Transforming Access to Evidence-Based Trauma Interventions in Low and Middle Income Contexts

Transforming Access to Evidence-Based Trauma Interventions in Low and Middle Income Contexts

Srishti Sardana, Anushka R. Patel, Debra Kaminer, Duane D. Booysen, Kate Ellis, Christian H. Kristensen, & Katy Robjant

May 20, 2024

Overview

Low and middle-income countries (LMICs) bear a disproportionate burden of traumatic events due to various factors including armed conflict, natural disasters, and socioeconomic disparities (Koenen et al., 2017; Patel et al., 2018). For example, refugees and asylum seekers from LMICs experience high rates of trauma exposure, with prevalence estimates ranging from 30% to 40% (Steel et al., 2009). Similarly, there is an elevated risk of trauma exposure among internally displaced populations in conflict-affected regions, where violence and loss of livelihoods is pervasive (Roberts et al., 2011). In these contexts, rates of mental health difficulties such as PTSD and depression are high, with an estimated aggregate prevalence of 29% and 24% repsectively (Lim et al., 2022). These mental health challenges not only inflict significant personal suffering but also impede economic development and social progress in LMICs (Patel et al., 2018). This underscores the urgent need for comprehensive mental health care services tailored to the specific needs of vulnerable populations in low resource settings. Addressing trauma-related mental health difficulties in LMICs aligns with several sustainable development goals (SDGs) proposed by the United Nations, including Goal 3 (Good Health and Well-Being) and Goal 10 (Reduced Inequities), by promoting mental health equity and ensuring access to quality mental health services for all (United Nations, 2015). 

Challenges to Accessing Evidence-Based Trauma Treatments

The delivery of proper care for trauma-related mental health difficulties in LMIC settings presents intricate challenges. Structural barriers such as limited financial resources, healthcare infrastructure deficits, and a scarcity of trained mental health professionals often impede the provision of comprehensive trauma interventions (World Health Organization, 2019). Moreover, several attitudinal barriers significantly deter trauma survivors from seeking help. These include stigma, low perceived need for treatment, and low confidence in the effectiveness of treatment (Thornicroft et al., 2018). Due to the accumulation of structural and attitudinal treatment barriers, the majority of trauma-affected adults in LMICs do not access treatment at all. Of those that do, only a minority receive appropriate or adequate treatment. In contrast to the 41% of trauma-affect individuals in high-income countries who access appropriate or effective mental health treatment, a meagre 5% can access or afford the same in LMICs (Stein et al., 2023). These challenges necessitate innovative and culturally sensitive approaches to improving access to effective treatments (Patel, 2018). 

Innovative Interventions to Improve Trauma Treatment Access

To address these challenges, community-based interventions have emerged as promising strategies, leveraging existing social structures and community health workers to extend the reach of mental health services (Kohrt et al., 2018). For example, integrating trauma-informed care into primary healthcare settings has shown the potential to enhance the accessibility and acceptability of interventions among underserved populations (Bass et al., 2019). Research trials show that task-sharing models, hwere non-specialist providers such as primary health care nurses or community-based lay counsellors are trained in evidence-based trauma treatments, offer a pragmatic approach to briding the treatment gap in resource-constrained contexts (Murray et al., 2014). However, the long-term sustainability of task-shared initiatives post-research is an ongoing concern. Additionally, technology-driven solutions, such as telemedicine and mobile applications, have demonstrated effectiveness in delivering psychoeducation, self-help interventions, and remote counseling to marginalized communities (Naslund et al., 2020) and show promise for treating PTSD in LMICs (Bröcker et al., 2022; Miller Graff et al., 2021). There is growing evidence that technology-driven solutions may be effective in overcoming attitudinal barriers such as stigma, as well as structural access barriers. Remote interventions also allow for the training of non-specialists in remote or rural areas, making possible the scaling up and accessibilty of interventions at considerably reduced costs when compared to in-person interventions (Naslund et al., 2019; Munoz 2022; Ellis et al., 2022). Finally, treating comorbid mental and behavioral health difficulties among trauma survivors using multiproblem (i.e., transdiagnostic) interventions can be both effective and cost-efficacious in LMICs (Bolton et al., 2014; Murray et al., 2014). However, task-shared, digital, and transdiagnostic trauma interventions must be carefully adapted for specific cultural settings to enhance their acceptability and effectiveness (Benish et al., 2011; Hinton & Patel, 2017). Close collaboration with local stakeholders is needed and involving survivors with lived experience of traumatic stress - which is rarely done - can guide this process (Ennis, 2020). 

