with women in need, participants maintained knowledge and skill use. Providers also reported feeling more valued in their communities, and they continued providing services beyond the planned intervention period despite a lack of ongoing support. In addition, participants described a strong desire to continue psychosocial interventions for trauma and learn more about this type of intervention. Reframing the evaluation of psychological interventions as program development and maintaining a strong working relationship with community partners may allow for increased sustainability of mental health services beyond the end of academic research studies in low-resource contexts.

Maintenance of intervention effects: long-term outcomes for participants in a group talk-therapy trial in the Democratic Republic of Congo.

Background: Despite the growth of psychotherapy trials in low- and middle-income countries, there have been limited follow-up studies of more than 2 years. This study follows up female sexual violence survivors approximately 6 years after completing a 12-session group cognitive processing therapy (CPT) program in the eastern Democratic Republic of Congo. Methods: Baseline trial data were collected in December 2010 from 134 women in 7 study villages randomly allocated to CPT. Study women were over 18 years, reported personally experiencing or witnessing sexual violence, and reported elevated depression, anxiety and/or posttraumatic stress symptoms. Women were followed up (1) post-treatment (6-months after baseline); (2) 6 months later; (3) 12 months later; and (4) in March 2017 (6.3 years after baseline). At the long-term follow-up, 103 women (77%) in 6 of 7 CPT villages were re-assessed; one village was not visited due to ongoing insecurity. Results: We found strong continued intervention effects; nearly all women maintained treatment impacts over the first two years; at long-term follow-up, approximately half continued to maintain low symptom scores. Relapse rates for probable PTSD and probable depression and anxiety were 20%. Conclusions: This study extends prior research to show that treatment impacts can be maintained for several years despite experiences of ongoing trauma. The women described continuing to meet with the women in their therapy group and using the skills they learned in the psychotherapy, providing evidence of the potential for these programs to provide valuable social supports and skills that people use as they continue to face adversity.

Development of a knowledge broker group to support evidence-informed policy: lessons learned from Myanmar.

BACKGROUND: Globally, policy-makers face challenges to using evidence in health decision-making, particularly lack of interaction between research and policy. Knowledge-brokering mechanisms can fill research-policy gaps and facilitate evidence-informed policy-making. In Myanmar, the need to promote evidence-informed policy is significant, and thus a mechanism was set up for this purpose. This paper discusses lessons learned from the development of the Knowledge Broker Group-Myanmar (KBG-M), supported by the Johns Hopkins Bloomberg School of Public Health's Applied Mental Health Research Group (JHU) and Community Partners International (CPI). METHODS: Sixteen stakeholders were interviewed to explore challenges in formulating evidence-informed policy. Two workshops were held: the first to further understand the needs of policy-makers and discuss knowledge-brokering approaches, and the second to co-create the KBG-M structure and process. The KBG-M was then envisioned as an independent body, with former officials of the Ministry of Health and Sports (MoHS) and representatives from the nongovernmental sector actively engaging in the health sector, with an official collaboration with the MoHS. RESULTS: A development task force that served as an advisory committee was established. Then, steps were taken to establish the KBG-M and obtain official recognition from the MoHS. Finally, when the technical agreement with the MoHS was nearly complete, the process stopped because of the military coup on 1 February 2021, and is now on hold indefinitely. CONCLUSIONS: Learning from this process may be helpful for future or current knowledge-brokering efforts, particularly in fragile, conflict-affected settings. Experienced and committed advisory committee members enhanced stakeholder relationships. Responsive coordination mechanisms allowed for adjustments to a changing bureaucratic landscape. Coordination with similar initiatives avoided overlap and identified areas needing technical support. Recommendations to continue the work of the KBG-M itself or similar platforms include the following: increase resilience to contextual changes by ensuring diverse partnerships, maintain advisory committee members experienced and influential in the policy-making process, ensure strong organizational and funding support for effective functioning and sustainability, have budget and timeline flexibility to allow sufficient time and resources for establishment, organize ongoing needs assessments to identify areas needing technical support and to develop responsive corrective approaches, and conduct information sharing and collaboration between stakeholders to ensure alignment.

A randomized-controlled trial of community-based transdiagnostic psychotherapy for veterans and internally displaced persons in Ukraine.

