Addressing Sexual Violence
Related Trauma
In Eastern DRC with Cognitive
Processing Therapy
JUNE 2013
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Addressing Sexual Violence
Related Trauma
In Eastern DRC with Cognitive
Processing Therapy
Conducted by:
International Rescue Committee (IRC) and the
Applied Mental Health Research Group (AMHR) at
Johns Hopkins Bloomberg School of Public Health (JHBSPH)
Authors:
Judith Bass
Paul Bolton
Debra Kaysen
Shelly Griffith
Sarah Murray
Talita Cetinoglu
Katie Robinette
Marie-France Guimond
Karin Wachter
Jeannie Annan
JUNE 2013
Table of Contents
EXECUTIVE SUMMARY.......................................................................................... 1
ACKNOWLEDGEMENTS........................................................................................ 4
INTRODUCTION..................................................................................................... 5
Background and Purpose of this study............................................................................................................... 5
Context of Services for Women in eastern DRC.............................................................................................. 5
History of collaboration between JHU and the IRC....................................................................................... 8
Review of preliminary qualitative needs assessments .................................................................................... 9
Review of instrument development process...................................................................................................11
Review of the mental health section validation process...............................................................................12
INTERVENTIONS..................................................................................................14
Review of process for intervention selection..................................................................................................14
Description of CPT and evidence behind it in other populations.............................................................14
Training of PSAs and Intervention Implementation.....................................................................................15
Supervision description......................................................................................................................................15
CPT piloting..........................................................................................................................................................16
STUDY METHODS.................................................................................................17
Village selection and randomization.................................................................................................................17
Recruitment, baseline assessment and eligibility...........................................................................................17
Intervention monitoring system........................................................................................................................18
Follow-up Assessments ......................................................................................................................................18
Analysis process....................................................................................................................................................19
RESULTS..................................................................................................................23
Description of participation...............................................................................................................................23
Baseline demographic, mental health, and functioning characteristics of the CPT
and IS samples.......................................................................................................................................................25
Mental Health Outcomes ...................................................................................................................................28
Function and Social Resource Outcomes.......................................................................................................30
Economic Outcomes ..........................................................................................................................................31
Qualitative follow-up results..............................................................................................................................35
DISCUSSION...........................................................................................................39
Mental health Outcomes.....................................................................................................................................39
Function and Social Outcomes.........................................................................................................................40
Economic Outcomes...........................................................................................................................................41
Limitations.............................................................................................................................................................41
CONCLUSIONS AND RECOMMENDATIONS....................................................43
Recommendations ..............................................................................................................................................44
REFERENCES.........................................................................................................45
APPENDICES..........................................................................................................49
EXECUTIVE SUMMARY
S
exual violence (SV) is recognized as a significant problem in the Democratic Republic of
the Congo (DRC). The DRC also has a recent
history of persistent conflict and insecurity, largescale displacement of civilians and the death of millions. Systems of protection and prevention are necessary for women in this region, as are healing and
empowerment programs for those who have experienced SV. Yet access to services in eastern DRC—
both emergency and longer-term care—remains a
major challenge. Having delivered services in the region for more than a decade, the IRC has identified a
wide range of challenges faced by women related to
accessing services in this region, including difficulties in accessing services of quality in a timely manner and lack of empowerment opportunities. The
IRC has been working with local NGOs and their
case managers (psychosocial assistants – PSAs) to
provide psychosocial services to survivors of SV.
Reports from the local NGOs indicate a need for
services to address women with high levels of persistent symptoms who are not improving through
standard care.
SV can contribute to high levels of mental health
symptoms, impaired functioning, and experiences
of social stigmatization in female survivors, many
of whom also face extreme economic hardship and
poverty. Little is known about how improvements in
mental health impact social and economic improvement, and conversely, how social and economic improvement programs impact mental health. Based
on this, JHU and the IRC set as their overall goal to
identify low-cost and scalable interventions which
demonstrate improvement in the mental, social,
physical and economic functioning of sexual violence (SV) survivors1 living in eastern DRC. This
1 In this study, “sexual violence survivors” includes women who
report having experienced sexual violence (locally defined as “rape”)
themselves, as well as women who report having directly witnessed
such acts.
report provides results addressing the impact of
a mental health intervention, Cognitive Processing Therapy (CPT), on specific domains of social,
physical and economic functioning, and on the reduction of mental health problems, including depression, anxiety, and feelings of stigma and shame,
associated with being an SV survivor.
Trial Description
Prior to initiation of the impact evaluation of CPT,
JHU and the IRC together implemented a series of
formative studies, including qualitative studies to
understand the needs of survivors of SV in their local languages and the development, validation and
piloting of tools to assess survivors mental health
and functionality. Following these steps, JHU and
the IRC implemented a randomized controlled trial
of CPT provided by psychosocial assistants (PSAs)
compared with access to a individual support condition, with participants in both conditions having
received the usual care (i.e. case management and
supportive care) at some earlier time point.
Sixteen rural villages in South and bordering North
Kivu provinces were selected from among 23 villages served by 3 Congolese NGOs. Selection was
based on accessibility, security, and availability of a
PSA for trial duration. PSAs in all villages had 1-9
years prior experience providing case management
and individual supportive counseling to sexual violence survivors and at least 4 years post-primary
school education. At time of hire, all PSAs received
5-6 day trainings by the International Rescue Committee (IRC) in case management and topic-specific
trainings.
Based on the results from the initial qualitative studies, the Hopkins Symptom Checklist (HSCL-25)
was used to assess combined depression and anxiety and the PTSD Checklist (PCL) civilian version
to assess PTSD symptoms. Participants rated frequency of each symptom in the prior four weeks using a 4-point Likert scale (0=not at all, 1=little bit,
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
1
2=moderate amount, 3= a lot). Average per-item
scores were generated for each measure; possible
range 0-3 with higher scores indicating greater severity. Cut-off criteria (average HSCL-25 > 1.75, average PCL > 1.75, i.e. total score 30 averaged across 17
items), were used as predictive of clinically-defined
depression/anxiety and PTSD. Functional impairment was assessed measuring difficulty performing important tasks of daily living identified from
qualitative data from study villages. For each of 20
tasks, responses used a 5-point Likert scale for difficulty doing the task (0=none, 1=little, 2=moderate
amount, 3= a lot, 4=often cannot do). An average
per-item score was generated for each participant;
possible range 0-4 with higher scores indicating
greater impairment.
Study eligibility included: age 18 or older; experienced or witnessed sexual violence (translated as
rape locally); total symptom score of at least 55 (i.e.
average score of 1 for each of 55 symptoms including the HSCL-25 items, PCL items plus additional
locally relevant symptoms); and a functional impairment score greater than 9 (i.e. some dysfunction
on at least half the tasks). Exclusion was only for suicidality judged by clinical staff to require immediate
treatment. Study measures were translated from
French into 5 languages: Kibembe, Kifuliro, Kihavu,
Mashi and Swahili.
Treatment conditions
PSAs in comparison villages provided access to individual support (IS). When women were informed
of their eligibility, PSAs invited them to the office as
often as they wanted to receive IS services, which
consisted of psychosocial counseling and referral for
legal, medical and economic services.
PSAs in the intervention villages received a 2-week
training in the group format of CPT. The CPT treatment included one 1-hour individual session and
eleven 2-hour sessions with 6-8 women per group.
Each PSA concurrently led three therapy groups.
Ongoing supervision was provided through multitiered supervision: Congolese psychosocial supervisors employed by the IRC provided direct supervision to PSAs through weekly phone or in-person
meetings; a bilingual US-trained clinical social
worker provided in-country supervision and com-
2
municated with US-based trainers weekly. PSAs
also provided access to individual support to CPT
participants as needed.
