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. 2024 Jun 4;37(6):1021–1027. doi: 10.1002/jts.23062

Trauma‐informed systems change training has transcultural, transcontinental transformative healing power: An analysis of leaders in the United States and Angola, Africa

Daniel Capuia 1, Maria da Cruz 1, Ana Masseca 1, Engracia Marques 1, Paulo Leite 1, Alexandra R Mangus 2, E Kate Webb 2,3, Caitlin Ravichandran 2,4,5, Kerry J Ressler 2,3, Alisha Moreland‐Capuia 2,3,✉
PMCID: PMC11615150  NIHMSID: NIHMS1997579  PMID: 38837449

Abstract

The Institute for Trauma‐Informed Systems Change (ITISC) facilitated a 2‐day, 12‐hr trauma‐informed workshop, delivered virtually, using the Training for Change curriculum. The workshop took place in Portuguese in September 2021 with a group of Angolan leaders (N = 51) and in May 2022, in English, with neonatal intensive care unit (NICU) workers from the United States (N = 73). Surveys were administered before (Time [T] 0) and after the workshop (T1) and consisted of demographic questions and the Survey for Trauma‐Informed Systems Change (STISC), which assesses system‐wide knowledge and attitudes about trauma‐informed systems change and the intersection of culture, safety, and acceptance in the workplace. At T1, 18 (35.3%) participants in the Angolan leaders’ group and 46 (63.0%) in the NICU group completed the surveys. Mean scores on the STISC Self‐Assessed Knowledge and Attitudes subscale and STISC System‐Wide Knowledge and Attitudes subscale increased significantly in both groups after the training. Effect sizes were large for self‐assessed knowledge and attitudes, Angolan leaders: d = 1.11, NICU: d = 1.97, and small‐to‐medium for system‐wide knowledge and attitudes, Angolan leaders: d = 0.52, NICU: d = 0.38. Limitations include the relatively small sample size and low participation rates for survey responses. Future research should examine the efficacy of the curriculum in larger samples that include individuals from diverse professions and additional countries. Together, the findings provide initial support that this training can be directly translated and implemented on a global scale.

Exposure to trauma is globally common and can lead to serious mental and physical consequences. An analysis of survey data from over 68,000 individuals in 24 countries indicated that nearly 75% of respondents experienced at least one lifetime traumatic event (Kessler et al., 2017). Studies suggest that support and interventions for trauma‐exposed individuals can help prevent the development of adverse posttrauma outcomes, such as posttraumatic stress disorder (PTSD; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). With these findings in mind, researchers in multiple fields have sought to become “trauma‐informed” and gain trauma‐informed knowledge through training and consideration of how best to support trauma survivors and understand how current policies and practices may impact trauma survivors (DeAndrade et al., 2020; H.B. 4002, 2016; Purtle, 2020; SAMHSA, 2014). Historically, most trauma‐informed trainings have been conducted in high‐income countries and are often focused on a single profession, namely health care. Given the incredible burden of trauma on the global population, it is necessary to engage in trauma‐informed change across systems (e.g., health care, government) and cultures (SAMHSA, 2014).

Secondary trauma exposure in the workplace has been well‐studied in neonatal intensive care unit (NICU) nurses, with 50% reporting moderate‐to‐severe secondary traumatic stress (Beck et al., 2017). Studies in the NICU highlight the significant trauma burden of patients and the important need for the application of trauma‐informed practices and approaches when caring for them (Evans & Porter, 2009; Sanders & Hall, 2018). Health care settings like the NICU are not the only settings that may benefit from trauma‐informed training. Given the widespread, global nature of trauma, a trauma‐informed approach may be widely beneficial across cultures and professions (Kessler et al., 2017).

Trauma‐informed approaches in countries with a disproportionate trauma burden may help ensure multilevel intervention and healing. In specific, several studies have demonstrated the impact of war‐inflicted trauma on the mental health of individuals, families, communities, and society in sub‐Saharan Africa (Musisi, 2004; Neugebauer, 1996). Civil war and colonialism have been shown to contribute to generational and transgenerational trauma (Danieli, 2007). The long‐term consequences of trauma can be further perpetuated through a lack of resources, disparate access to trauma care, suboptimal health and education infrastructure, and a limited ability of individuals to be economically upwardly mobile (Alayande et al, 2022; Moreland‐Capuia, 2021).

