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SMART Africa Hub Project Summary


DR. MCKAY: Hello. I'm Mary McKay. I'm the Vice Provost of Interdisciplinary Initiatives at Washington University in St. Louis, and it's my privilege to be able to present the SMART Africa Center to you.

SMART stands for Strengthening Mental Health and Research Training. We refer to our center as the SMART Africa Center. And it's my turn to introduce my two incredible collaborators, without whom this work would not have gone nearly as well as it had. So please, Dr. Fred, and then Dr. Ozge.

DR. FRED SSEWAMALA: Hello. My name is Fred Ssewamala. I'm a professor at the Brown School here at Washington University in St. Louis, but I'm also the associate dean for transdisciplinary faculty research, and in SMART Africa, I was one of the three lead MPIs. I worked in Uganda, in Kenya, in Ghana, and it was really a great honor for me to work with a group of scholars from these different countries, but also with colleagues like Mary, Ozge, Kimberly, and others. So thank you so much for listening, and we hope that you enjoy our presentation.

I'll pass this on to Dr. Ozge Sensoy Bahar, our colleague.

DR. OZGE SENSOY BAHAR: Hi, everyone. My name is Ozge. I am on the faculty at the Brown School as a research assistant professor. I am also a coinvestigator on our SMART Africa Center. And it's been a true pleasure to work under our MPI's leadership, as well as collaborating with our colleagues from Ghana, Uganda, South Africa, and Kenya.

DR. MCKAY: Wonderful. So, thank you, colleagues, and Fred, also, thank you for acknowledging Kimberly Hoagwood and the driving role that she played in this work.
Over the next ten or so minutes, I'm going to try to take us through some of the major issues that SMART Africa was meant to address, and some of our major findings from our main study that was set in Uganda. But first, let me just introduce you to SMART Africa.

We are one of the centers that focus in on children, children's mental health, and particularly focus in on those children with emerging conduct challenges. these are prevalent challenges for children. Sometimes they're referred to as disruptive behavior disorders. They're prevalent, but they can truly impair a child's functioning, at home, at school, in the community. So our charge in SMART Africa was really to think about effective scalable solutions that would support children and help them to be on a pathway toward behavioral success.

These are our specific aims, the overall goals of our center. We stand in partnership with many. A transdisciplinary research consortium that represents a number of different country contexts. My colleagues mentioned Uganda, Ghana, Kenya, South Africa, having scholars in-country that were leading this work. And our other aims really focus on building research capacity, being able to scale up evidence-based practices that support children and those that are raising them, as well as really try to partner not only with scholars across the continent, but also to partner with government officials, with policymakers, so that we can enhance the capacity of children's mental health within sub-Saharan Africa.

I cannot tell you about all the activities that went on during our almost six years as a SMART Africa Center, but I will take your through the main study that was set in Uganda. This was a longitudinal experimental study. We used mixed methods to really look at the both the effectiveness and the implementation of an evidence-based practice.

We refer to that evidence-based practice as a multiple family group. What does that mean? It means that children and their caregivers came together within schools and community settings to really help children be behaviorally successful. And our experiment had us contrast three different conditions. That evidence-based practice delivered by trained and supervised and supported parent-peers in the community. In condition two, that evidence-based practice was delivered by community health workers. And we had an active comparison group, disseminating information around mental health wellness and educational supports for children in school.

So we really concentrated on supporting children with emerging conduct difficulties, and we did smaller trials, similarly designed, in our partner countries in Ghana and in Kenya.

What's the evidence-based practice that we adapted and collaboratively really worked on with our partners in-country? I referred to this as a multiple family group, and this intervention is meant to strengthen families of children with DBDs. Our community partners, parents, young people, schoolteachers, heads of school, really worked on having the evidence-based principles be culturally and contextually translated, and so that this intervention could be also successfully delivered by people in natural existing settings for children in Uganda.

What was our research question, which is what difference did this intervention make in terms of children's behavioral functioning and other impairments that might be emerging in their lives, across school-going children residing in very low resource settings and communities in Uganda?

Our hypothesis certainly was on the side of our active conditions. We expected that evidence-based practice that was delivered by parent-peers and child health workers, those outcomes would be significantly different than those children's outcomes in our comparison condition. And again, we looked at children's behavioral patterns as well as their impairment across a set of domains that were real important for functioning of children.

This beautiful slide -- thank you, colleagues that created that -- really helps you to kind of take a look at our design. This is a design where we initially involved 26 primary schools and randomized schools to the different conditions that I talked about. You'll see also, at the top, that COVID-19 and the pandemic did impact slightly our recruitment, but robustly. Out of thousands of children, we identified hundreds, 636 children, to be exact, that were presenting with emerging difficulties, and really focused in on them; but also other children in these primary schools to inoculate them from emerging conduct difficulties.

Here's our eligibility criteria. Children were between 8 and 13 years of age. They were in grades primary 2 through 7. They were screened for emerging behavioral challenges. The children assented, caregivers consented, and it was multiple periods of data collection across time to be able to look at the outcomes associated with this intervention. We used a myriad of outcome measures, but I'm going to focus in here on a couple of the measures that we'll present, and I'll present some additional data.

