Innovation summary

In Haiti, a significant gap persists between mental health need and available evidence-based support. After the disastrous earthquake on January 12, 2010, hundreds of thousands lost their lives. Those left in its wake, experienced intensified poverty, weakened governance structures, increased levels of violence and further environmental degradation. Haitians across the country experienced the residual effects of major trauma in the context of an under-resourced mental health system.

Six years later, the gap between mental health needs and accessible resources remains a critical challenge to population health. The number of trained health providers remains relatively low: namely, 27 psychiatrists, 194 psychologists, 3 psychiatric nurses and 1 neurologist serving a population of more than 10 million people1. For many families, this human resource scarcity is often further complicated by barriers related to cost, distance and stigma. Consequently, accessibility to mental health care is extremely limited and many turn to spiritual leaders for healing and support.

To bridge the treatment gap, this project sought to integrate an easy-to-use talk therapy into the spiritual practice of the main informal care providers: spiritual leaders. Cognitive-Behavioural Therapy (CBT) is a well-researched treatment that focuses on changing patterns of thinking and actions that contribute to emotional distress. Over a series of sessions, these procedures have been shown to help reduce symptoms of depression and other mental disorders. This feasibility study analyses the introduction of culturally adapted CBT (CA-CBT) to spiritual leaders from Catholic, Protestant and Vodou communities. The project aimed to develop knowledge and skills in providing therapy for depression, build skills in training others in CA-CBT, and improve access to mental health care for those in need of support in Port-au-Prince. The potential impacts of this research include:

  • Increasing capacity of religious and spiritual leaders to recognize need, make appropriate referrals, and provide care.
  • Providing a culturally validated tool for improving access to effective and affordable community-based mental health care.
  • Transforming the point of mental health care by reducing the divide between local beliefs and modern treatments.
  • Introducing a mental health care model that is holistic, blended and scalable.

Impact summary

As of November 2016:

  • 30 primary spiritual leaders have been trained in CA-CBT methods
  • 18 people with depression have been treated by spiritual leaders
  • 67% of primary spiritual leaders were retained in the intervention and there was a 26% improvement in knowledge post-training with strong retention of knowledge at 4-month follow up
  • The main costs are tied to core personnel and honoraria as well as the adaptation, translation, and printing of key educational materials

        

 

"This project depends greatly on conceptions of the self; the Vodou concept of mind…It’s a different world and it has to be approached with care."  

 

- Ati Max Beauvoir, Chief Supreme of Haitian Vodou 

This innovation is funded by Grand Challenges Canada.

Innovation details

This feasibility study analyses the introduction of culturally adapted cognitive behavioural therapy (CA-CBT) to spiritual leaders from Catholic, Protestant and Vodou communities.  The project aimed to develop knowledge and skills in providing therapy for depression, build skills in training others in CA-CBT, and improve access to mental health care for those in need of support in Port-au-Prince. 

The project consisted of three main phases:

  1. Authenticating and validating CA-CBT materials
  2. Training spiritual leaders as future trainers and as therapists for depression
  3. Observing trainer skills and impact on persons with depression.

 

Key drivers

  • High prevalence of mental health problems found in the community through assessments and through discussion with community partners, indicating a strong need for the intervention
  • High degrees of enthusiasm and willingness to participate from all three spiritual groups (especially the Vodou group)
  • Strong commitment and buy-in from partner groups. Plans underway to incorporate intervention in ongoing activities.

 

Challenges

  • Working within a socio-politically unstable environment, leading to political disruptions, turnovers and delays
  • Aligning project protocol for three very different research groups. Each require tailoring and special considerations
  • Absence of/limited local expertise in cognitive behavior therapy to provide mentorship and supervision for lay therapists
  • Use of largely print-based materials of technical material with population groups that face literacy barriers. 

 

Continuation

The project team is working toward a number of different avenues to ensure the lessons learned from this feasibility study are optimized appropriately. Mainly, the team is currently producing an education film with the support of the Cine Institute, which will effectively transform the CA-CBT manual and minimize accessibility barriers. The plan is to create a culturally relevant film guided by CBT competencies to provide a resource for Vodou leaders on evidence-based mental health therapy. The educational script will be inspired by anecdotes collected through field research with 25 Vodou leaders regarding help seeking behavior, consultation rituals/norms, and healing practices to ensure that the storyline remains true to the Vodou reality. The goal is to equip the Vodou community with the proper knowledge and skills so that they can sustain this blended therapy beyond the project’s timeline. Specifically, the objectives of this educational film are to:

  • Raise public awareness of mental health issues by creating an engaging storyline based on the Vodou and Haitian reality.
  • Improve access to mental health information by sharing the educational film with Vodou temples in Haiti.
  • Provide a resource for ongoing knowledge and skills-building in mental health care within Vodou communities through continuous learning, mentorship and support.