In Angola, where approximately 50% of the country's 35,000,000 residents are under 21 years of age, research indicates that up to 90% of adolescents meet the criteria for PTSD (Wessells & Monteiro, 2004). African scholars like Musisi (2004) have written eloquently about Africa's “general lack of public awareness of mass trauma and its geopolitical impact” (p. 81) in describing the need for trauma‐informed approaches in African countries affected by war, especially at the government level. Therefore, culturally competent trauma‐informed trainings for Angolan leaders may offer an opportunity to discuss the long‐lasting effects of trauma and support Angola's journey to deserved healing (Moreland‐Capuia, 2021).

Although there are several effective trauma‐informed training, education, and practice initiatives in the United States and the United Kingdom (Beck et al., 2017; D'Andrea et al., 2013; Purtle, 2020; Raja et al., 2015), these opportunities have not been readily available to individuals from African countries (Baker et al., 2016; Bassuk et al., 2017; Sinko et al., 2022). Therefore, in the present study, we evaluated the cross‐cultural and cross‐discipline efficacy of an established trauma‐informed systems change workshop using the Training for Change curriculum (Moreland‐Capuia, 2021). We examined changes in trauma‐informed knowledge, attitudes, and policies in two unique groups: NICU nurses based in the Pacific Northwest region of the United States and Angolan government officials. We hypothesized that despite differences in professions, geography, trauma exposure, and cultural backgrounds, both groups would show similar increases in attitudes and knowledge surrounding trauma‐informed practices and policies.

METHOD

Participants and procedure

Training

Between July 2021 and May 2022, the Institute for Trauma‐informed Systems Change (ITISC) at McLean Hospital in Boston facilitated monthly 2‐day, 12‐hr trauma‐informed workshop training sessions for 598 participants online via Zoom. During this period, 2 months were reserved for workshops with Angolan government officials (N = 51), delivered in English with Portuguese translators (September 2021), and NICU nurses in the Pacific Northwest region of the United States (N = 73; May 2022). All workshops were based on the Training for Change curriculum, which included presentations on the following topics: the neurobiological impacts of fear and trauma, trauma and racism, and trauma within systems. The training had multiple expert lecturers (e.g., neuroscientists who study the effects of trauma, psychologists with a specialization in trauma‐informed treatments and approaches).

Evaluation study

Surveys were delivered to all 598 participants electronically via RedCap before the workshop (Time [T] 0) and after completing the workshop (T1). These surveys consisted of demographic questions as well as the validated Survey for Trauma‐Informed Systems Change (STISC; Moreland‐Capuia et al., 2023). As described in previous work (Mangus et al., 2023; Moreland‐Capuia et al., 2023), the pretraining survey (i.e., T0) was sent to participants’ e‐mail addresses 24 hr before the training and expired before the first content‐based lecture began. The posttraining survey (i.e., T1) was sent to participants directly after the training and expired 48 hr after both days concluded. Study procedures were approved by the Mass General Brigham Institutional Review Board (IRB2021P002889). All participants provided informed consent.

Participant characteristics

Survey completion rates and characteristics for the full sample of 598 training participants have been reported previously (Mangus et al., 2023). As noted, the present analysis focused on two groups: Angolan leaders and NICU nurses. Of the 51 total individuals who participated in the Angolan leadership group, 24 (47.1%) completed the T0 survey, and 18 (35.3%) completed the T1 survey. Of the 73 individuals who participated in the NICU group, 63 (86.3%) completed the T0 survey, and 46 (63.0%) completed the T1 survey. The mean age for participants who completed the T0 survey was 41.30 years (SD = 12.53) in the Angolan leadership group and 37.81 years (SD = 10.08) years in the NICU group. The mean age for T1 completers was 40.22 years (SD = 12.61) for the Angolan leadership group and 36.87 years (SD = 9.06) years for the NICU group. Additional demographic characteristics for both groups are provided in Table 1.

