Developing the intervention
Developing this intervention involved the review of pre-existing group counselling conducted in the PCAF trauma clinics1 and conducting focus group discussions with community members to identify community perceptions of depression, local strategies used to deal with depression, community experiences with group interventions and opinions on what would be the most culturally acceptable components of a group support psychotherapy intervention to alleviate depression symptoms among HIV affected adults. Based on the findings from these two activities, a manual for implementing the 8-week group support psychotherapeutic intervention was developed by the investigating team. Details of the development process and structure of the intervention are available elsewhere.2
Briefly, the first session addressed issues relevant for rapport and psychological education on the group process, techniques, ground rules and expectations. In the second session, participants were educated about triggers, symptoms, complications, and treatment options for depression. The relationship between depression and HIV/AIDS was also discussed. Participants were given the opportunity to share and externalize any problem that they may have in sessions 3 and 4. Given the high burden of war-related trauma among participants, sharing trauma stories was encouraged. In session 5, participants were taught positive coping skills, in particular skills to manage depressive thinking and excessive worries. Problem solving skills and skills for coping with stigma and discrimination were taught in session 6. Given that poverty is a known risk factor for depression, the last two sessions were dedicated to training participants in basic livelihood skills.
These final two sessions focus on helping group members acquire basic livelihood skills that will enable them to identify income generating activities that will improve their livelihoods, thus enabling them to take control of their lives. The group facilitators lead a discussion about the kind of life the group members want to live after their group sessions and what they can do together or in smaller groups in the future. The group facilitator encourages them to think and plan more towards a different future shaped by them. The group facilitator helps them make decisions on the possible viable enterprises-- the smallest ones they can manage as they begin, which can enhance their sense of control and success. Examples include: forming a group which cleans school compounds and charges fees for this service; forming a group that collects rubbish and disposes it in a safe place and charge fees for this; forming a group which grows and sells a crop e.g maize, fruits, etc.
The intervention was delivered in a group format over 8 weeks with intervention sessions lasting 2-3 hours each. The groups were gender specific and problem specific. Intervention facilitators were mental health workers with diploma level and degree training in psychiatric nursing, social work, counselling and clinical psychiatry. They were of the same gender as the participants and delivered the intervention materials following a scripted intervention manual. Apart from sessions 3 and 4, all other sessions were followed by homework activities designed to get participants to practice new skills between sessions, with feedback and discussions at the next session.
Facilitator training and quality assurance
Intervention facilitators at both sites received a manual containing the intervention content and guidelines for conducting the intervention sessions. To ensure consistent interpretation of the manual, all facilitators participated in a seven-day training workshop at the Kitgum PCAF trauma clinic. Training included pre-tests and post-tests, classroom work utilizing frequent role plays and feedback. ideo recordings of each training session were provided to facilitators which they reviewed prior to onset of each intervention session. One of the investigators (J.O.) had monthly supervision with facilitators to address issues arising from the on-going intervention sessions.
Participant evaluation of the interventions
At the end of the 8 sessions, participants were asked to rate the intervention on 5 items that assessed perceived effects of the intervention, how they liked the group leaders, and their overall impression of the intervention. These items were adapted from items used to evaluate previous interventions.9 Items were rated on a five-point Likert-type scale (from strongly agree = 1 to strongly disagree = 4).