The end of the trial: Perspectives on cognitive processing therapy from community-based providers in the Democratic Republic of Congo

Abstract

Despite calls forincreased mental health programming in low-resource and humanitarian contexts and effectiveness trials of psychotherapy in these settings, little research exists on the extent to which providers and recipients continue to practice skills learned during trials of these programs. To understand if and how providers continued to use mental health intervention skills without ongoing institutional support following the completion of randomized controlled trials (RCTs), we analyzed data from semistructured interviews with six of seven providers who participated in an RCT of cognitive processing therapy (CPT) in the Democratic Republic of Congo 7 years prior. Provider interviews revealed continued knowledge of and, in some cases, the practice of core CPT skills as well as efforts to keep meeting with women in the community and a strong desire to learn new skills. Although financial limitations sometimes prohibited providers from formally convening CPT groups with women in need, participants maintained knowledge and skill use. Providers also reported feeling more valued in their communities, and they continued providing services beyond the planned intervention period despite a lack of ongoing support. In addition, participants described a strong desire to continue psychosocial interventions for trauma and learn more about this type of intervention. Reframing the evaluation of psychological interventions as program development and maintaining a strong working relationship with community partners may allow for increased sustainability of mental health services beyond the end of academic research studies in low-resource contexts.

The burden of mental disorders is disproportionately borne by low- and middle-income countries (LMICs; C. J. L. Murray et al., 2012; Vos et al., 2012). Although a growing number of randomized controlled trials (RCTs) have demonstrated that adapted evidence-based psychotherapy interventions can be effective in LMICs (Andrade et al., 2014; V. Patel et al., 2007; Saraceno et al., 2007; Semrau et al., 2015; Whaley & Davis, 2007), the extent to which these interventions can be sustained in communities beyond the conclusion of research activities is unclear. Without funding, training, or oversight, behavioral health programs are difficult to sustain (Jerene et al., 2017), and the ability of a community health worker to continue providing services may be directly related to the amount of institutional support they receive (Scott et al., 2018). Further, provider motivation to continue services is often predicated on feeling financially and organizationally supported (Takasugi & Lee, 2012).

There is an increased understanding of how instituting novel mental health programming might be improved in humanitarian or low-income contexts writ large (Javadi et al., 2017). Many have advocated for governmental policy that enshrines evidence-based, locally adapted mental and behavioral health programming in humanitarian response (Interagency Standing Committee [IASC] Reference Group for Mental Health and Psychosocial Support in Emergency Settings, 2017; P. P. Patel et al., 2011). Cognitive processing therapy (CPT) is one such evidence-based treatment that has been found to be effective in multiple LMIC settings (Bass et al., 2013; Bolton et al., 2014). Designed to address posttraumatic stress symptoms (PTSS) and PTSS comorbid with depression over 12 sessions (Kaysen et al., 2013; Resick et al., 2008; Resick & Schnicke, 1992), CPT involves teaching participants skills to manage thoughts, feelings, and behaviors, typically related to sexual trauma. Specifically, CPT integrates cognitive restructuring with emotional processing of trauma-related events so individuals can identify and modify negative beliefs and reconceptualize traumatic experiences in a way that reduces their continued negative impact on the patient’s current life (Resick & Schnicke, 1992).

The eastern region of the Democratic Republic of Congo (DRC), one of the world’s poorest countries (International Monetary Fund, 2018), have experienced prolonged political instability and ongoing conflicts in several administrative districts. Within the eastern region, South Kivu province has been affected by decades of fighting between multiple rebel militias, paramilitary groups, and government military forces, which have led to many casualties and human rights abuses, particularly regarding violence against women and girls (Mukwege & Nangini, 2009); for example, Johnson et al. (2010) found that nearly 40% of women in conflict-affected areas of eastern DRC reported an experience of sexual violence in the years following the 1994 civil war. Survivors of sexual violence face a range of mental health problems, such as PTSS, depression, and suicidality (Bartels et al., 2010; Dossa et al., 2014; Johnson et al., 2010; Verelst et al., 2014). In South Kivu, there is extremely limited access to medical care and still less care available for the psychological sequelae of extreme sexual violence (Mukwege & Nangini, 2009). These gaps exist on top of high levels of poverty and limited access to income-generating activities for women and girls that can be exacerbated by exclusion precipitated by sexual violence (Kelly et al., 2011; Kohli et al., 2014).