TABLE 1.

Demographic characteristics for participants with complete pretraining (Time [T] 0) and posttraining (T1) survey data, by training group

Angolan leadership NICU workers
(N = 51) (N = 73)
T0 T1 T0 T1
(n = 24) (n = 18) (n = 63) (n = 46)
Variable n % n % n % n %
Gender
Woman 10 41.7 8 44.4 60 95.2 43 93.5
Man 14 58.3 10 55.6 2 3.2 2 4.3
Nonbinary 0 0.0 0 0.0 1 1.6 1 2.2
Educational attainment
Some college or associate's degree 3 12.5 3 16.7 1 1.6 0 0.0
Bachelor's degree 3 12.5 2 11.1 37 58.7 31 67.4
Master's degree 9 37.5 6 33.3 8 12.7 5 10.9
Professional or doctoral degree 9 37.5 7 38.9 17 27.0 10 21.7
Race/ethnicity
White 1 4.2 0 0.0 53 84.1 39 84.8
Black or African American 23 95.8 18 100.0 5 7.9 2 4.3
American Indian or Alaskan Native 0 0.0 0 0.0 1 1.6 0 0.0
Hispanic or Latinx 0 0.0 0 0.0 6 9.5 5 10.9
Asian 0 0.0 0 0.0 6 9.5 5 10.9
Hawaiian/other Pacific Islander 0 0.0 0 0.0 1 1.6 1 2.2
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Measures

The STISC was administered at T0 and T1. The purpose of the questionnaire is to evaluate trauma‐informed systems change across multiple systems as opposed to measuring trauma‐informed change in a single profession or field. The 59‐item scale includes five subscales: Self‐Assessed Knowledge and Attitudes (23 items, score range: 23–115), Safety and Acceptance at Work (seven items, score range: 7–35), System‐Wide Knowledge and Attitudes (six items, score range: 6–30), Training and Employee Support (20 items, score range: 20–100), and Awareness of Cultural Background at Work (three items, score range: 3–15). A preliminary validation study of the STISC using T0 data from 257 participants (Moreland‐Capuia et al., 2023) estimated internal consistency, as quantified using hierarchical omega, to range from .89 to .95 across subscales for the final assignments of items to relevant subscales, with 95% confidence interval (CI) lower limits greater than or equal to 0.85. The test–retest reliability of the STISC has not been evaluated.

Data analysis

Internal consistency reliability was estimated for each training group using hierarchical omega (Kelley & Pornprasertmanit, 2016) and alpha coefficients. Participant demographic characteristics were summarized by training group using means and standard deviations for age and frequencies and percentages for all other characteristics. STISC subscale scores before (T0) and following (T1) training were characterized by training group using means and standard deviations. Cohen's d, with within‐group standard deviations at T0 as the measure of variability, was used as a standardized measure of effect size for posttraining change within groups. To aid in the interpretation of Cohen's d values, we used conventional thresholds of 0.20 for small effects, 0.50 for medium effects, and 0.80 for large effects (Cohen, 1988). We considered these thresholds relevant in our setting due to summary or median effect sizes characterizing pre–post change following training or education approaching or exceeding 0.50 in four studies of trauma‐informed training, and a summary or median effect size exceeding 0.80 in one of the four studies (Conners‐Burrow et al., 2013; Davis et al., 2024; Kenny et al., 2017; Raja et al., 2015). Paired t tests were conducted to assess the statistical significance of mean T1–T0 change within training groups, and independent sample unequal variance t tests were conducted to assess between‐group differences in subscale means at T0 and for T1–T0 change. Only participants who provided complete T0 and T1 survey data were included in analyses of survey scores; participants who were partially or completely missing survey responses at T0 or T1 were excluded. All statistical tests were two‐sided, and an alpha of .050 was set to indicate significance. Estimates of hierarchical omega and alpha coefficients were calculated using the MBESS package (Kelley, 2023) in R (Version 4.3.2) statistical software. All other statistical analyses were conducted using SPSS (Version 28.0 or higher).

