Integrating a trauma-informed psychological intervention for PTSD among PLWH on the Friendship Bench in Zimbabwe : a mixed methods formative study

Verhey, Ruth (2018-12)

Thesis (PhD)--Stellenbosch University, 2018.

Thesis

ENGLISH SUMMARY : Introduction: Posttraumatic Stress Disorder (PTSD) and other Common Mental Disorders (CMD), such as depression and anxiety disorders, are highly prevalent in people living with HIV (PLWH). In Zimbabwe, an effective and culturally acceptable task-shifted psychological intervention for CMD, the Friendship Bench (FB), is offered in primary health care facilities (PHC). We found high levels of PTSD comorbidity among FB beneficiaries with CMD in preliminary studies and therefore sought to enhance the existing program by including a trauma-informed care component. Finding a strategy for such an inclusion has been the focus of this PhD thesis. Method: Formative work included a systematic literature review that was carried out first to establish knowledge about existing programs addressing PTSD in PLWH. Secondly, a qualitative study to explore the counseling experiences of clients and counselors with regards to PTSD-symptomatology was undertaken. It used a thematic content approach to analysing semi-structured interviews with beneficiaries (n=10) and lay health workers (LHWs) (n=5) that were conducted with an interview guide. Thirdly, the PTSD Checklist (PCL-5) was validated against the Clinician-Administered PTSD Scale (CAPS-5). Finally, we established prevalence and factors associated with PTSD in PHC clients (n=204) and LHWs (=183) through a cross-sectional study. Results: There is a dearth of evidence-based interventions in low- and middle-income countries (LMIC) with identified interventions being from high-income countries (HIC). The qualitative study identified the term kufungisisa kwenjodzi (excessive thinking due to trauma) as the local equivalent for PTSD/HIV-related PTSD. Traumatic events were defined as circumscribed incidents and ongoing pervasive experiences while LHWs recognized PTSD Symptoms. Clients described receiving psychological support as helpful. The PCL-5 cut-off of ≥33 yielded a sensitivity and specificity of 74.5% (95%CI: 60.4-85.7) and 70.6% (95%CI: 62.7-77.7), respectively, and good internal consistency (Cronbach’s alpha = 0.92). The prevalence of PTSD amongst PHC clients, of whom 91 (44.6%) were HIV-positive, using the PCL-5, was 40.7% (n=83), and of those 69.5% (n=57) had comorbid CMD as measured with the Shona Symptom Questionnaire (SSQ14>=9) (OR 6.48 (95%CI [3.35-12.54]). Results showed that PTSD was associated with recent negative life events (past six months) (OR 3.73 95%CI [1.49-9.34]) and chronic illness (OR 2.07 95%CI [1.15-3.72]). Amongst the FB counselors (n=182), the survey found a low prevalence of PTSD of 6% (n=11) and of CMD of 11% (n=17). Discussion: To our knowledge there are no task-shifted PTSD approaches for PLWH in LMICs. PTSD symptomatology and its conceptualization can be defined using cultural idioms of distress. The high prevalence of HIV-related PTSD and comorbidity with other CMD emphasizes the need for a trauma-informed intervention. Furthermore, the low rates of PTSD and CMD among LHWs suggests that it is feasible to train them to deliver trauma-informed care. This thesis recommends a trauma-informed approach that includes basic screening for trauma exposure, followed by questions about the main symptom clusters with incorporation of emotional regulation skills. It concludes with an algorithm for a trauma-informed FB component to address the needs of those suffering from PTSD and CMD and makes recommendations for future research.