Study design
The trial included 15 study villages (7 CPT and 8
IS). Recruitment and baseline assessments occurred
in December 2010. PSAs reviewed their current and
prior client files to identify women currently suffering from significant psychological problems and invited them to their offices where research assistants
administered consent and study questionnaires. The
intervention period lasted from April to July 2011.
Follow-up data were collected within 1-month postintervention and 6-months later.
Results
A total of 494 were screened for eligibility with
the final study sample including 405 women (157
CPT; 248 IS). Two-hundred and thirty-one women
(57%) completed all three assessments while 354
(87%) completed baseline and at least one followup assessment. For CPT participants, the average
number of sessions attended was 8.5 out of 12 sessions offered, with 141 (89%) completing at least 9
(defined as treatment completion). Among women
in IS villages, 182 (73%) participated in at least one
session with the PSA. Among those who participated in at least one session, their average number of
sessions was 5 during the study period. Compared
with CPT, women in IS villages were younger, less
likely to be married, and lived with fewer people.
On average women in IS villages reported higher
symptom scores at baseline compared with women
in CPT villages across all measures.
On average, women in both IS and CPT arms experienced significant improvements during treatment
with effects maintained at 6-months. For depression/anxiety symptoms and PTSD symptoms, CPT
participants showed significantly greater improvements compared with women in IS villages at both
follow-ups. Approximately 70% of CPT participants met our criteria for probable depression/anxiety at baseline, with 10% or fewer meeting criteria
at both follow-up assessments. Among women in
IS villages, 83% met cut-off criteria at baseline, 53%
met criteria post-intervention, and 42% at 6-month
follow-up.
CPT was effective in reducing symptoms of combined depression/anxiety and PTSD and improving
function, compared with individual support alone
among female survivors of sexual violence in eastern DRC. The benefits were large and maintained
6-months post-intervention. Therapy participants
were significantly less likely to meet criteria for
probable depression/anxiety and PTSD.
1) while the average scores for women in the IS villages scores remained closer to a ‘moderate amount’.
Differences in how CPT and IS were provided may
affect our conclusions. CPT, but not IS, was provided in groups. CPT PSAs received greater supervision than IS PSAs. CPT participants also had on
average a greater number of treatment sessions compared with IS participants.
Limitations
Conclusions
There are several limitations that need noting, including differences in symptom severity across
study arms. Randomization was done within blocks
of 2-4 villages grouped together based on language
and proximity. The small number of village clusters
(n=6) made randomization less likely to result in
comparability. An additional limitation is unknown
validity of the cutoff score used to identify clinically
significant cases of combined depression/anxiety
and PTSD. While the locally appropriate cut-off
scores may be uncertain, the score itself can still be
meaningfully interpreted: 1.75 means women are
reporting that symptoms occur, on average, nearly
a ‘moderate’ amount of the time (a score of 2.0). On
average, women in CPT scores dropped to lower
than ‘a little bit’ for the average response (a score of
This trial provides evidence of effectiveness of a
mental health intervention, CPT, for SV survivors
experiencing high levels of mental health symptoms
in a low-income conflict setting. Given the differences in how CPT and IS services were provided,
the CPT effects must be taken as program effects,
which include CPT, number of sessions, group process and supervision systems.
The results indicate that with appropriate training
and supervision, psychotherapeutic treatments such
as CPT can be successfully implemented and show
impact in settings with few specially trained mental
health professionals. To meet the goal of identifying
low-cost and scalable interventions for this population and context, a cost-impact analysis is planned.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
3
ACKNOWLEDGEMENTS
IRC DRC staff: Catherine Poulton, Robyn Baron,
Gabrielle Cole, Maria Scicchitano, Lionel Laforgue,
Georges Mugaruka, Daniela Greco, Claudine Rusasura, Viviane Maroy Bora, Maimona Mabila, Theresita Zihalirwa, Cesarine Barhasima Nabintu, Bertille
Matambura Kamole.
Psychosocial Assistants and partner NGO staff:
Programme de secours pour les vulnérables et sinistrés
(PSVS) – Amini Magangala, Macozi Wabiwa, Furaha Seza, Nyota Amani, Furaha Amunazo, Mwajuma
Kashindi, Nabindu Jumatatu, Kashindi Kisesa.
Action pour le développement intégral de la femme
(ADIF) – Desiré Kalwira Hamuli, Judith Iragi Rwizibuka, Jacqueline Cibalonza Cinesha, Safina Lingoma, Fungaroho Mastaki, Naminani Cimonge, Bora
Kaharamba.
4
Union pour l’émancipation de la femme autochtone
(UEFA) – Bahati Bizibu, Verediane Kivanga, Nyota
Muhindo, Providence Musema.
CPT intervention assistance:
Carie Rogers for her assistance with preparation of
the initial CPT treatment manual. Janny Jinor for
providing in-country clinical supervision during the
CPT intervention implementation.
Other technical assistance:
Amani Matabaro for translation of written materials
and live translation during CPT and research trainings. Alden Gross for providing rapid and comprehensive statistical advice and assistance.
INTRODUCTION
Background and Purpose of this
study
Sexual violence (SV) is recognized as a significant
problem in the Democratic Republic of the Congo
(DRC). Much international interest on SV in the
DRC focuses on SV in the country’s conflict-ridden eastern provinces: North Kivu, South Kivu,
Maniema, and Orientale. For 15 years, there has
been persistent conflict and insecurity, leading to
large-scale civilian death and displacement. Despite
a period of relative calm beginning in 2009, the
country’s security deteriorated in 2012. According
to the United Nations Office for the Coordination
of Humanitarian Affairs (OCHA), the number of
displaced people increased from 1.7 million at the
end of 2011 to more than 2.2 million by the end of
June 2012 (OCHA press release, July 2012). One
consequence of the conflict has been systematic violence against women and girls. While rape by armed
groups continues, recent reports indicate that perpetrators are both armed actors and civilians, including intimate partners (Stony Brook University
Research Brief 2011; Bartels et al., 2012; Duroch et
al., 2011; Peterman et al., 2011). A recent study in
conflict-affected regions of eastern DRC indicated
that nearly 40% of adult females reported experiencing SV ( Johnson K et al. 2010). This violence
is largely perpetuated within a culture of impunity
for perpetrators, negative societal attitudes toward
women, and the absence of a functioning judicial
system.
Systems of protection and prevention are necessary for women in this region, as are healing and
empowerment programs for those who have experienced SV. Yet access to services in eastern DRC—
both emergency and longer-term care—remains
a major challenge. Limited services as well as the
potential stigma of seeking services, including the
risk of rejection by husbands and/or communities,
mean that many survivors never receive adequate
care (Baelani & Dünser, 2011; Casey et al., 2011;
Kohli et al., 2012; Scott et al., 2012). Monitoring
data from ongoing International Rescue Committee (IRC) programming for SV survivors has found
that many of those who do seek care demonstrate
substantially reduced ability to function, including
reduced ability to perform basic tasks and activities
related to earning, self care, caring for family, and
contributing to their communities. These survivors
also describe mental health and psychosocial problems including mood disorders, anxiety, withdrawal,
and stigmatization and rejection by family and community (Murray et al., 2006).
Context of Services for Women in
eastern DRC
Having delivered services in the region for more
than a decade, the IRC has identified a wide range
of challenges faced by women related to accessing
services in this region, including:
Difficulties in Accessing Services of Quality in a Timely
Manner:
• Distance to services – With limited public
transportation and the costs often prohibitive
for survivors, many walk for hours and sometimes days to reach assistance.