RESULTS

Mean T0 and T1 scores for each of the five STISC subscales and associated T1–T0 statistical comparisons, stratified by group, are presented in Table 2. There were no significant between‐group differences in T0 means for any of the five STISC subscales, ps = .165–591. For the NICU group, mean scores on each of the five subscales increased significantly posttraining. The effect size estimates corresponding to the increases, as quantified by Cohen's d, ranged from 0.30 for the Safety and Acceptance at Work subscale (small effect) to 1.97 for the Self‐Assessed Knowledge and Attitudes subscale (large effect). For the Angolan leadership group, mean scores for the Self‐Assessed Knowledge and Attitudes subscale and the System‐Wide Knowledge and Attitudes subscales increased significantly posttraining. Cohen's d estimates associated with the increases were 0.52 for System‐Wide Knowledge and Attitudes (medium effect) and 1.11 for Self‐Assessed Knowledge and Attitudes (large effect). Cohen's d estimates associated with changes in the remaining three scales (i.e., Safety and Acceptance at Work; Training, Support, Interaction and Environment; and Awareness of Cultural Background at Work) were less than 0.10. In between‐group comparisons, there were no significant differences in mean posttraining changes between the Angolan leadership and NICU groups for any of the five subscales, ps = .143–.786.

TABLE 2.

Pretraining (Time [T] 0) and posttraining (T1) Survey for Trauma‐Informed Systems Change (STISC) subscale mean scores, by training group

Angolan leadership NICU workers
(n = 18) (n = 46)
T0 T1 T0 T1
STISC subscale M SD M SD d t(17) p M SD M SD d t(45) p
Self‐Assessed Knowledge and Attitudes 79.72 18.73 100.56 8.28 1.11 4.94 <0.001 72.96 11.22 95.04 9.20 1.97 12.53 <0.001
Safety and Acceptance at Work 28.17 6.02 27.94 6.92 −0.04 −0.15 0.879 26.89 4.39 28.20 5.74 0.30 2.46 0.018
System‐Wide Knowledge and Attitudes 26.83 2.68 28.22 2.51 0.52 2.68 0.016 25.63 5.12 27.59 3.03 0.38 3.09 0.003
Training, Support, Interaction, and Environment 55.28 12.55 56.06 14.63 0.06 0.21 0.836 51.02 11.04 56.96 13.78 0.54 4.04 <0.001
Awareness of Cultural Background at Work 11.72 2.99 11.89 2.32 0.06 0.34 0.736 12.13 1.71 13.13 1.76 0.59 3.82 <0.001
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Note: Cohen's d was calculated using the within‐group standard deviation at T0.

For Angolan leaders and NICU participants who provided complete T0 and T1 survey data, estimates of internal consistency reliability as quantified by hierarchical omega across the STISC subscales ranged from .82 to .93 for the Angolan leaders group and from .87 to .98 for the NICU group. However, for the Angolan leadership group, hierarchical omega could not be calculated for the Self‐Assessed Knowledge and Attitudes subscale or the Training and Employee Support subscale due to the small sample size. Coefficient alpha estimates across the five subscales ranged from .81 to .96 for the Angolan leadership group and from .84 to .98 for the NICU group.

DISCUSSION

The present study provides evidence that the Training for Change curriculum holds promise as a scalable trauma‐informed curriculum that can be implemented across professions, fields, and cultures. There were relatively few differences between the groups in their posttraining knowledge and attitudes toward trauma‐informed practices. These findings suggest the training could be directly translated and implemented on a global scale. Moreover, the results suggest that the training did not work favorably solely for individuals who speak English or those involved in health care versus government; rather, the results demonstrate that the training can be applied cross‐culturally and across professions with comparable results.