In terms of measuring children's conduct-related difficulties, we used a scale called the Iowa-Conners, Impairment Rating Scale, looked at functioning across domains that are really important to children, across their peer relationships, with siblings, with adult caregivers, at school, and overall functioning. And I'll talk a little bit more about some of the other measures as we get to some of the outcomes.

In terms of analysis, I want to acknowledge our colleague Dr. Rachel, who worked with a team to really look at these data across time and used a number of methods including mixed-effects models, to be able to look at the difference between baseline to eight weeks post baseline, 16 weeks, and across time, six months from baseline. We evaluated main effects for group, time, and group-by-time interactions.

So I'll present just very briefly some of the main findings of the study. What you'll see here is just a little bit of demographic information. And this study is in press, and we're happy to actually provide copies of some of this, if you're interested in the composition of the young people, as well as those that were the deliverers of the intervention.

Again, these are the characteristics of the children that were involved. You'll notice that we also collected information about children's circumstances, particularly their orphan status, who was raising them. Those were important for us to look at as well.
I'm going to breeze through these next set of slides, but what you'll see in these particular slides, this particular slide focuses in on children's behavioral functioning.

What you'll see is our active conditions, the evidence-based practice that was delivered by parent-peers, the evidence-based practice that was delivered by community health workers, the exact same intervention. You saw significant declines in children's behavioral symptoms, those challenging behaviors that get children in trouble at home and in school, and you'll see that that same effect, that same improvement, was not present in our comparison group.

Same thing for impairment. You'll see significant differences between the trajectories of young people that journeyed through our active conditions, relative to our controls.
I will also just present some of these additional graphs for you, to let you know that not only did we track children's behavioral challenges, but we also tried to track more positive concepts around self-concept. We think that that's one of the factors that can inoculate young people and help them be more successful, as well as we looked at comorbidities around depressive symptoms as well.

Again, I mentioned that much of these data are either in press, about to be published. We're happy to go into more details about each of the models that are included in those papers.

We also took a look at caregivers' mental health, and what you'll see here again is a mental health distress among caregivers. You saw some significant declines in those domains relative to comparison, as well as parental stress related to caregiving. Again, from a family intervention model, bringing children and their families together with other families in their community, we wanted to improve children's behavioral functioning and the framework that we used to how children improve behaviorally is we also support the caregivers who are raising them.

Our evidence-based practice -- we saw a potential to reduce the behavioral and mental health challenges that often burden children and adolescents, as well as the promise that this adapted evidence-based practice could improve caregivers' mental health. We also saw some evidence that naturally occurring resources, parent-peers, community health workers, could be supported to deliver in high quality an intervention and actually their service could be associated with positive outcomes for kids.

We have a number of publications out of SMART Africa. This is a portion of them. Again, we're happy to chare this work with any of you that are interested in it. And with that, I'm going to turn this back over to my colleagues, and while I do that, to really thank our collaborators. SMART Africa is truly a consortium of amazing collaborators, both in the United States but also in-country, and so it's my privilege to turn it back over to Ozge and Fred.
Any final words, Fred or Ozge?

DR. FRED SSEWAMALA: Just one. Just really to thank our funders. Really, this work would not have been possible without the funding of NIH, but also without the commitment of our program officials, including Bivery(ph.), including Ahouri(ph.), and including Steish(ph.). These are people we have worked with for six years, and so we are extremely grateful. But also, scientifically, the takeaway is maybe not to just emphasize what Mary talked about, that these naturally occurring resources in our communities, the peer parents and really the community health workers can deliver these manualized interventions if they are trained, and we can see real effects really happening.

And we also have the cost-effectiveness paper, which has been published out of this, so people can be able to, we'll be happy to send out versions of the same, so that they can see how much this costs.

But I'll pass this on to Ozge to say a few words.

DR. MCKAY: Ozge, maybe you could also say the name of the intervention, because Ugandan is not so good, but yours is better, and Dr. Fred's is even better than mine.

DR. OZGE SENSOY BAHAR: I appreciate your confidence in my Ugandan, Dr. Mary. So our intervention is called Amaka Amasanyufu. It means happy families in Uganda. I got Dr. Fred's approval, so I'm very proud.

But I just I just wanted to add that it's really promising and exciting that we didn't find any difference between community health workers and parent-peers, because this really allows us to expand the workforce that could deliver metal health interventions to support our children and families in the communities.

And we're currently working on some qualitative data from our facilitators, and our preliminary findings show how excited and dedicated and motivated they were in participating in this intervention, and they observed significant changes in the families, both caregivers and children. But my favorite part is that they also took the information and applied in their own families, which I think is really a motivation for community health workers and parent-peers to participate in this intervention in the first place. They really saw the benefit of the intervention, even within their own families.

DR. FRED SSEWAMALA: Just to add a word, because since Ozge mentioned about community healthcare workers, it's really also exciting to see that really policymakers are interested in this. And now as we think about scaling up and sustainability, this is probably the most easiest intervention provided these manuals can be printed, provided schools are very much interested. We have over 100 schools that are really now interested in implementing this. We have policymakers in the Ministry of Education in Uganda with whom we have engaged. So this is very exciting to see that, at least this intervention is likely to be taken on to scale by the different key actors in our community.

DR. MCKAY: With that, let me thank our colleagues. Let me thank you, who are listening to us, and we're happy to share information as needed. Thank you very much.