Future Directions

Political will and recognition that adequate treatment funding will yield social and economic benefits remain imperative for establishing sustainable mental health care systems in low-resource settings (Patel, 2018). Research should focus on finding sustainable models for the large-scale implementation of task-shared, culturally adapted, digital, and multiproblem interventions for trauma-affected populations in LMICs. This should include comparisons of interventions delivered by both specialists and non-specialists and evaluation of different delivery models and large-scale psychoeducation and treatment awareness programs. 

Discussion Questions

1. What are the comparative advantages and disadvantages of using specialist versus non-specialist providers to deliver trauma interventions in LMICs?
2. Is there potential for digital trauma interventions to be delivered on a large scale in LMICs?
3. How and why could multiproblem (transdiagnostic) interventions be beneficial in LMICs?
4. Why are cultural adaptation processes necessary to deliver evidence-based trauma interventions in LMICs?

About the Authors

Dr. Srishti Sardana, MSc., Ph.D., is a T32 postdoctoral fellow in the Department of Mental Health at Johns Hopkins University, Adjunct Assistant Professor at Columbia University, and a forthcoming Assistant Professor and Founder and Director of the Translational Global Mental Health Lab at University of Wisconsin. Queries and comments for this blog post can be directed to Dr. Sardana at ssardan1@jh.edu.

Dr. Anushka R. Patel, Ph.D., is a trauma-focused clinical psychologist at the Harvard Chan School of Public Health in the United States. She specializes in treating gender-based violence survivors, with a focus on cultural adaptation in assessment and treatment. 

Dr. Debra Kaminer, Ph.D., is a clinical psychologist and Associate Professor in the Department of Psychology at the University of Cape Town, South Africa. She is an Associate Editor for the European Journal of Psychotraumatology and a member of the ISTSS Public Health and Policy Committee.

Dr. Duane D. Booysen, Ph.D., is a clinical psychologist and senior lecturer in the Department of Psychology at Rhodes University in South Africa. He is a Y-2 National Research Foundation-rated researcher and a visiting scholar at Emory University in Atlanta, GA USA. 

Dr. Kate Ellis, Ph.D., is an Associate Professor and clinical psychologist in the Department of Psychology at the American University in Cairo, Egypt and the Director of Leadership in Mental Health Course, Eastern Mediterranean Region. She specializes in treating survivors of political and community violence, with a focus on cultural adaptation and appropriateness. 

Dr. Christian H. Kristensen, Ph.D., is a Professor of Psychology in the Graduate Program of Psychology a tthe Pontifical Catholic University of Rio Grande do Sul (PUCRS), Brazil, and Diretor of the Center for Studies and Research in Traumatic Stress (NEPTE-PUCRS). He has served on the Board of Directors of the ISTSS since 2019. 

Dr. Katy Robjant, Ph.D., is a consultant clinical psychologist specializing in the treatment of PTDS and other trauma-related disorders in asylum seekers, refugees, and victims of trafficking. She is the Narrative Exposure Therapy lead at Trauma Treatment International and Director of National Clinic Services at Freedom from Torture. 

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Read the full briefing paper on improving access to evidence-based trauma interventions for low- and middle-income countries here in JOTS:

Kaminer D, Booysen D, Ellis K, Kristensen CH, Patel AR, Robjant K, Sardana S. Improving access to evidence-based interventions for trauma-exposed adults in low- and middle-income countries. J Trauma Stress. 2024 Mar 8. doi: 10.1002/jts.23031. Epub ahead of print. PMID: 38459223.