A group of NICU workers from the United States and a group of Angolan leaders have different lived experiences, histories, and trauma exposures, and their day‐to‐day professional lives likely look vastly different from each other. NICU nurses can experience stress and secondary traumatization in the workplace due to relationships with newborns’ parents, the health and well‐being of newborn patients, chaotic working environments, and/or feelings of being unable to support a patient (Beck et al., 2017; Oehler et al., 1991. To better understand the group of Angolan leaders, it is important to understand the history of Angola, including nearly five centuries of colonization by Portugal, nearly three decades of civil war that began shortly after the nation gained independence in 1975, and a period of recovery following the end of the war in 2002 (Kibble, 2000; Moreland‐Capuia, 2021). A few studies have demonstrated the deleterious impact of civil war in perpetuating physical and psychological trauma and worsening social determinants of health (Collier, 2007; Collins et al., 2010; De Bellis & Zisk, 2014; Felitti et al., 1998; Hecht et al., 2018; Kelly et al., 2012).

A strength of this study was the use of the STISC, which is not specific to any profession and could be used to directly compare the groups. The two areas where between‐group differences emerged were self‐assessed knowledge and attitudes and system‐wide knowledge and attitudes. Angolan government officials may have demonstrated a higher mean score for self‐assessed knowledge and attitudes because they represent a multidisciplinary group of professionals. The Self‐Assessed Knowledge and Attitudes subscale included items about the neurobiology of trauma and drug use along with items related to historical trauma, trauma stewardship, and trauma‐informed practices. The interdisciplinary nature of the questions could explain why a group composed of different types of professionals from a wide variety of fields who possess varying levels of educational attainment scored higher. Still, the results suggest that two vastly different populations can be trained using the same curriculum and surveyed using the same instrument.

Scores on the Attitudes and Beliefs About Safety; Acceptance at Work; Training, Support, Interaction, and Environment; and Cultural Awareness subscales did not change significantly among Angolan leaders from pretraining to posttraining. This could be explained by the small, 18‐person sample size, highlighting a limitation of this study. Future work should consider leveraging a larger sample. Additionally, limited access to economic opportunities may make the presence of workplace trauma less salient.

Another limitation of this study is the high percentage of participants who did not complete both surveys and were, therefore, excluded from our analysis (i.e., 65.0% in the Angolan leadership group and 37.0% in the NICU group), which could have biased our change estimates. We did not collect data from participants who did not respond to survey invitations and, thus, are unable to determine the reasons underlying the low response rates.

We have previously shown that professionals from all fields can be given the same survey to assess trauma‐informed practices and policies in their organization (Mangus et al., 2023). The current study extends our previous work by demonstrating that the Training for Change curriculum might be effectively translatable across professions and fields among individuals who speak many languages and come from different countries. Further, addressing the impact of trauma exposure on individuals and societies will require a multilevel effort that can be facilitated by trauma‐informed system change.

OPEN PRACTICES STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request at amoreland@mclean.harvard.edu.

AUTHOR NOTE

Funding was provided by the McLean Hospital Center for Excellence for Anxiety and Depressive Disorders and the Bank of America Foundation.

Kerry J. Ressler has received consulting income from Alkermes and Takeda, as well as research support from the National Institutes of Health (NIH), Genomind, and Brainsway, and he is on scientific advisory boards for Janssen and Verily; none of these disclosures are related to the present work. Alisha Moreland‐Capuia receives royalties from two SpringerNature publications, Training for Change and The Trauma of Racism. Caitlin Ravichandran receives research support from the NIH (MH115874), the Robert E. and Donna Landreth Fund for the Study of Neuroinflammation in Autism, the Williams Syndrome Association, the Jerome Lejeune Foundation, and Mass General Brigham. E. Kate Webb was supported by the National Institute of Mental Health (F32MH134443). Alexandra Mangus, Daniel Capuia, Maria da Cruz, Paulo Leite, Engracia Marques, and Ana Masseca have no conflicts of interest to declare.

The authors wish to thank their colleagues at McLean Hospital in the Center for Excellence for Anxiety and Depressive Disorders for their support.

Capuia, D. , da Cruz, M. , Masseca, A. , Marques, E. , Leite, P. , Mangus, A. R. , Webb, E. K. , Ravichandran, C. , Ressler, K. J. , & Moreland‐Capuia, A. (2024). Trauma‐informed systems change training has transcultural, transcontinental transformative healing power: An analysis of leaders in the United States and Angola, Africa. Journal of Traumatic Stress, 37, 1021–1027. 10.1002/jts.23062

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