In 2012, Johns Hopkins University’s Bloomberg School of Public Health, the University of Washington, the International Rescue Committee (IRC), and three Congolese nongovernmental organizations (NGOs) implemented a cluster-randomized control trial of CPT to assess its effectiveness in addressing negative mental health outcomes among female survivors of sexual violence in South Kivu (Bass et al., 2013). In this study, seven villages received CPT and seven received individualized support. In villages randomized to receive CPT, psychosocial assistants (i.e., assistant psychosociale; APSs) working within the three local NGOs were trained to deliver CPT, supervised, and available during the trial for women who sought their services. APSs taught women engaged in CPT to question whether their thoughts (a) were accurate, (b) were overly extreme, (c) took the entire situation into account, (d) were likely to be true, and (e) were based on facts. The process of Socratic dialogue, or asking these types of questions to guide clients in evaluating their thoughts and determining appropriate emotional and behavioral responses, is a central tenant of the treatment (Bass et al., 2013; Resick & Schnicke, 1992). Individual support consisted of general psychological counseling and referrals for economic, medical, and legal services provided by the APSs in control villages. Women who participated in CPT demonstrated strong symptom reductions in depression, anxiety, and PTSS. A posttreatment assessment indicated that CPT also reduced perceive stigma associated with the experience of sexual violence and increased group participation (Bass et al., 2013; Hall et al., 2014; S. Murray et al., 2018). These effects were attenuated but largely sustained 6 months later.

Given the potential social and economic impacts of experiencing sexual violence, the study of CPT was expanded to assess whether an economic intervention might aid in addressing the intersectional issues that sexual violence survivors experiencing mental distress were facing. There is an established link between poverty and mental health problems (Haushofer & Fehr, 2014; Lund et al., 2011), and microfinance interventions have proven to be an effective tool in poverty alleviation, with some evidence of an impact on mental health outcomes (e.g., Green et al., 2016). Although a study design with a direct comparison was not possible due to logistical field challenges (e.g., political instability, travel issues), members of the same research collaborative were able to simultaneously conduct a waitlist-controlled trial of a second intervention, a village saving and loan association (VSLA) program, from 2011 to 2013 in different areas of South Kivu. This program was assessed for effectiveness in addressing poverty, stigma, and mental health outcomes (Bass et al., 2016). To examine the potential benefits of additional financial interventions on psychosocial outcomes among women who received CPT and provide insight into the benefits of combining psychotherapy and economic programming, women in villages allocated to the treatment condition in the RCT of CPT were also given the option to be trained to form and ultimately establish VSLAs after they completed CPT.

In the VSLA groups that were formed by CPT participants, women from the trial invited other women, some who had experienced sexual violence and some who had not, to form a VSLA. Within the VSLA, women contributed a small amount of money to a community fund each week. At the end of each month, a woman was chosen at random from the group to collect the resulting funds and spend them on whatever the recipient believed to be important, such as school fees, new roofing materials, or additional stock for stores. A different woman was chosen to receive the collected fund each month. After an initial round of VSLA was completed, researchers followed up with the women in these groups who were also part of the original CPT trial. Significant positive effects of VSLA emerged with regard to food consumption and perceived stigma, although there were no significant impacts on mental health symptom severity (Bass et al., 2016).

Mental health programming in humanitarian settings can impact community well-being beyond symptom reduction, as participants in similar group interventions have reported increased family cohesion and reduced familial conflict (Lewandowski et al., 2016). However, the extent to which these and positive findings for mental health symptoms can be sustained despite a lack of sustained organizational support is uncertain. Continued supervision, booster training, and funding security are often considered necessary for continued care provision and sustained results (Pallas et al., 2013). After these initial investigations of CPT and VSLA in South Kivu, the IRC changed their approach to working in the region from partnering with Congolese NGOs to focusing on supporting programming through community-based organizations (CBOs). As a result, the three local NGOs that participated in the study stopped receiving financial or administrative support from the IRC for mental health and psychosocial support (MHPSS) operations. Five years after all research activity ceased and the IRC had withdrawn, members of the research collaborative decided to evaluate the extent to which the MHPSS interventions (i.e., CPT and VSLA) continued following the elimination of organizational support. Specifically, the present article presents the findings from a qualitative investigation with the APSs from the original CPT trial, many of whom continued to work for their respective NGOs, that explored the extent to which they maintained an interest in or skills related to CPT. These interviews also explored how the APSs experience with CPT affected their own occupational trajectory and role in the community after the end of the trial.

