MISC-CBO: a Cluster Randomized Control Trial to Improve the Mental Health of OVC in South Africa

The negative impact of acquired immunodeficiency syndrome (HIV/AIDS) on child mental health through orphanhood, parental chronic illness and poverty is well documented. These interconnecting factors led to the operational term "orphans and vulnerable children" (OVC). Currently, there are +16 million OVC, the vast majority in sub-Saharan Africa (SSA), with estimates between 1.95-3.7 million in South Africa (SA). Given the scarcity of mental health workers in SSA, community-based organizations (CBOs) offer a strategic point of intervention as an essential response to shortages in human resources for mental health. However, as yet, no Randomized Control Trial (RCT) has evaluated the effects of improving the quality of caregiving of CBO caseworkers in their daily interactions with children, conferring a missed opportunity to leverage the CBO environment directly to improve child mental health. Over the past 5 years, the investigators have successfully adapted and implemented the Mediational Intervention for Sensitizing Caregivers for CBOs building on Co-Investigator Boivin's parent-based RCTs in Uganda . MISC adapted for CBOs (MISC-CBO) is a year-long semi-structured, manualized video-feedback intervention designed to enhance the caregiving capacity of CBO caseworkers to improve child outcomes, by targeting the Research Domain Criteria systems for social processes (affiliation and attachment) in daily caseworker-child interactions. The investigators showed that MISC-CBO significantly improved caregiving quality and mental health outcomes of OVC over a 12-month period12. However, the study was a quasi-experimental feasibility trial that limits causal conclusions, did not have statistical power to detect mediating and moderating effects, did not follow up with children beyond post-intervention, and did not assess cost-effectiveness or implementation climate and readiness. Consistent with the Research Domain Criteria's dimensional approach to psychopathology, the overall goal of the proposed study is to conduct a repeated measures cluster randomized control trial to fully establish the effectiveness and trans-diagnostic mechanisms of action of MISC-CBO in high risk 7-11 year olds - a developmental stage critical for building mental health resilience against the adolescent onset of psychiatric problems. 24 CBOs will participate, each with 15 OVC and 3 caseworkers, recruited using existing NGO partner (Childline) and infrastructure in two districts in the Free State, SA, totaling 360 children (50% female; 7-11 year old, equal age bands) and 72 CBO caseworkers (100% female). The 24 CBOs will be randomly assigned to receive either one year of bi-weekly MISC-CBO or TAU. Video-based observations of caseworker caregiving quality and multi-informant child mental health will be assessed at baseline, 12 (end-of-intervention time point), 18 and 24 months. Next, the investigators will use Consolidated Framework for Implementation Research (CFIR13) constructs and input from a Community Advisory Board (CAB) to leverage the RCT to evaluate implementation costs, climate and readiness that would better position the RCT results for future uptake, scale up, and sustainability. Aim 1. Evaluate the direct effects of MISC-CBO on child mental health. Hypotheses include that CBO caseworkers assigned to MISC-CBO vs. TAU will show continued improvement in quality of caregiving at post-intervention (12 months), 18 months, and 24 months follow-up and that children assigned to MISC-CBO vs. TAU will show continued and significant reductions in mental health symptoms at 12 months, 18 months, and 24 months follow-up. Aim 2. Evaluate improved caregiving as mediator of follow-up outcomes (Aim 2a) and child and home characteristics as moderators of MISC-CBO vs. TAU intervention effects (Aim 2b). The investigators hypothesize that reduction in child mental health symptoms at 18 and 24 months will be mediated by improved CBO caseworker caregiving quality observed through video at post intervention (12 months), and that positive effects of MISC-CBO vs. TAU at 12, 18 and 24 months will be reduced for maternal and double orphans, and children from impoverished home environments compared to children without these risk characteristics. Aim 3. Evaluate the cost-effectiveness of MISC-CBO for improved child mental health (Aim 3a) and evaluate implementation climate and readiness for future scale-up (Aim 3b). For Aim 3a, the investigators will follow World Health Organization (WHO) metrics to determine the cost-effectiveness of public health interventions through assessment of disability-adjusted life years (DALYs) averted. The investigators hypothesize that MISC-CBO will prove a cost-effective method to improve child mental health. For Aim 3b, the investigators will conduct three focus groups (each n=7 to total 21) with representatives from the government sector (Departments of the Free State Provincial Government), non-governmental or organized civil society (Non-Governmental Organizations and CBOs) and the University sector (Departments of Psychology and Education), at post-intervention (12 months post baseline). The investigators hypothesize that relevant community stakeholders will deem the climate favorable and ready for the implementation and scale-up of MISC-CBO, and that additional barriers and facilitators for scale-up and implementation will be identified. Study impact. The proposed work will test the real-world effectiveness, mechanisms of action, cost-effectiveness and implementation readiness of a culturally sensitive, community-based mental health intervention, MISC-CBO, during the critical developmental window of at-risk children aging into adolescence. The program of research is therefore in line with the third strategic objective of the National Institute of Mental Health ("Strive for prevention and cure") that articulates the need for validated targets for interventions, and improved methods to match interventions to under-served individuals and populations that can be scaled for greater public health impact.