• Rights of women and girls not respected –
Women and girls in North and South Kivu
provinces have difficulties accessing essential
health services, particularly family planning,
due to legal and customary limitations.
• Impunity – A comprehensive law against SV
was adopted in 20062, yet impunity contin-
2 Loi numero 06/018 du 20 juillet 2006 modifiant et completant le
decret du 30 janvier 1940 portant Code penal congolais
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
5
ues due to judicial inaction and existing cultural norms that are at odds with protections
laid out in the legal text3. Many cases are also
settled out of the official judicial system and
survivors’ best interests are hampered.
• Emergency situations – In a conflict-affected
setting where incidents of fighting occur regularly, health services are often the first services affected by the violence. This means that
women and girls who already have difficulty
accessing services have even less options for
care.
Lack of Empowerment Opportunities:
• Education – In the DRC, enrollment rates for
girls are low, especially for secondary school.
While 47.4% of boys aged 14 to 19 years old
are attending secondary school, only 32.7%
of girls are doing the same4.
• Economic opportunities and financial decision-making power – Women and girls in
the DRC have limited opportunities to access
capital and financial resources, and even less
power to manage such resources. Even if they
have access to employment or income-generating activities, the men in their lives often
control how that money is used.
• Confidence and leadership – Women and
girls in the DRC have limited opportunities
for leadership, both inside and outside the
home.
• Solidarity with other women and girls –
Women and girls often lack safe social spaces
and opportunities to share ideas and challenge
each other in a constructive and trusted setting.
The IRC has been working with local NGOs and
3 “Analysis: New laws have little impact on sexual violence in
DRC,” IRIN News, June 7, 2011. Accessed June 14, 2011 at: http://
www.irinnews.org/Report.aspx?ReportID=92925
4 “The Adolescent Experience In-Depth: Using Data to Identify
and Reach the Most Vulnerable People”. 2007. Population Council
and UNFPA, p. 19. Accessed June 20, 2012.
6
their case managers (psychosocial assistants –
PSAs) to provide psychosocial services to survivors
of SV. The IRC also works with volunteers from
community-based organizations (CBOs) to provide social support and advocate for at-risk women
at the village level. Reports from the local NGOs
indicate a need for services to address women with
high levels of persistent symptoms who are not improving through standard care. The IRC has also
noted a great need for economic support among
women survivors because of their reduced function
and frequent alienation from family and community
coupled with their often-extreme poverty.
Objective and Aims of this Study
SV can contribute to high levels of mental health
symptoms, impaired functioning, and experiences
of social stigmatization in female survivors, many
of whom also face extreme economic hardship and
poverty. There is limited evidence for intervention
approaches that address these multiple, complex
problems. One approach may be to treat women’s
mental health problems through an advanced psychosocial intervention5 in order to reduce symptoms and improve functioning. Another may be
to provide new ways to encourage participation in
economic activities to reduce poverty and improve
functioning. A third option may be to combine the
two approaches: first providing a mental health intervention and then providing new economic opportunities. Currently, it is not known which of
these approaches are effective in ultimately helping these women function better in their daily lives,
since little is known about how improvements in
mental health impact social and economic improvement, and conversely, how social and economic improvement programs impact mental health. Based
on this, the current study has the following overall
objective and specific aims:
Study Objective: To identify low-cost and scalable interventions which demonstrate improvement in the
mental, social, physical and economic functioning
5 “Advanced psychosocial intervention” is a term used by the
WHO to include specialized care and evidence-based treatments
such as cognitive behavioural therapies.
of sexual violence (SV) survivors6 living in Eastern
DRC.
Specific Aim 1: To investigate the impact of a
mental health intervention, Cognitive Processing Therapy (CPT), on specific domains of social, physical and economic functioning, and
on the reduction of mental health problems,
including depression, anxiety, and feelings of
stigma and shame, associated with being an SV
survivor.
Specific Aim 2: To investigate the impact of a
socio-economic intervention, Village Savings
and Loans Associations (VSLA), on specific
domains of social, physical and economic functioning, and on the reduction of mental health
problems, including depression, anxiety, and
feelings of stigma and shame, associated with
being an SV survivor.
Specific Aim 3: To investigate the combined
impact of a mental health intervention (CPT)
followed by a socio-economic program
(VSLA) on specific domains of social, physical and economic functioning, and on the reduction of mental health problems, including
depression, anxiety, and feelings of stigma and
shame, associated with being an SV survivor.
This report will address Specific Aim 1. The other
Aims will be addressed in subsequent reports.
Mental Health and Evidence for Services
Distress and mental disorders are common consequences of SV in both general settings (Booth et al,
2011; Campbell et al., 2009; Chen et al., 2010; Chivers-Wilson et al, 2006; Resick et al., 1993; Tjaden
& Thoennes, 2006) as well as settings affected by
conflict (Betancourt et al., 2011; Johnson et al.,
2010; Loncar et al., 2006; Roberts et al., 2008). Yet,
a recent systematic review demonstrated a paucity
of evidence for mental health and psychosocial support interventions for SV survivors from conflict-af-
6 In this study, “sexual violence survivors” includes women who
report having experienced sexual violence (locally defined as “rape”)
themselves, as well as women who report having directly witnessed
such acts.
fected communities (Tol et al, in press). Of the five
studies identified in the review, all had serious methodological limitations including lack of controls and
high attrition. While there are published guidelines
for the treatment of mental health problems in lowand middle-income countries (mhGAP) as well as
guidelines for mental health in emergencies (IASC
2007), guidelines have not yet been published for
the specific treatment of trauma-related mental
health problems, though a trauma module from the
World Health Organization (WHO) is in development. Despite this gap, there is an evidence-base
for the treatment of mental health problems related
to trauma, including but not limited to post-traumatic stress disorder (PTSD), and specifically for
mental health problems related to SV. Data from
high-income countries has shown that cognitivebehavioral-based therapies both with and without
components of exposure therapy are evidenced for
the treatment of mental health problems among SV
survivors (Foa et al., 2010; Vickerman & Margolin,
2009). Cognitive Processing Therapy (CPT), in
particular, has a preponderance of empirical support
among SV survivors, with treatment effects lasting
five or more years following intervention (Chard,
2005; Resick et al., 2002; Resick et al., 2012).
In these high-income country studies, these evidence-based therapies were provided by mental
health professionals working in contexts of relative
stability. The context of eastern DRC is quite different, and includes a general lack of mental health
professionals; long distances between villages and
urban centers and poor travel conditions; stigma associated with being a SV survivor; and, ongoing political and economic instability. Effectively adapting
evidence-based therapies to this context will have
important public health implications for SV survivors in low-income and conflict-affected contexts
globally.
The IRC’s Programming for Women and Girls
in this Region
The evidence-based therapy referred to above was
implemented within the context of IRC’s Women’s
Empowerment and Protection (WPE) program,
which works to strengthen and improve local partners’ provision of quality case management, psycho-
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
7
social, medical, economic, empowerment and legal
services for women and girls. Included in the IRC’s
WPE program are:
• Psychosocial and mental health service provision: The IRC strengthens the technical
capacity of IRC staff and partner NGOs and
CBOs to provide quality psychosocial services
to survivors of gender-based violence (GBV),
conduct case management and counseling for
survivors of GBV, and meet relevant international standards.
• Clinical service provision: The IRC supports the Ministry of Public Health (MoPH)
to provide quality clinical care for survivors of
sexual assault by providing material and technical inputs such as training on Clinical Care
for Sexual Assault Survivors (CCSAS).
• Legal service provision: IRC is currently
partnering with local NGOs to provide legal
information as well as legal representation at
the court level.