AFRIKAANSE OPSOMMING : Inleiding: Posttraumatiese stresversteuring (PTSV) en ander Algemene Geestesversteurings (AGV) soos depressie en angsversteurings, is hoogs algemeen in mense wat met MIV leef (MMML). In Zimbabwe word ’n effektiewe en kultureel-aanvaarbare taakverskuifde sielkundige ingryping vir AGV, die sogenaamde Friendship Bench (FB), in primêregesondheidsorg (PGS)-fasiliteite aangebied. Ons het hoë vlakke van PTSV-medemorbiditeit onder FB-begunstigdes met AGV in voorlopige studies gevind en daarom probeer om die bestaande program te verbeter deur ’n trauma-ingeligte sorgkomponent in te sluit. Om ’n strategie vir só ’n insluiting te vind, het die fokus van hierdie PhD-proefskrif gevorm. Metodes: Die formatiewe werk sluit in ’n sistematiese literatuuroorsig wat eerste gedoen is ten einde kennis daar te stel oor bestaande programme wat PTSV in MMML aanspreek. Tweedens is ’n kwalitatiewe studie onderneem om die beradingservarings van kliënte en beraders ten opsigte van die PTSV-simptomatologie te ondersoek. Dit het ’n tematieseinhoud-benadering gebruik vir die ontleding van semi-gestruktureerde onderhoude wat aan die hand van ’n onderhoudsgids met begunstigdes (n=10) en lekegesondheidswerkers (LGW) (N=5) gevoer is. Derdens is die PTSV-kontrolelys (PKL-5) teenoor die Klinies-geadministreerde PTSD-skaal (KAPS-5) bekragtig. Ten slotte het ons die voorkoms en faktore geassosieer met PTSV in PGS-kliënte (n=204) en LGW’s (n=83) deur middel van ’n dwarssnitstudie bepaal. Resultate: Daar is ’n gebrek aan bewys-gebaseerde intervensies in lae- en middelinkomstelande (LMIL) met geïdentifiseerde intervensies slegs uit hoë-inkomstelande (HIL). Die kwalitatiewe studie het die term kufungisisa kwenjodzi (oormatige denke weens trauma) geïdentifiseer as die plaaslike ekwivalent vir PTSV-/MIV-verwante PTSD. Traumatiese gebeure is omskryf as beperkende insidente en volgehoue omvattende ervarings namate LGW’s die PTSV-simptome herken het. Kliënte het die ontvangs van sielkundige steun as nuttig beskryf. Die PKL-5-afsnypunt van ≥33 het ’n sensitiwiteit en spesifisiteit van onderskeidelik 74,5% (95% vertroubaarheidsinterval [VI]: 60,4-85,7) en 70,6% (95% VI: 62,7-77,7) opgelewer, asook goeie interne konsekwentheid (Cronbach se alfa=0.92). Die voorkoms van PTSV onder PGS-kliënte, waarvan 91 (44,6%) MIV-positief was, met die gebruik van die PKL-5 was 40,7% (n=83), en daarvan het 69,5% (n=57) medemorbiede AGV gehad, gemeet met die Shona-simptoomvraelys (SSV14>=9) (OF 6.48 (95% VI [3.35-12.54]). Resultate het getoon dat PTSV verband hou met onlangse negatiewe lewensgebeure (afgelope ses maande) (OF 3.73 95% VI [1,49- 9.34] en chroniese siekte (OF 2.07 95% VI [1.15-3.72]). Onder die FB-beraders (n=182) het die opname ’n lae voorkoms van PTSV, naamlik 6% (n=11) en van AGV, naamlik 11% (n=17) gevind. Bespreking: Sover ons kennis strek, is daar geen taakverskuifde PTSV-benaderings vir MMML in LMIL’e nie. PTSD-simptomatologie en die konseptualisering daarvan kan omskryf word deur kulturele idiome van nood te gebruik. Die hoë voorkoms van MIV-verwante PTSV en medemorbiditeit met ander AGV beklemtoon die behoefte aan ’n trauma-ingeligte intervensie. Verder dui die lae syfers van PTSV en AGV onder LGW’s dat dit haalbaar is om hulle op te lei om trauma-ingeligte sorg te lewer. Hierdie proefskrif beveel ’n trauma-ingeligte benadering aan wat basiese sifting vir trauma-blootstelling insluit, gevolg deur vrae oor die hoofsimptoomgroepe met die insluiting van emosioneleregulering-vaardighede. Dit sluit af met ’n algoritme vir ’n trauma-ingeligte FB-komponent om die behoeftes van diegene wat aan PTSV en AGV ly aan te spreek en voorsien aanbevelings wat toekomstige navorsing betref.

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