METHOD

Participants and data sources

We conducted in-depth interviews with six of the seven APSs who were trained to provide CPT in these villages (for details of the original trial, see Bass et al. 2013). A member of the author team (Amani Mataboro) contacted the APSs to inform them of the follow-up study and ask for their assistance with locating the women who had been enrolled in the 2012 trial and inviting them to participate. We were able to contact all but one of the APSs and met with each in their respective village; these six APSs consented to participate. The seventh village was not included in the 2017 follow-up due to high political instability and a likelihood of conflict in the region at the time of the study. All of the women were living in South Kivu province in eastern DRC: Three women lived in an area approximately 50 km north of the regional capital, Bukavu, and three lived in an area 120 km south, near the city of Uvira. All of the included villages were rural, typically had fewer than 1,000 residents, and were situated in areas of ongoing instability and conflict. Several communities also had a recent history of natural disasters, including landslides and flooding. Although all APSs were residents of the villages in which they provided services during the original trial, one had relocated to Bukavu by the time of the follow-up study.

As noted, one author (Amani Mataboro) contacted the APSs to inform them of the follow-up study and ask for their help locating the women who had been enrolled in the 2012 trial. The APSs were also asked if they were interested in participating in an in-depth qualitative interview about their own experiences as a trained CPT provider in the time since the study activities concluded. Oral informed consent in each respondent’s preferred language (i.e., Swahili or French) was obtained before interviews were conducted. We received Institutional Review Board approval for this study from the Johns Hopkins University Institutional Review Board as an amendment to the original RCT protocol.

In-depth, one-on-one interviews with APSs were conducted by two of the authors (Daniel Lakin, n = 4; Sarah M. Murray, n = 2) with the assistance of a French or Swahili interpreter who had at least a bachelor’s degree, depending on the APS’s language preference. Interviews were conducted using a semistructured guide that addressed whether and how APSs continued to use their skills in CPT, the nature of their relationship with women who participated in CPT during the interim period, and their work trajectory and role in their community after having provided CPT as a part of the RCT. The complete semistructured interview guideline is available in the Supplementary Materials. Interviews were audio-recorded with participant permission and conducted in February and March 2017. Audio recordings were transcribed verbatim by the lead author (Daniel Lakin) in the United States following the completion of data collection. For the present analysis and discussion, the women were assigned pseudonyms to protect confidentiality. The interviewers also recorded additional contextual field notes related to the interviewee’s appearance, setting, and other elements of the interview. Interviews lasted between 45 min and 1 hr and took place in each APS’s village in a secluded area to ensure some degree of privacy for the interviewee (e.g., a shaded area near the APS’s home, an empty schoolhouse, the back seat of a vehicle).

Data analysis

The analysis framework drew on principles of interpretive phenomenological analysis, as developed by Smith et al. (1999). This methodology seeks to investigate the fundamental nature of a given experience through the exploration of cultural, situational, and social contexts. Interpretive phenomenological analysis focuses on the processes of understanding, interpretation, and truthfulness for an experience or event of interest (Brennan, 2010; Freeman, 2008). We selected this approach based on the goal of obtaining detailed descriptions of provider experiences following the trial.

The analyses consisted of memoing and thematic coding of interview transcripts (Daniel Lakin, Sarah M. Murray). This process involved the extensive annotation of transcripts, followed by grouping annotations based on content and subject matter. To corroborate the findings and explore emergent themes (Huberman & Miles, 2002), the same two authors who performed the memoing and coding read and added memos to each translated transcript twice: first to identify broad thematic elements and then to make note of specific potential codes. These authors subsequently compiled the codes into their own spreadsheets with supporting quotations from their texts before meeting with one another in person to discuss the codes identified and compile a final codebook that included elements from both authors’ original conceptualizations of the interview themes. One author (Daniel Lakin) used these final codes in a third reading of the transcripts to elucidate critical themes regarding the providers’ experiences following their training as a CPT provider in the original trial. The CPT participants’ responses to the open-ended questions on the follow-up instrument were used to provide additional context for the APSs responses and to triangulate themes developed in the analysis of APS interviews.