BACKGROUND: There is limited research on community-based mental health interventions in former Soviet countries despite different contextual factors from where most research has been conducted. Ongoing military conflict has resulted in many displaced persons and veterans and their families with high burdens of mental health problems. Lack of community-based services and poor uptake of existing psychiatric services led to the current trial to determine the effectiveness of the common elements treatment approach (CETA) on anxiety, depression, and posttraumatic stress symptoms (PTS) among conflict affected adults in Ukraine. METHODS: We conducted a three-armed randomized-controlled trial of CETA delivered in its standard form (8-12 sessions), a brief form (five-sessions), and a wait-control condition. Eligible participants were displaced adults, army veterans and their adult family members with elevated depression and/or PTS and impaired functioning. Treatment was delivered by community-based providers trained in both standard and brief CETA. Outcome data were collected monthly. RESULTS: There were 302 trial participants (n = 117 brief CETA, n = 129 standard CETA, n = 56 wait-controls). Compared with wait-controls, participants in standard and brief CETA experienced clinically and statistically significant reductions in depression, anxiety, and PTS and dysfunction (effect sizes d = 0.46-1.0-6). Comparing those who received standard CETA with brief CETA, the former reported fewer symptoms and less dysfunction with small-to-medium effect sized (d = 0.20-0.55). CONCLUSIONS: Standard CETA is more effective than brief CETA, but brief CETA also had significant effects compared with wait-controls. Given demonstrated effectiveness, CETA could be scaled up as an effective community-based approach.

Two-year treatment effects of the common elements treatment approach (CETA) for reducing intimate partner violence and unhealthy alcohol use in Zambia.

BACKGROUND: Intimate partner violence (IPV) and unhealthy alcohol use are common yet often unaddressed public health problems in low- and middle-income countries. In a randomized trial, we found that the common elements treatment approach (CETA), a multi-problem, flexible, transdiagnostic intervention, was effective in reducing IPV and unhealthy alcohol use among couples in Zambia at a 12-month post-baseline assessment. In this follow-up study, we investigated whether treatment effects were sustained among CETA participants at 24-months post-baseline. METHODS: Participants were heterosexual couples in Zambia in which the woman reported IPV perpetrated by the male partner and in which the male had hazardous alcohol use. Couples were randomized to CETA or treatment as usual plus safety checks. Measures were the Severity of Violence Against Women Scale (SVAWS) and the Alcohol Use Disorders Identification Test (AUDIT). The trial was stopped early upon recommendation by the trial's DSMB due to CETA's effectiveness following the 12-month assessment. Control participants exited the study and were offered CETA. This brief report presents data from an additional follow-up assessment conducted among original CETA participants at a 24-month visit. RESULTS: There were no meaningful changes in SVAWS or AUDIT scores between 12- and 24-months. The within-group treatment effect for SVAWS from baseline to 24-months was d = 1.37 (p < 0.0001) and AUDIT was d = 0.85 (p < 0.0001). CONCLUSIONS: The lack of change in levels of IPV and unhealthy alcohol use between the 12- and 24-month post-baseline timepoints suggests that treatment gains were sustained among participants who received CETA for at least two years from intervention commencement.

Experiences of mental health and functioning among conflict-affected populations: A qualitative study with military veterans and displaced persons in Ukraine.

Objective: This article reports findings from a qualitative study that sought to identify and describe psychosocial and mental health consequences of conflict among internally displaced persons (IDPs) and military veterans in Ukraine. The study was the first phase of a clinical intervention trial and was designed to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, and guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons. Method: Free-list interviews (FLs), key informant interviews (KIIs), and focus group discussions (FDGs) were conducted with IDPs, military veterans, and providers working with these two groups. A total of 227 respondents were interviewed from two study regions in eastern Ukraine-Zaporizhia and Kharkiv-including 136 IDPs and 91 military veterans. Results: Both IDPs and veterans were described as experiencing high levels of psychological stress symptoms, including depression, isolation, anxiety, and intrusive memories. Although IDPs and veterans were exposed to different traumas, they both identified struggles with social adaptation, including feeling isolated and misunderstood by their communities. Both groups also described relational conflict within and outside the family. Social support mechanisms were considered essential for recovery, and positive social interaction was described as a key example of healthy functioning. Conclusion: Findings suggest a need for community-based programming that facilitates social adaptation, supports social network building, and helps engage conflict-affected people into mental health services. Programs that promote greater awareness, interaction, and understanding among the general public, military veterans, and IDPs are also warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessing trauma and related distress in refugee youth and their caregivers: should we be concerned about iatrogenic effects?

Assessment of potentially traumatic events and related psychological symptoms in refugee youth is common in epidemiological and intervention research. The objective of this study is to characterize reactions to assessments of trauma exposure and psychological symptoms, including traumatic stress, in refugee youth and their caregivers. Eighty-eight Somali youth and their caregivers participated in a screening and baseline interview for a psychological intervention in three refugee camps in Ethiopia. Participants were asked about their levels of distress prior to, immediately after, and approximately two weeks after completing the interview. Other quantitative and qualitative questions inquired about specific reactions to interview questions and procedures. Children and caregivers became increasingly relaxed over the course of the interview, on average. Few children (5.3%) or caregivers (6.5%) who reported being relaxed at the beginning of the interview became upset by the end of the interview. Some children and caregivers reported that certain assessment questions were upsetting and that feeling upset interfered with their activities. Despite some participants reporting persistent negative reactions, most reported liking and benefitting from the interview. While the majority of refugee youth and their caregivers reported positive experiences associated with completing trauma-related assessments, some reported negative reactions. Researchers and practitioners must consider the necessity, risks, and benefits of including questions about potentially traumatic events and related symptoms that are particularly upsetting in screening, survey research, and clinical assessment. When included, it is important that researchers and practitioners monitor negative reactions to these assessments and connect participants who become distressed with appropriate services.