• Strengthening the referral networks: The
IRC ensures a working referral network by
working to improve stakeholder understanding of the need for other services, and to create stronger links between psychosocial service
providers, health care personnel and legal assistance providers.
• Community outreach: The IRC constantly
disseminates information to the communities
in which it works about services available and
how to access them. In addition, it works with
key stakeholders to increase acceptability of
services and community support for survivors.
• Emergency service provision: In collaboration with local partners, the IRC responds to
emergency situations with rapid, high quality
holistic service provision.
• Village Savings and Loans Associations
(VSLA): The VSLA model provides participants with access to a safe place to keep savings
as well as the opportunity to take out loans. It
also includes an emergency solidarity fund as
a safety net. VSLAs are designed to be empow-
8
ering because participants build upon their
own savings and—following a few months of
intense training and follow-up—run the associations themselves. In North Kivu, the IRC
runs its Economic and Social Empowerment
(EA$E) activities. These include VSLAs but
also encompass business-skills training and a
discussion series between VSLA members and
their spouses on economic decision-making in
the household aimed at addressing the power
imbalances that are at the root of GBV.
• Community-based recovery: The IRC works
with women-led CBOs to educate leaders on
the meaning and consequences of GBV and
service availability, while also offering trainings on women’s rights, project management
and advocacy techniques. The IRC also provides technical and financial help in the design and implementation of micro-projects to
increase the social integration and economic
independence of survivors and other vulnerable women.
• Confidentiality of data: The IRC seeks to improve understanding and knowledge among
the practitioner community, UN agencies in
the DRC, and the Congolese government
about responsible and ethical ways to collect,
store, and analyze GBV data in order to respect survivor rights and ensure their security
as well as that of service provider staff and
communities.
History of collaboration between
JHU and the IRC
Since November 2005, JHU faculty (at that time
working at Boston University) has provided technical assistance to the IRC, beginning with the development of a tool to monitor and measure the functionality of SV survivors for the IRC WPE program
in eastern DRC. During this initial period, IRC,
JHU faculty, and USAID also agreed on terms of
reference for a more complete program of technical assistance to support program monitoring and
evaluation of the functionality of SV survivors. The
IRC subsequently developed a program log frame
for their SV activities, including an indicator on im-
provement of SV survivor functionality following
case management, measured with the functionality
tool developed by JHU. The overall technical assistance included the following activities:
1. A qualitative study of how SV survivors
view their own needs (Murray et al., 2006).
2. Development and testing of a quantitative
instrument to assess those needs and to assess ability to function (functionality tool).
3. Training of IRC SV program staff in the
supervision of data collection using the
functionality tool and the management of
the resulting data.
4. Training of local partner staff in its use,
specifically those staff acting as counselors
and directly providing services to SV survivors.
5. Implementation of the instrument into the
program regimen (counselors interview
new program participants using the instrument, then interview them again after participation in the program).
6. Management and analysis of data by JHU
and the IRC data management staff to
monitor changes among clients receiving
services.
As part of a USAID evaluation report, faculty from
JHU reviewed functionality data in 2009 that had
been collected as part of the ongoing monitoring
of psychosocial services provided by IRC partner
NGOs. Preliminary analysis suggested that the levels of symptoms and dysfunction at first interview
were high with improvements as measured after participation in the program. These data provided some
information on the impact of the psychosocial services. However, without a systematic evaluation and
a control population to compare the changes over
time, it was not possible to conclude that changes
in functioning were specifically a result of the psychosocial services or other unmeasured factors. This
monitoring data established the basis for the current
study (Bolton P & Locket D, 2009; Bolton 2009).
Following this report and subsequent to additional
acquisition of funding from USAID, the IRC and
JHU held an initial meeting in Bukavu later in 2009
to outline priority questions and initial methodology for an impact evaluation. In early 2010, to further
develop the operational plan of the study (i.e., how
the newly-introduced services and impact evaluation would be implemented) JHU had a 3-day meeting in Bukavu with IRC staff from the New York,
Kinshasa and Bukavu offices. During this meeting,
participants clarified program and evaluation aims
and worked collaboratively to meet the needs of
both. The IRC identified geographic areas and specific villages that could be included in the mental
health (CPT) program specifically for the evaluation study. The decision on which areas and villages
would be targeted for each program was based on
the availability of a partner NGO (for CPT activities) as well as logistics and security considerations.
Also during this meeting, plans for program recruitment, implementation and evaluation design were
further refined. One of the biggest challenges of doing this extensive work in this region is the logistics
of transporting staff and supervisors to sites that are
often a full-day’s journey from Bukavu, particularly
as the security situation is ever-changing. The 3-day
meeting was successful in getting buy-in from all of
the Bukavu and Kinshasa-based staff who had previously only heard about the evaluation program via
emails. Thus, JHU and the IRC were able to draft a
plan of action and move forward on the budgeting
of all research and program components. The result
was the finalization of a design framework document included as Appendix A.
Review of preliminary qualitative
needs assessments
A series of qualitative needs assessments were conducted following the 3-day planning meeting in order to identify psychosocial needs of SV survivors,
inform the adaptation of instruments for use with
current programming, and inform the selection of
intervention strategies. The information from these
assessments were intended to provide a basis for:
• Identifying current problems that can be addressed by programs for SV survivors;
• Informing the selection of intervention(s) to
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
9
address these problems that are acceptable and
feasible, by reviewing what local respondents
describe as existing ways in which these problems are dealt with;
• Selecting indicators and instruments to be
used to assess the level of mental health problems, monitor the progress of interventions,
and assess their impact.
An important consideration when doing work
in South Kivu is the diversity of languages. In reviewing all the primary and secondary languages
of the areas in which the evaluation would be implemented, JHU and the IRC selected three languages (Swahili, Mashi, Kifulero) representing the
most probable languages spoken in all the different
mental health program evaluation villages. It was
decided that three independent qualitative needs
assessments were needed to cover the three different languages in order to identify whether problems
were described similarly or differently across the
languages. A copy of the report from these qualitative studies is available at from the authors (jbass@
jhsph.edu).
With logistical and technical support from the IRC,
JHU first trained 20 local interviewers and conducted a qualitative needs assessment initially in two
villages representing two of the study languages.
A second group of 10 local interviewers were then
trained by an IRC staff to implement the study in a
third village representing the third language. These
assessments were conducted to identify the mental
health service needs of women affected by SV. The
interviewers were all women, and were required to
pass a written and verbal evaluation of their language
capacity in at least one of the three study languages.
Two interviewing methods were used:
1. Free Listing, to identify problems perceived by local people to be the results of
SV, and to explore the tasks and activities
that constitute normal functioning for
men and women;
2. Key Informant Interviewing, to obtain
detailed information on those psychosocial problems emerging from the free lists.
10
During free listing, participants were asked to identify problems that survivors of SV tend to have. The
most frequently mentioned problems were financial
in nature (poverty/ lack of food/ lack of medicine).
Following that, the problems and description of
problems, particularly the psychosocial issues, varied by village. The three psychosocial problems that
were the most common across the three villages and
that formed the basis for the subsequent key informant interviewing were feeling abandoned/ rejected by family and friends, fear (e.g., of disease), and
having too many thoughts.
Key informants were then asked to describe individuals suffering from these problems. These informants identified the following signs and symptoms7:
madness, tension and shame were most commonly
mentioned across communities, with wanting to
die/ feeling dead, crying, trauma, feeling cold (cold
body) and fainting following close behind. Symptoms that were mentioned by respondents from
some, but not all, of the communities include symptoms that are common to many mental health problems (e.g., sleeping and appetite problems) as well
as signs and symptoms commonly associated with
depression-like problems (e.g., hurting heart, thinking of death), and/or anxiety-like problems (e.g.,
tension, thoughts not focused/too many thoughts).