This film is expected to be completed by early 2017 and shared through existing Vodou networks and partners.

Other opportunities to scale the project to a larger population will also be explored.

 

Partners

Funder

Evaluation methods

This research project is a mixed-methods feasibility study that aimed to test the intervention process. It sought to determine whether the intervention could be appropriately adapted and implemented in the local Haitian context. This approach was adopted because of the inherent difficulty in evaluating the effectiveness of cognitive behaviour therapy without a control group. A controlled trial was also deemed premature given the many unknowns. The findings enabled the team to assess preliminary trends and potential impact of the intervention on outcomes which can be used to better estimate effect sizes for future research.

This design followed a developmental evaluation approach. It relied on rapid, real time problem solving to make iterative changes to our social innovations and was particularly useful for the complex socio-political environment we encountered2. As the primary aim of this study was to understand the process, and the receptivity to the intervention, an evaluation plan was structured around a conceptual framework for implementation research outcomes3.

Qualitative data

  • CBT session recording transcripts
  • Train-the-trainer observation
  • Interviews & focus groups

Quantitative data

  • 10-item knowledge test (pre, post and 4 month follow up)
  • Self-report of symptoms & CES-D score (pre, post)
  • Training satisfaction survey

 

Cost of implementation

The main costs associated with the project are tied to core personnel and honoraria as well as the adaptation, translation and printing of key educational materials. 

 

Impact details

Early findings from this feasibility study indicate promising viability of harnessing spiritual leaders as therapists to fill the mental health treatment gap in Haiti. All three research groups demonstrate significant improvement in knowledge related to mental health and CA-CBT, comparable trainer skills, and strong degrees of satisfaction with the therapeutic material presented.

By the numbers:

  • 50 key informants for cultural adaptation of cognitive behaviour therapy (CBT)
  • 30 spiritual leaders trained and enrolled
  • 31 new spiritual leaders trained by main spiritual leaders
  • 18 persons with depression treated in at least one CBT session
  • 125 CBT sessions delivered (in total)
  • 6.9 average number of CBT sessions completed in therapy

Knowledge

After an analysis of the reliability of the knowledge test, the 10 item version was found to be good and for the 5 items is reasonable. KR20 coefficient was calculated, which is the Cronbach Alpha coefficient for binary scales, for both the 10 and the 5 items scales. The total for 10-items = 0.73 and for 5-items = 0.59.

Knowledge scores indicate high improvement pre/post and strong retention for all groups, and in both phases. In general there is a time effect caused by the fact that the knowledge is higher at post as compared to baseline. A significant improvement was found in knowledge scores across all three spiritual groups from baseline (64% correct) to post-training assessment (90% correct) with strong retention at 4-month follow up (87% correct). Though Catholic and Protestant groups received significantly higher overall scores than the Vodou group, the Vodou group showed greatest improvement in score of 42% between baseline and post-training assessment as compared to Catholic and Protestant groups (20% and 16%, respectively).

Satisfaction

Exceptionally strong levels of satisfaction from the participants at the 5-day training led by mental health professionals. Among the 41 spiritual leaders and 11 stakeholders participating in the 5-day training, 71% (n=37) reported overall satisfaction as “Excellent”,  98% (n=51) agreed that the training met expectations, and 96% (n=50) agreed that they would be able to apply the lessons learned in practice.

Treatment

Of 37 community members referred by spiritual leaders for depression screening, 26 were deemed eligible to participate (70.3%) and 18 of those eligible proceeded with treatment sessions. For the total 18 persons, 125 therapy sessions were completed in each spiritual group (Catholic: 38; Protestants: 66; Vodou: 21). There were a total of 6 persons that completed the suggested 12 session treatment period and an additional 5 persons that completed at least 6 sessions.

 

References

  1. Raviola, G., Severe, J., Therosme, T., Oswald, C., Belkin, G., & Eustache, F. E. (2013). The 2010 Haiti earthquake response. Psychiatric Clinics of North America, 36(3), 431-450.
  2. Patton, M. Q. (2011). Developmental evaluation: Applying complexity concepts to enhance innovation and use. Guilford Press.
  3. Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., ... & Hensley, M. (2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76.

Research

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Country

Haiti

Affiliated organizations

Centre for Addiction and Mental Health (CAMH)

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