Evidence for suicide prevention strategies with populations in displacement: a systematic review.

Little is known about effective strategies to reduce rates of suicide among refugees and other displaced populations. This review aims to synthesise and assess the evidence base for suicide prevention and response programmes in refugee settings. We conducted a systematic review from peer-reviewed literature databases (five databases) and grey literature sources of literature published prior to November 27, 2017. We identified eight records (six peer-reviewed articles and two grey literature reports) that met our inclusion criteria. None of the eight records provided conclusive evidence of effectiveness. Five records had an unclear level of evidence and three records were potentially promising or promising. Most of the studies reviewed utilised multiple synergistic strategies. The most rigorous study showed the effectiveness of Brief Intervention and Contact and Safety planning. There is limited evidence of the effectiveness of other suicide prevention strategies for these groups. Future studies should attempt to better understand the impact of suicide prevention strategies, and explicitly unpack the individual and synergistic effects of multiple-strategies on suicide-related outcomes. Evidence from this review supports the use of Brief Intervention and Contact type interventions, but more research is needed to replicate findings particularly among populations in displacement.

Impact of setting insecurity on Cognitive Processing Therapy implementation and outcomes in eastern Democratic Republic of the Congo.

Background: While evidence is growing for the efficacy of trauma-focused mental health interventions in low- and middle-income countries, concerns have been raised about whether these types of interventions can be effectively delivered in contexts with ongoing conflict and violence. Cognitive Processing Therapy (CPT) has been shown to be effective in reducing sexual violence survivors' psychological symptoms in eastern Democratic Republic of the Congo (DRC), a region with a history of chronic conflict. Objective: The purpose of the present study is to assess the degree to which exposure to different levels of ongoing insecurity impacts effectiveness of an evidence-based trauma-focused psychotherapy for sexual violence survivors. Method: Participants were 158 female sexual violence survivors receiving CPT in seven communities in South Kivu. Participants completed weekly assessments of their symptoms of PTSD and depression as part of CPT. Degree of site insecurity was categorized as high or low levels of ongoing insecurity based on information collected from supervisors and clinicians. Hierarchical linear modelling was used to examine change over time moderated by level of insecurity at the site. Results: Overall, women reported a significant reduction in psychological symptoms over time (b = -2.04, p <.001). Residing in a site of greater insecurity was associated with higher initial symptoms (b = 5.91, p <.01), but similar improvement over time (b = -0.30, p =.10) compared to women living in relatively more secure sites. High rates of attendance and treatment completion were observed. Conclusions: These results support the effectiveness of trauma-focused therapies when provided in a well-structured and well-supervised program even in contexts of ongoing conflict and violence.

Antecedentes: Mientras que existe evidencia creciente sobre la eficacia de las intervenciones en salud mental enfocadas en trauma en países de escasos y medianos ingresos, existe preocupación sobre si este tipo de intervenciones pueden ser realizadas de manera efectiva en contextos en los que aún existen conflictos y violencia. La Terapia de Procesamiento Cognitivo (CPT, por sus siglas en inglés) ha mostrado ser efectiva en reducir los síntomas psicológicos de sobrevivientes a violencia sexual en la zona oriental de la República Democrática del Congo, una región con una historia de conflicto crónico.Objetivo: El propósito del presente estudio es evaluar el grado en el que la exposición a diferentes niveles de inseguridad en el entorno ejerce un impacto sobre la efectividad de una psicoterapia enfocada en trauma y basada en evidencias para sobrevivientes a violencia sexual.Método: Las participantes fueron 158 sobrevivientes a violencia sexual recibiendo CPT en siete comunidades en Kivu del Sur. Las participantes completaron evaluaciones semanales sobre síntomas de trastorno de estrés postraumático y depresión como parte de la CPT. El grado de inseguridad del entorno fue categorizado en niveles de inseguridad continua altos o bajos según la información proporcionada por supervisores y terapeutas.Resultados: Se empleó un modelo de regresión linear jerárquica para evaluar el cambio en el tiempo modulado por el nivel de inseguridad del entorno. En general, las mujeres reportaron una reducción significativa en los síntomas psicológicos en el tiempo (b = −2.04, p <.001). El vivir en un entorno de mayor inseguridad se asoció a síntomas iniciales más altos (b = 5.91, p <.01) pero a una mejoría similar en el tiempo (b = −0.30, p =.10) comparado con mujeres viviendo en entornos relativamente más seguros.Conclusiones: Estos resultados apoyan la efectividad de las terapias enfocadas en trauma al ser brindadas en programas bien estructurados y bien supervisados incluso en contextos de conflicto y violencia en curso.