Over the course of the qualitative interviews, the local informants did not indicate the existence of specific disorders or grouping of symptoms. This could
be an indication that there are many diffuse symptoms being experienced by these populations rather
than more specific syndromes, but confirming this
would require more extensive research.
During the free listing interviews, data were also
gathered on specific tasks and activities that women
regularly do to take care of themselves, their family
and participate in their communities. These items
were used to further refine the functionality tool
already in use in the IRC psychosocial monitoring
system.
7 These are English translations of the words and terms used by
the survivors themselves and by other women and key informants
in the communities. The words and terms were first recorded in
the local languages, then translated into French and then translated
into English.
Review of instrument development
process
The process of adding, removing and deciding on
items to be included in the final study instrument
was a collaborative process between several JHU
faculty and IRC staff, with all involved providing
feedback and suggestions throughout the process.
In addition to the mental health and function assessments described below, demographic questions were included, as were questions regarding
exposures to a range of traumatic events and use of
services. The study instrument (Appendix B) was
translated from English into French and then into
local languages. Following a review of all the study
villages, two additional local languages were identified (Kihavu and Kibembe), resulting in five local
language versions of the study instrument. Following the translation of the instrument, a review
of each question was undertaken during the initial
training by all the interviewers familiar with the local language. After adjustments were made to the
instrument based on the interviewers’ feedback, the
instruments were all pilot tested with small samples
in each of the linguistic communities to ensure local
comprehension.
Mental Health Assessment
Results from the qualitative study indicated that the
functionality tool currently used by the IRC captured some but not all of the relevant mental health
problems particularly relevant to the SV survivor
populations in the study villages. Based on this, and
the desire to expand the range of outcomes for the
formal impact evaluation, a longer and more complete assessment of mental health and psychosocial
problems and functional impairment was developed.
For the assessment of mental health problems, the
first step was to review existing questionnaires for
identifying mental health problems. These questionnaires are generally referred to as screening instruments as they do not specifically generate mental health disorder diagnoses (as a clinical interview
might). Rather, screening instruments are used in
mental health to identify individuals with high levels of symptoms in order to ‘screen’ in those who
require services.
Several depression, anxiety, and posttraumatic
stress screeners were reviewed to identify those
covering the many symptoms that were also found
in the preliminary qualitative studies, indicating
appropriateness for local adaptation. For depression, we reviewed the Hopkins Symptom Checklist
– Depression scale (HSCL-D) and the Center for
Epidemiologic Studies – Depression Scale (CESD). For anxiety, we reviewed the HSCL – Anxiety
scale (HSCL-A). And for post-traumatic stress we
reviewed the PTSD Checklist – Civilian version
(PCL-C), the Post-trauma Symptom Scale (PTSS10), the Impact of Events Scale – Revised (IES-R),
and the Harvard Trauma Questionnaire (HTQ)
PTSD symptoms section. Based on the review, the
Hopkins Symptom Checklist-25 (HSCL-25 Depression and Anxiety subscales) (Hesbacher et al.,
1980; Winoker et al., 1984) and the civilian version of the PTSD Checklist (PCL-C) (Weathers
et al. 1994) were adapted to assess for depression,
anxiety, and PTSD symptoms. JHU has extensive
experience with the HSCL-25 and have found it to
be easy to adapt and use as well as reliable in crosscultural contexts. Both the HSCL-25 and PTSD
Checklist have been used internationally with sexual
violence survivors (Tsutsumi et al., 2008) and have
solid psychometric properties with conflict-affected
samples (Conybeare et al., 2012; Ruggiero et al.,
2003; Ventevogel et al., 2007).
Items probing additional locally-relevant symptoms
of distress that were not found in either of these
screeners were also included in the complete assessment of mental health problems. The final version
consisted of questions on 55 signs and symptoms.
For each symptom, participants were asked to rate
how often they perceived that they experienced the
problem in the prior four weeks on a Likert scale
(0=not at all, 1=little bit, 2=moderate amount, 3=
a lot). A graphical representation was provided to
help the women distinguish between these different
levels. The mental health symptom questions are located in section B of the study instrument.
Functionality Assessment
To assess functioning, we expanded the IRC functionality tool using data collected during the qualitative needs assessments (described above) iden-
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
11
tifying important tasks and activities that women
regularly do to care for themselves, their families,
and participate in their communities. JHU and the
IRC included items from each domain (caring for
self; caring for family; participating in community)
mentioned by women in at least two of the three
qualitative study communities and combined these
with the tasks and activities already in the IRC functionality tool for a total of 20 tasks and activities. Participants were asked to rate how much difficulty they
had performing each task or activity in the prior four
weeks on a Likert scale (0=none, 1=little, 2=moderate amount, 3= a lot, 4=often cannot do). As with
the mental health questions, a pictoral representation of the different levels of difficulty was provided
to the respondents. The function questions are located in section A of the study instrument.
In addition to functioning related to tasks and activities of daily living, JHU and the IRC included a series of measures on coping, social participation and
familial and community connectedness in order to
understand the social experiences of the participating women. In the qualitative studies, many of the
respondents talked about the isolation and rejection
survivors experienced. Therefore, JHU and the IRC
wanted to look at whether participating in the group
intervention may have an impact on a range of social
resources, including socialization and connectedness. The coping and social resource questions are
in sections C and D of the study instrument.
Economic functioning and standard of living were
assessed using standard economic modules widely
used in comprehensive socioeconomic household
surveys (such as the World Bank’s Living Standards
Measurement Surveys-LSMS- and the UNDP’s
Core Welfare Indicators Questionnaire-CWIQ).
To measure economic functioning, we focused on
women’s participation in the labor market, measured by the supply of labor for economic and domestic activities, both inside and outside the home.
The hypothesis is that as women’s mental status improves, so will their economic functioning through
increased participation in the labor market. To measure the standard of living of the women’s households, we included a series of questions on household-level asset holdings, quality of housing and
food consumption. Over time, improved economic
12
functioning should lead to higher household living
standards. The economic questions are in sections
E and F of the study instrument.
Review of the mental health section
validation process
Prior to initiating the interventions and impact evaluation study, JHU and the IRC needed to confirm
the ability of the mental health section of the study
instrument to identify eligible women. Eligibility
was based on self-reported exposure to SV (defined
locally as “rape”) and having severe enough mental
health problems and functional impairment to warrant participation in the new program. Because no
locally-validated measures of mental health problems and functional impairment existed, JHU and
the IRC implemented a validation study for the
mental health and functional impairment sections
of the evaluation instrument in order to determine
what scores might define severe enough symptoms
to warrant services.
To evaluate the validity and utility of the mental
health section of the study instrument we conducted an initial pilot test followed by a validation study
in villages representing two of the study languages
(Mashi and Kifuliro). Human and financial resources constrained our ability to conduct full validation
studies in all five local study languages. For the pilot test and validation study, we interviewed 172
women in two different areas of South Kivu where
two of the study languages were spoken. The study
participants were identified by NGO staff who provided psychosocial services in the study villages (the
psychosocial assistants-PSAs). These PSAs were
asked to review their case files and identify women
they thought had few/no symptoms and problems as well as women they thought had a moderate amount/a lot of symptoms and problems. The
symptoms and problems JHU and the IRC asked
the PSAs to think about were those on the functionality tool used in the program monitoring process.
