New York State Psychiatric Institute, Columbia University, Department of Psychiatry, New York, NY, 10032, USA; Duke Global Health Institute, Durham, NC, USA.
Duke Global Health Institute, Durham, NC, USA; Department of Psychiatry Duke University School of Medicine, Durham, NC, USA.
Behav Res Ther. 2022 Dec;159:104219. doi: 10.1016/j.brat.2022.104219. Epub 2022 Oct 19.
To increase cultural relevance and maximize access for historically underserved populations, there is a need to explore mechanisms underlying treatment outcomes during piloting. We developed a mixed-method approach, Integrated Clinical and Implementation Mapping (ICIM), to explore clinical and implementation mechanisms to inform improvements in content and delivery. We applied ICIM in a pilot of Tuko Pamoja, a lay counselor-delivered family intervention in Kenya (10 families with adolescents ages 12-17). ICIM is a 3-phase process to triangulate data sources to analyze how and why change occurs within individual cases and across cases. We synthesized data from session and supervision transcripts, fidelity and clinical skills ratings, surveys, and interviews. Outputs included a comprehensive narrative and visual map depicting how content and implementation factors influenced change. For Tuko Pamoja, ICIM results showed common presenting problems, including financial strain and caregivers' distress, triggering negative interactions and adolescent distress. ICIM demonstrated that active treatment ingredients included communication skills and facilitated, prescribed time together. Families improved communication, empathy, and hope, facilitated improved family functioning and mental health. Key implementation mechanisms included provider clinical competencies, alliance-building, treatment-aligned adaptations, and consistent attendance. Results guided manual and training refinements and generated hypotheses about mechanisms to test in larger trials.
为了提高文化相关性并最大限度地为历史上服务不足的人群提供服务，有必要探索试点过程中治疗结果的背后机制。我们开发了一种混合方法，即综合临床和实施映射（ICIM），以探索临床和实施机制，为内容和交付的改进提供信息。我们在肯尼亚（10 个有 12-17 岁青少年的家庭）的 Tuko Pamoja （由非专业辅导员提供的家庭干预）试点中应用了 ICIM。ICIM 是一个 3 阶段的过程，旨在对数据源进行三角剖分，以分析个体案例和案例之间的变化是如何以及为何发生的。我们综合了来自会议和监督记录、保真度和临床技能评分、调查和访谈的数据。产出包括一个全面的叙述和可视化地图，描述了内容和实施因素如何影响变化。对于 Tuko Pamoja，ICIM 结果显示了常见的问题，包括经济压力和照顾者的痛苦，这引发了负面的互动和青少年的痛苦。ICIM 表明，积极的治疗成分包括沟通技巧和促进、规定的相处时间。家庭改善了沟通、同理心和希望，促进了家庭功能和心理健康的改善。关键的实施机制包括提供者的临床能力、联盟建设、与治疗一致的适应性调整以及一致的出勤率。结果指导了手册和培训的改进，并产生了关于在更大规模试验中测试机制的假设。