Effectiveness of the Common Elements Treatment Approach (CETA) in reducing intimate partner violence and hazardous alcohol use in Zambia (VATU): A randomized controlled trial.

BACKGROUND: Both intimate partner violence (IPV) and alcohol misuse are highly prevalent, and partner alcohol misuse is a significant contributor to women's risk for IPV. There are few evidence-based interventions to address these problems in low- and middle-income countries (LMICs). We evaluated the effectiveness of an evidence-based, multi-problem, flexible, transdiagnostic intervention, the Common Elements Treatment Approach (CETA) in reducing (a) women's experience of IPV and (b) their male partner's alcohol misuse among couples in urban Zambia. METHODS AND FINDINGS: This was a single-blind, parallel-assignment randomized controlled trial in Lusaka, Zambia. Women who reported moderate or higher levels of IPV and their male partners with hazardous alcohol use were enrolled as a couple and randomized to CETA or treatment as usual plus safety checks (TAU-Plus). The primary outcome, IPV, was assessed by the Severity of Violence Against Women Scale (SVAWS) physical/sexual violence subscale, and the secondary outcome, male alcohol misuse, by the Alcohol Use Disorders Identification Test (AUDIT). Assessors were blinded. Analyses were intent-to-treat. Primary outcome assessments were planned at post-treatment, 12 months post-baseline, and 24 months post-baseline. Enrollment was conducted between May 23, 2016, and December 17, 2016. In total, 123 couples were randomized to CETA, 125 to TAU-Plus. The majority of female (66%) and a plurality of male (48%) participants were between 18 and 35 years of age. Mean reduction in IPV (via SVAWS subscale score) at 12 months post-baseline was statistically significantly greater among women who received CETA compared to women who received TAU-Plus (-8.2, 95% CI -14.9 to -1.5, p = 0.02, Cohen's d effect size = 0.49). Similarly, mean reduction in AUDIT score at 12 months post-baseline was statistically significantly greater among men who received CETA compared to men who received TAU (-4.5, 95% CI -6.9 to -2.2, p < 0.001, Cohen's d effect size = 0.43). The Data and Safety Monitoring Board recommended the trial be stopped early due to treatment effectiveness following the 12-month post-baseline assessment, and CETA was offered to control participants. Limitations of the trial included the lack of a true control condition (i.e., that received no intervention), self-reported outcomes that may be subject to social desirability bias, and low statistical power for secondary IPV outcomes. CONCLUSIONS: Results showed that CETA was more effective than TAU-Plus in reducing IPV and hazardous alcohol use among high-risk couples in Zambia. Future research and programming should include tertiary prevention approaches to IPV, such as CETA, rather than offering only community mobilization and primary prevention. TRIAL REGISTRATION: The trial was registered on ClinicalTrials.gov (NCT02790827).

When less is more: reducing redundancy in mental health and psychosocial instruments using Item Response Theory.

BACKGROUND: There is a need for accurate and efficient assessment tools that cover a range of mental health and psychosocial problems. Existing, lengthy self-report assessments may reduce accuracy due to respondent fatigue. Using data from a sample of adults enrolled in a psychotherapy randomized trial in Thailand and a cross-sectional sample of adolescents in Zambia, we leveraged Item Response Theory (IRT) methods to create brief, psychometrically sound, mental health measures. METHODS: We used graded-response models to refine scales by identifying and removing poor performing items that were not well correlated with the underlying trait, and by identifying well-performing items at varying levels of a latent trait to assist in screening or monitoring purposes. RESULTS: In Thailand, the original 17-item depression scale was shortened to seven items and the 30-item Posttraumatic Stress Scale (PTS) was shortened to 10. In Zambia, the Child Posttraumatic Stress Scale (CPSS) was shortened from 17 items to six. Shortened scales in both settings retained the strength of their psychometric properties. When examining longitudinal intervention effects in Thailand, effect sizes were comparable in magnitude for the shortened and standard versions. CONCLUSIONS: Using Item Response Theory (IRT) we created shortened valid measures that can be used to help guide clinical decisions and function as longitudinal research tools. The results of this analysis demonstrate the reliability and validity of shortened scales in each of the two settings and an approach that can be generalized more broadly to help improve screening, monitoring, and evaluation of mental health and psychosocial programs globally.