We relied on the functionality tool, which included
both symptoms and functional impairment items,
because the PSAs had already been using it in their
programs and would be able to identify women with
different severity levels based on their experience
with it. Across the study villages, N=65 women were
identified by the PSAs as having few/no symptoms
and problems and N=107 women were identified as
having a moderate amount/a lot of symptoms and
problems.
For the validation process, we focus on discriminant
validity; that is, we focus on whether our mental
health assessment can validly distinguish (or discriminate between) women identified as having a
lot of symptoms with those having few or no symptoms. When discriminant validity is established, the
average scores of the group having a moderate to a
lot of symptoms can be used as a cut-off score for
inclusion in the study.
During data analysis with 172 study women, it became clear that although the PSAs identified women they thought had few or no problems, in reality
nearly all of the women had a significant number of
mental health and psychosocial problems8. Thus,
our standard methods for validating the measure
and identifying cut-off symptom scores were not appropriate and we had to come up with an alternative
method of defining study eligibility.
The symptom questions were rated by each respon-
8 This inability to correctly classify cases was confirmed by study
PSAs during a review after the impact evaluation was complete. The
PSAs at this review session commented that regular case management did not always give them the tools to explore the survivor’s feelings beyond what the survivors reported directly to them and thus
they may have missed important problems.
dent on a 4-point Likert scale for how often the
respondent had experienced each symptom in the
prior 4 weeks: 0=not at all, 1=little bit, 2=moderate
amount, 3= a lot. With the instrument including
55 symptom questions, we decided that a minimum
score of 55 – or an average score of 1 on every symptom – would be an indication of enough psychosocial and mental health problems to warrant receiving
services. Using this cut-off, 98% of the validity study
sample met the symptom criteria.
We went through the same process for the identification of a functional impairment cut-off score. There
are 20 functioning questions, each rated on a 5-point
Likert scale in terms of degree of difficulty engaging
in the task (0=none, 1=little, 2=moderate amount,
3= a lot, 4=often cannot do). Given that the goal of
the intervention was to improve both mental health
symptoms and functioning, we needed to identify a
cut-off score that indicated at least some functional
impairment, but not so much that we would exclude
women who had significant mental health problems
yet were managing to take care of themselves and
their families at a minimum level of success. We
decided that experiencing at least some difficulty (a
score of 1) on at least half of the functioning items
(i.e., a total score of at least 10) would provide sufficient rigor to ensure we were including women with
significant problems while not excluding women
who had at least some functional capacity. Using
this cut-off, 90% of our validity study sample met
the function criteria.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
13
INTERVENTIONS
Review of process for intervention
selection
Relying on results from an earlier qualitative investigation (Murray L et al., 2006) of mental health
needs of men and women in one area of South Kivu
(Uvira and Sange), we considered implementing
interpersonal psychotherapy (IPT) as the mental
health intervention. This consideration was guided
by the depression-oriented symptoms identified in
that earlier qualitative study. The qualitative studies
implemented specifically for this study (described
above) identified both depression and trauma-related symptoms, such as avoidance of situations that
remind women of the trauma and fears specific to
the trauma. Thus, a review of interventions with evidence for both depression and trauma-related mental health problems was warranted.
In addition to a review of the evidence-based psychotherapy treatments for trauma (e.g., Ougrin D,
2011), we consulted several trauma-treatment experts, including clinicians and researchers who have
experience working with trauma survivors generally and with SV survivors specifically. We provided
them with results from the qualitative studies as
well as a brief description of the context and types
of violence women may have been exposed to. The
treatments with research evidence of their effectiveness for trauma-related symptoms among adults
included prolonged exposure (PE), narrative exposure treatment (NET), and several different cognitive-behavioral therapies. Included in this last group
was Cognitive Processing Therapy (CPT), which
was originally developed for survivors of rape and
SV and has a strong evidence base. CPT has proven
effectiveness for treating depression, anxiety, and
PTSD among SV survivors (Resick P et al, 1992,
2008; Nishith P et al. 2005). The group format represented a cost-effective method for reaching large
numbers of women. We used the Cognitive-Only
14
model (i.e., without written exposure) because it has
comparable efficacy to the original model (Resick P
et al. 2002), while providing greater retention and
ease of administration in groups (Chard KM 2005).
Additionally, evidence from JHU trial in Northern
Iraq (Kaysen D et al., 2011) indicated that it could
be adapted for low-literacy and illiterate clients. We
therefore decided that CPT was the best option for
implementation in this study.
Description of CPT and evidence
behind it in other populations
Cognitive processing therapy (CPT) is a structured,
protocol-based therapy. It provides participants
with skills to recognize maladaptive beliefs they
have related to the trauma and learn to challenge
those beliefs, thereby reducing negative emotions.
The theory behind CPT is that through discussing
the trauma and these maladaptive beliefs, the participant can decrease internalized feelings of stigma
related to the trauma, reduce avoidance around
trauma-related cues and reminders, reformulate
feelings and thoughts about the event, and cope better with daily challenges. More information about
the theory and development of CPT is available in
the manual developed for this study (available from
the developers at [email protected] on
request).
In this study, the CPT program was comprised of
one individual meeting with study participants followed by 11 weekly 2-hour group sessions with 6-8
women per CPT group. NGO PSAs living in the
study villages provided the CPT intervention. The
PSAs were employed by local NGOs partnering
with the IRC, and all had at least one year of previous experience providing case management services
for survivors.
Training of PSAs and Intervention
Implementation
For the impact evaluation, the study villages were
randomly allocated to offer additional access to individual support (IS) if survivors wished it (n=8
villages) or to provide the new CPT program (n=8
villages).
PSAs in all study villages had at least four years postprimary school education and 1-9 years prior experience providing psychosocial services to sexual violence survivors. When they first were hired as PSAs
they received 5-6 day trainings by the IRC in case
management and topic-specific trainings including
counseling, family mediation, stress management,
clinical care of survivors, and HIV/sexually transmitted disease prevention, with refresher trainings
PSAs regularly provided. This case management
and individual supportive counseling services make
up the usual care that all study participants received
when they first accessed the PSA-provided services.
For this trial, which only included women who had
previously accessed services from the PSAs and thus
were in their client files, the comparison services
including access to general individual support (IS)
which in this study included psychosocial counseling and medical, legal and economic referrals.
The PSAs who worked in the villages randomized
to receive CPT participated in a two week in-person
training from expert US-based CPT trainers based
on an adapted therapist manual for the eastern DRC
context and translated into French (available from
Debra Kaysen [email protected] by request). The training, which was done in English
with simultaneous French translation, included
didactic presentations of the components of CPT
as well as role play and practice sessions. Trainingbased quizzes and observation of skills by trainers
during role plays were used to evaluate the impact of
the training on PSA learning.
Women in the CPT villages had access to the PSAs
as desired outside of the therapy. The frequency
with which CPT participants utilized the PSAs
outside of the group sessions was not monitored. Given the time commitment required to receive
therapy and the busyness of the PSAs, our assumption was that the use of additional services would
be minimal. Little mention of these additional
services were reported in the regular weekly supervision reports provided by the PSAs. During the
debriefing of the PSAs with the US-based trainers
in October 2012, the US-based trainers reported
that although a few PSAs mentioned this happened
they did not indicate it was a regular or frequent occurrence. When IRC contacted the PSAs after the
study was complete, the PSAs reported that seeking individual support happened occasionally with
some, but not all, group members. According to
the PSAs, group members requested these sessions
mainly to discuss issues or problems that they did
not feel comfortable discussing with the group.