RESULTS

The results are presented here by thematic category as derived from the interpretive phenomenological analysis: CPT skills, sustainability, and APS personal experiences following the completion of the 2012 RCT. “CPT skills” refers to concrete principles, practices, and tenets associated with the application of CPT as a group intervention. “Sustainability” refers to an APS’s ability to continue practicing CPT in any capacity as well as the potential barriers to that practice. “Personal experience” concerns barriers, achievements, or other experiences following the end of the original trial. The names used throughout the body of the results section are pseudonyms. Education among the providers ranged from 4 to 6 years of postprimary schooling, and the APSs’ ages ranged from 31 years to 64 years. Two providers had 1 year of training in narrative exposure therapy, and four APSs had received training in general psychosocial assistance and psychoeducation before the CPT trial. Two APSs described participating in additional CPT training after the completion of the RCT.

CPT skills

All six APSs maintained an operating knowledge of CPT practice, techniques, and principles. Each APS was able to cite specific examples of preferred techniques and situations in which they would use them. Three APSs mentioned in their respective interviews that CPT was an improvement on the previous psychosocial counseling strategies employed by their NGOs or CBOs and that the focus on cognitive restructuring in CPT was more consistently helpful than the modalities they had used previously for helping clients address mental health problems. When asked about providing psychosocial counseling before CPT, one participant, Helene, mentioned it seemed “superficial” as compared to CPT in which “you went deeper.” She went on to say that in CPT “women [were] discovering really their problems and how to…face them. How to handle them.” She noted that women who were receiving individual psychosocial counseling were not really getting better and would keep coming back to see her. This belief was shared by another respondent, Julienne, who stated that individual, more general psychosocial counseling “didn’t go deeply to the problem. It is as if we are healing the wound partially instead of healing it totally.” In contrast, Julianne noted that CPT techniques “show the survivor about the situation, how to change their mind…so she can [feel] secure or safe, and then you see that it helps more, it helps her to change the feelings and thoughts she has.” The APSs’ comments suggest that they believed CPT skills were of “deeper,” or more significant, clinical value compared to their other experiences with mental health interventions.

With regards to CPT components, all of the APSs could recall the names of at least some specific worksheets, techniques, and essential practices they had used. Even when they were not able to recall the specific name of a CPT technique, the APSs could recall the principle and intended use of a given skill, such as “balancing thoughts and feelings” and “helping women notice that they are stuck.” Of all the skills in which they were trained, the APSs spoke about the “five thinking questions” as the best-retained and most widely employed skill following the completion of the trial. For example, clients might be asked to use thinking questions such as “is this thought accurate?” or “does the thought take into account the entire situation?” when confronting cognitions related to traumatic events. One APS, Fabrice, mentioned using questions like “Is this a habit or a fact?” to help calm herself down when dealing with interpersonal problems that left her feeling angry or upset. Helene described the five thinking questions as “the engine that drives CPT forward,” and other APSs used similar terminology to describe the essential nature of this skill.

Sustained use of CPT

All the APSs reported continuing to use CPT in different capacities with community members in their village—some through meeting regularly with individual clients, some in group settings or daily interactions with community members, and some with their personal problems. Several APSs mentioned using the skills to manage daily stress. Additionally, APSs mentioned that they used CPT skills regularly on themselves to manage conflicts with their husbands, “help with burnout,” and manage workloads.

Three of the APSs (Yvette, Fabrice, and Helene) reported combining principles of CPT with the social-economic program (i.e., VSLA) that was introduced by IRC soon after the completion of the initial CPT trial. Spurred by community interest, the APSs found an opportunity to merge their CPT skills with this economic support program. Julienne stated that CPT was successful in addressing psychosocial concerns, but an additional economic component seemed necessary to address the daily hardships associated with poverty. Many women “can’t find 200 francs [$0.12 USD] to live on,” Julienne noted, and VSLA made it easier to address basic community needs as well as MHPSS concerns.

Three of the APSs reported regular meetings with groups of women for VSLA and CPT activities on a weekly or monthly basis, whereas one APS maintained separate CPT and VSLA groups. Yvette and Fabrice individually described maintaining four groups of roughly 25 women total in each of their respective villages that meet once a week for a combined VSLA/CPT session without external financial support from any CBO or NGO. Julienne maintained concurrent groups of her original five CPT participants as well as a VSLA program, although these groups were kept separate. However, according to Fabrice, the CPT groups grew in size as the original participants brought in “other women if they see another woman having a problem. They [could] not abandon her they, [brought] her to the group.”

The use of worksheets for concept memorization was difficult to sustain after the trial. Helene noted that one particular form—a sheet designed to help participants identify triggering events, beliefs about those events, and the subsequent emotional response (i.e., the ABC sheet)—was difficult for participants to understand during the trial due to limited literacy, and she had not used it since. However, the purpose of that assignment, which was to help with cognitive restructuring through Socratic questioning, was still used in face-to-face encounters described by the APSs. One APS, Nathalie, mentioned helping women in her community “return to… where the rape happened” to confront triggering circumstances and reframe them by “working on their thoughts and feelings.”