Supervision description
PSAs at each IS site were continuously supervised
through monthly site visits by supervisors from
their own NGO, as well as by psychosocial technical
advisors (conseillères techniques – CTs) employed
by the IRC. Supervision was conducted through
observation during case management sessions using a checklist as well as one-on-one debriefing sessions with each PSA to discuss the findings of the
checklist, observations made in terms of behavior
and approach towards the survivor, as well as more
challenging cases. PSAs were also in touch with
IRC staff and NGO supervisors over the phone as
needed when problems arose.
For the CPT program, supervision was provided
through a multi-tiered supervision structure (details
on the content of the supervision provided below in
the supervision section). The IRC CTs9 provided
direct supervision through weekly in-person meetings or phone consultations with the PSAs. The
CTs were supervised by a US-trained clinical social
worker based in Bukavu through weekly CT meetings during which the PSA and individual clients
progress were reviewed. The clinical social worker
was supervised by the US-based CPT trainers
through weekly phone/skype calls to provide ad-
9 The IRC CTs who supervised the CPT intervention also went
through the 2-week CPT training with the US-trainers and were provided with additional supervisory training during those two weeks.
In addition, they all co-led a CPT group during the pilot training
period in order to get first hand experience with the intervention.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
15
ditional support and quality assurance during the
implementation of the trial.
CPT piloting
After participating in the 2-week in-person CPT
training, the PSAs and CTs led 4-person pilot
groups to practice implementing CPT and to determine if any adjustments to the intervention content
were needed. These seven pilot groups (one for each
PSA) were successfully completed using the supervision structure described above, with the conclusion being that the CPT trainers felt the PSAs were
ready to implement the CPT groups for the impact
evaluation study. The adaptations made to the CPT
intervention based on the interactions and conversations during the in-person training and as a result
of the pilot implementation are described in Appendix C.
16
An implementation process issue learned from the
pilot groups was that the amount of time needed for
the PSAs to implement the three concurrent CPT
groups, maintain the paperwork, and participate
in supervision was enough to take up most of their
work time over the course of the week. This made
it difficult for them to provide ongoing services to
non-study women and to be available to new women who might come to the centers for services during the study period. In consultation with the IRC
and the local NGOs, the decision was made to hire
temporary PSAs to work in the villages where CPT
was being implemented for the 4-month study period, thus ensuring that services for survivors not
involved in the study were maintained. The IRC
trained the new PSAs in the basic case management
program to maintain quality services during the
study.
STUDY METHODS
Village selection and randomization
Sixteen villages were selected to participate in the
study from the 23 villages served by the three collaborating Congolese NGOs. Selection was based
on accessibility of the sites (road conditions, security) and availability of the PSA from start to finish
of study activities (mainly, some PSAs were pregnant or on maternity leave during this time which
disqualified them from being in the study).
The 16 study villages, each with one PSA, were
grouped into blocks of 2-4 villages based on proximity and shared language and randomized to CPT
or to access to IS services. After CPT training, one
PSA (Katongo village) was dropped because of
competency concerns identified during trainingbased oral quizzes and skill observation. The study
thus included 15 study villages (7 CPT; 8 IS).
Recruitment, baseline assessment
and eligibility
Recruitment of clients in the study villages occurred
in December 2010. The PSAs worked with the
study team to identify potentially eligible women
through a review of current and previous client case
management files. Only women who had previously
or were currently receiving services from the PSAs
were invited to participate in the study; no new
clients were considered. Information on when the
cases first presented to the PSAs and when the SV
occurred was not recorded. Women who the PSAs
thought were currently suffering from mental health
and psychosocial problems were invited by the PSA
to come to the NGO sponsored ‘listening center’
(maison d’ecoute – the office at which the psychosocial services were provided) in their village where
Congolese interviewers employed by the IRC informed the women about the study and implemented the consent process. If women consented, the
interviewers administered the full study question-
naire that included demographic and trauma-related
questions, assessments of social and task functioning, mental health signs and symptoms, and a complete economic battery. Two interviewers worked
in each study village, with interviewing continued
until 28-30 eligible women were identified in each
village. These interviewers were temporarily hired
by the IRC specifically for this interviewing activity. The interviewers were identified based on their
prior interviewing (qualitative and/or quantitative)
experience and their literacy in the local study languages. Interviewers received a 1-week training in
the consent procedures and the full study questionnaire, including didactic training and active role
playing. The decision to use interviewers, rather
than the PSAs, to implement the questionnaire was
made to reduce potential bias in how the respondents reported their symptoms and problems.
Study eligibility included personally experiencing
and/or witnessing SV (translated locally as “rape”),
a total symptom score of at least 55 (i.e., an average
score of 1 for each of the 55 mental health signs and
symptoms from the questionnaire) and a functional
impairment score of at least 10 (i.e., some dysfunction on at least half of the tasks questions), as well as
a reported age of 18 years or older. Study exclusion
criteria included severe suicidality that the IRC and
US-based clinical staff felt required immediate services from the PSAs, which was provided with support from the IRC CTs.
After questionnaire administration, all completed
study instruments were brought back to the central
IRC office in Bukavu and reviewed by the impact
evaluation study team to review eligibility status for
each respondent. Lists of eligible women were returned to the PSAs to invite into the study. In the
CPT villages, the PSAs reviewed the lists and ordered them based on proximity to the NGO sponsored ‘listening center’ in order to prioritize women
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
17
who would have an easier time to regularly come
for treatment. The counselors then invited women,
based on these lists, to participate in the program until they had 24 (up to eight for each of the three CPT
groups) women who had agreed or they reached the
end of their lists. Remaining women (n=35) were
informed that the program was full but that they
would be invited into any new group(s) started after
the study period (four months) was complete. In
the IS villages, PSAs invited all eligible women to
continue receiving services or return to services if
they wanted; four eligible women refused services
and did not want to be part of the study. Sample size
limits were not required in the IS villages because
the existing services could handle the larger numbers as needed.
Intervention monitoring system
The intervention period ran from April to July 2011
in all study villages. PSAs in CPT and IS sites were
trained on the case management protocols for highrisk cases, mainly suicide risk (see Appendix E). A
total of 29 cases of high suicide risk (not including
the seven who were excluded from the study) were
followed until they were no longer determined to be
at risk. No incidents of suicide were reported.
CPT Intervention monitoring
To ensure intervention fidelity and to allow for ongoing supervision, a monitoring system was set up
that included forms that PSAs completed after each
group session as well as forms that supervisors completed after each supervision session with the PSAs.
The PSA forms included information on the current
symptom status on each group participant, information on the activities and topics covered during
the group session, plans for homework that the participant would complete during the week, and any
specific concerns about the group or any individual
participant. For the current symptom status of each
group participant, a summary score was generated
based on 10-symptoms that were assessed at each
session. The summary score for each participant was
recorded and shared with the IRC CTs, the clinical
supervisor, and the U.S. trainers to monitor significant improvements/declines that warranted special
attention. Copies of the CPT intervention monitoring forms are included in Appendix D. Throughout
18
the study, treatment fidelity was assessed by the USbased trainers through a review of checklists of key
treatment elements and global ratings of treatment
knowledge and skills, as observed and reported by
supervisors during group sessions.
IS program monitoring
Similar to the CPT intervention program, a simple
program monitoring form was developed for the IS
PSAs to be used each time a study participant came
in for services. Participants attended services according to their needs and wishes, and no specific
number of meetings with PSAs were arranged. This
form included the same 10 symptoms as the CPT
form as well as a list of activities and services in the
form of a service checklist that the IS PSAs had been
trained to provide. This form was used to monitor
IS services the study participants received during
the study period. A copy of this form is included in
Appendix D.