According to the APSs, combining the economic and CPT components seemed to bridge the gap between the daily stress of living in poverty and more chronic mental health symptoms. Per Yvette, “women who were living in fear they could not go back to their farms because it is where the rape happened. But after working on their thoughts, they are going back to their farms, and they are working again.” Yvette went on to note that “many of the problems that they face are no longer mental health problems, but socioeconomic…and recession-related problems,” suggesting that CPT as a standalone intervention was not able to meet the broader needs of her community. By merging elements from the CPT and VSLA principles, several APSs were able to address multiple extant concerns within their villages.

Given the demand for services in their villages and the continued expansion of the combined CPT/VSLA groups, four APSs mentioned that their activities had expanded to include men. Fabrice stated that men, who had noticed a change in their wives after CPT, became interested in whether the therapy could help with their own problems. In Yvette’s village, she began facilitating mixed groups of men and women for combined VSLA/CPT as men became more interested in ventures that could boost household earnings. Both Yvette and Fabrice stated that they encouraged women who had not experienced sexual assault to participate in VSLA/CPT groups to avoid stigmatizing these meetings and normalize mental health and economic ventures. Fabrice stated that “to avoid stigma, we agreed on not only having an exclusive VSLA group but also bringing other women from the community so… the group is not called the group of survivors or such.” This practice is a continuation of the original protocol for the VSLA trial, but combining CPT and VSLA was a novel decision.

None of the APSs were receiving payment for CPT-related activities in their villages at the time these interviews were conducted. As such, recruiting women for these groups, facilitating them, finding spaces to hold large meetings, and consulting with women were not compensated activities. Nathalie and another APS, Marceline, both stopped organizing and maintaining groups close to the end of the trial, stating that without being paid, it was simply not possible to continue the work. Marceline, a mother of two children, stated that she is presently “focusing on making sure [her] family can survive,” and, as a result, she “no longer meets formally or officially with the women as [she] did during the program,” although “women still come to [her] individually” to seek psychosocial support. Fabrice, Marceline, and Nathalie all reported pressure from their husbands to find work to support their families.

Experiences after the RCT

All six APSs described the CPT process as one that focused on community-building and pulling women out of isolation. As Nathalie mentioned, they “encountered survivors who were saying ‘it’s me alone here, having this problem,” but CPT allowed “women [who] were rejected by family members…[to be] accepted and join their families.” These groups allowed affected women to more effectively reintegrate into their communities by encouraging more open dialogue between survivors of sexual violence and their families and spouses and by occasionally working as mediators to ensure acceptance. The APSs reported that the women in the CPT groups provided support for one another and often encouraged women to not feel ashamed or guilty for the assault or helped women return to work in locations where a rape had occurred by walking to the scene together.

The APSs reported that their ability to guide women back to their communities and help them to feel more confident in relationships led to two prominent outcomes. First, they explained that men and women in their communities held them in high esteem (e.g., referring to them as “doctor” in some villages). Second, multiple APSs described that they felt as though providing mental health services was a “calling,” or a vocation that felt more personally important than other work. Fabrice mentioned that she believes her role is to be a part of “community development” and that “fixing” individuals’ mental health was a part of that mission. Yvette described this feeling as follows:

When we ended the training, the CPT training, going back to our communities, I personally was feeling like I was a medical doctor. People coming to me, helping them, coming to evaluate, see how I am conducting the CPT group, was amazing and I felt empowered, able to help.

She went on to say the training she received enabled her to more readily met women’s needs and help them rejoin their communities.

The APSs’ feelings that their position was a vocation rather than a short-term job often interfered with their ability to earn income for their household, as the CPT work was unpaid following the conclusion of the trial. Despite this lack of support, the APSs continued introducing new survivors of sexual violence to each group and worked to provide both psychosocial support and weekly guidance for the conduct of the social-economic program. The APSs reported that this was frequently a full-time job. Despite the lack of compensation for these activities, Fabrice mentioned that her “eager wish is [for]…CPT to continue, and I want to keep my job as an APS.”

DISCUSSION

In this qualitative follow-up with local providers of CPT, the APSs who were trained to provide therapy as part of an RCT nearly 7 years earlier continued to use the key tenets of CPT, although only two APSs participated in additional training during the intervening years. Four of the APSs continued to provide components of CPT to their communities despite that institutional support from NGOs or CBOs was not sustained following the end of the trial. Three of those APSs incorporated VSLA programming into their CPT groups. Although all of the APSs found the CPT training to be helpful, two of them were no longer providing any CPT or other psychosocial services to women due to a lack of financial support from local CBOs or larger NGOs. At the time these data were collected, none of the APSs interviewed were receiving institutional or financial support for any CPT-related work.

Perhaps the most important phenomenon described by the APSs was the development of an integrated service for addressing both the mental health and financial needs of some communities by combining the principles of VSLA and CPT (i.e., using time spent as a group to discuss CPT concepts with group members also participating in a VSLA). As mentioned in the interviews, once women’s symptoms improved, they were still confronted with a situation in which their immediate basic needs were not being met (e.g., living in poverty, the likelihood of exposure to conflict and violence). There is considerable interest in multisectoral interventions for global health initiatives (Chopra et al., 2009; Jordans et al., 2009; Tol et al., 2011), particularly for mental health and psychosocial service platforms, and this combined group underscores the natural demand for integrated platforms of service delivery. Given the organic nature by which this combined intervention developed, future research might evaluate this specific program more formally and examine its potential viability on a broader scale. Siloed efforts to address psychological distress and poverty individually are shortsighted in that they fail to address intersecting social determinants that help or hinder mental health. The participants’ decision to merge concurrent interventions within some of these communities to address complex issues may reflect that desire to improve community services and well-being via multi-sector solutions.

In these interviews, program sustainability was described in a more nuanced way. From a programming perspective, there are themes in the interviews to suggest that long-term sustainability was achieved: The core principals of the intervention were maintained and still used by both practitioners and clients, there was an effort to make the intervention more far-reaching and inclusive by incorporating VSLA and other community members (e.g., men), and there was a strong desire to continue pulling women out of isolation and enabling them to rejoin their respective communities. On an individual level, however, the findings are more mixed. There is considerable tension in the reports that a majority of the APSs believed it was a vocation to continue MHPSS work in their communities after local CBOs and NGOs decided not to fund those initiatives. It is similarly problematic that APSs reported feeling empowered via MHPSS training and enjoyed subsequently elevated social status while not being compensated for their work.

For international organizations, there is a boom–bust cycle for intervention funding that targets specific populations and problems. The Inter-Agency Standing Committee (Interagency Standing Committee Reference Group for Mental Health and Psychosocial Support in Emergency Settings, 2017) and others (P. P. Patel et al., 2011) have recommended policy-oriented steps to more effectively institutionalize MHPSS programming in humanitarian response through governmental involvement and calls to plan for sustained activities from the outset of research activities. However, for situations in which government instability is the norm, political will is low, and the focus of funding organizations can shift widely in short periods, these recommendations may not be feasible. As collective interests from the NGO community shift, interventions that once enjoyed community stakeholder support and funding opportunities are subsequently overshadowed by the desire to test interventions in new settings or assess other treatment modalities. The APS interviews suggest that participatory momentum was sustained individually and programmatically without institutional support. After 5 years, APSs were still eager to provide CPT, better their skills, and broaden the scope of the intervention itself. The cyclical nature of funding cycles may fail to foster such momentum, decrease interest in participation, and result in the loss of valuable information and infrastructure. There is a need to identify and maintain interventions that address a community’s perceived needs; have demonstrated efficacy; and are embraced by the community, providers, and clients.

The study must be discussed through the lens of its strengths and limitations. Although we were only able to interview six APSs, findings from studies with a similar design have demonstrated that there is no ideal sample size for phenomenologically oriented qualitative investigations (Chane & Adamek, 2015; Smith et al., 1999). Moreover, we were able to interview providers in six of the original seven villages included in the RCT. Importantly, we were able to conclude that the present study achieved a reasonable degree of agreement among respondents (Guest et al., 2006) given similarities in the APSs’ responses and the topics raised. The extent to which the CPT skills were maintained and the quality with which they are executed were not evaluated in this investigation. Future studies related to intervention sustainability would benefit from the measurement of skills retention, particularly where booster training and institutional support have not been sustained.

OPEN PRACTICES STATEMENT.

The original trial and subsequent waves of assessment were not formally preregistered. Anonymized versions of qualitative transcriptions and subsequent coding are available upon request to the corresponding author at dan.lakin@jhu.edu.