Maintenance period service monitoring
Following completion of the CPT treatment, women in the CPT and IS villages entered a maintenance
period (August-December 2011) during which they
could access services provided by the PSA in their
village as needed. To monitor any services received,
all PSAs (in the IS and CPT sites) used the simple
IS monitoring form. Additionally, though not required of them, some PSAs at CPT sites formed and
led new CPT groups with women who had not been
invited into the study in order to maintain their own
skills and to meet the needs of other women in the
community.
Follow-up Assessments
Qualitative
Following completion of the CPT intervention, a
brief post-intervention qualitative study was implemented in three of the CPT study villages (one from
each geographic area). The goal was to identify any
unexpected outcomes associated with the CPT intervention and to include questions about these
outcomes in the follow-up interviews (Bolton et
al., 2007). This study utilized free listing interviews
with CPT participants to provide information about
unintended positive and negative effects of participating in CPT as perceived by CPT group participants.
Interviewers who were involved in the qualitative
study conducted prior to the initiation of the evaluation study were contacted and those who were available and were literate in the local study languages
were invited to participate in this activity. Free list
interviewer training was held at the end of July 2011,
with data collection taking place the first week of
August in three CPT villages (Lushebere, Bishange,
and Luvungi). The goal was to interview 30 CPT
participants (10 in each site). For the interviews, respondents were asked two questions:
1. What are all the changes you and your family have experienced in the last 6 months?
2. What are all the changes you and your family have experienced in the last 6 months
because of the CPT program?
These two questions were selected to elicit information on the unintended impact of the CPT. The interviewers were trained to probe for general changes as
well as positive and negative changes. Each interview
was attended by the respondent, the interviewer and
a note-taker. The free list analysis was conducted by
the interviewers and facilitated by JHU. Based on
the analysis and a review of supervision forms by the
CTs and the research team, 28 questions on potential unexpected changes and life events were added
to the quantitative instrument (Section G of the instrument included as Appendix B).
Quantitative Follow-up:
Quantitative follow-up data were collected at two
time points, within one month post-CPT completion and approximately six months later. The followup interview was conducted using the same instrument as was used at baseline, with the addition of
the questions generated from the post-intervention
qualitative assessment (described above). At each
follow-up data collection, interviewers hired and
trained by the IRC, working in pairs, spent one week
in each village interviewing study women. The interviewers were blind to whether the village was a
CPT or IS village.
Immediate post-intervention
The primary objective of this data collection was to
re-interview all study women in the CPT and the
IS sites. A JHU graduate student, together with the
IRC M&E supervisor, trained 30 interviewers in
the quantitative data collection protocol and instrument. Most of these interviewers had been involved
with the baseline quantitative data collection and
were familiar with the process and the instrument,
which made the training more interactive as they
could assist the new interviewers. Data collection
was initiated in all 15 study villages (7 CPT, 8 IS)
during the same week – September 12-16 2011.
Only one village, Bishange, needed to be revisited to
follow-up with study women who had been missed
during the initial interview period. All of the interview forms were returned to the Bukavu IRC office
and data were double entered, cleaned and sent to
JHU for analysis.
Six-month follow-up
Having completed the maintenance period, a second quantitative interview with all study women
was implemented to provide some indication of the
duration of any initial CPT effects. The same instrument was used as for the post-intervention followup. Once again, 30 interviewers working in pairs
completed the interviews over the course of one
week.
Analysis process
Sample Size Determination
Assuming 20% drop-out, 180 participants in each
arm provided 80% power to detect at least a 0.5
point difference in reduction in average symptom
scores between the treatment arms, adjusting for a
variance inflation factor of 2.0. After removing one
CPT village, we expected fewer than 180 recruitments into the CPT arm.
Mental Health and Function score creation
Mental health symptom scores were generated using average scores for each of the measures used
in this study: depression (HSCL-D), anxiety
(HSCL-A), posttraumatic stress (PCL), the functionality tool (DRC), and a measure with only the
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
19
items from the qualitative study (Qual). In addition, two composite scores were generated for each
woman: An HSCL score, which included both the
depression and anxiety measures, as well as an average total symptom score based on all 55 symptom
questions. For each measure, an average of the responses for each question was generated rather than
a total score. Using the average score allowed us to
standardize responses, keeping all measures on the
same metric, with average scores ranging from 0-3.
In addition to measuring mental health symptoms,
an average functional impairment score was calculated for each woman by taking the average of her
responses to each of the 20 tasks. The average scores
could range of 0-4.
dard, two sets of constructs were created based on
the economic variables of the study instrument.
Mental Health cut-off score generation for ‘caseness’
• Hours of domestic work in the seven days preceding the interview
To determine clinically significant levels of distress
for depression and anxiety symptoms, we used a cutoff of an average HSCL score of 1.75, established as
optimal when compared to the Composite International Diagnostic Interview (CIDI) (Sandanger
et al., 1998, 1999) and used with other conflict-affected populations (Mollica, Wyshak, de Marneffe,
Khuon, & Lavelle, 1987)). For the PCL, we used
also used cut-off of 1.75, which is the average of the
standard cut-off score used to define PTSD caseness
for the PCL (i.e. score of 30 divided by 17 items)
(Bliese et al., 2008).
• Total hours of work (regardless of type) in the
seven days preceding the interview
Social resource assessment
A preliminary analysis was undertaken to assess
the impact of CPT on a few of the social resource
variables collected in this trial. For community
participation, we created a total community group
participation score based on the number of different
groups a women reported being a member of (up to
9 different types of groups were asked about). For
the social activities, we took the average of 2 questions asking women to report how often women
visited others or had others visit them (0=never,
1=rarely, 2=sometimes, 3=often).
Composite variables and scale creation for economic outcomes
To measure economic functioning and living stan-
20
The first set of constructs from section E of the study
instrument measures women’s participation in the
labor market and consists of five distinct indicators:
• Hours of paid economic work in the seven
days preceding the interview
• Hours of unpaid economic work in the seven
days preceding the interview
• Hours of total economic work (paid and unpaid) in the seven days preceding the interview
Economic work is defined as all activities that have
direct material benefits for the woman and her
household. This includes paid economic work such
as wage employment (either in cash or in kind) and
lucrative self-employment (e.g. small business, commerce of agricultural products), as well as unpaid
economic work in family-run business and cultivation of the household’s fields. The distinction is that
paid economic work provides the woman with cash
while unpaid economic work results in economic
benefits for the household, but does not result in
any payment for the woman. Domestic work relates
to a range of tasks typically carried out within the
home by women without any kind of remuneration,
and includes time spent cooking, fetching water and
firewood, cleaning the home and taking care of children and elderly persons in the household. These
indicators are standard in the economic literature to
measure women’s participation in the labor market
in developing countries.
The second set of constructs relates to household
living standards and is based on section F of the
study instrument. Two types of indicators were used
to assess the economic situation of households.
To measure current short-run living standards we
calculated the monetary value of the household’s
food consumption during the seven days preceding
the interview. Consumption is a direct measure for
living standards and is more accurate than income
in a context where unpaid economic work is widespread. Following common practice, we asked for
purchases and own-consumption of an extensive
itemized list of foodstuff most commonly consumed
in the region. Own-consumption (that is, consumption of food the woman produced/grew herself)
was converted to monetary values by evaluating the
quantity consumed at current market prices. This
was added to purchases to arrive at the total monetary value of the foodstuff consumed during seven
days. This amount was aggregated over all foodstuffs
and divided by household size to arrive at an estimation of consumption expenditures that can be
compared between households and across data collection time points.
To measure longer-run household living standards
we constructed a wealth index along the lines proposed by Filmer and Pritchett (2001). The idea of
the wealth index is to take all binary asset indicators
included in our study instrument (e.g., materials
used to build the home, ownership of assets and livestock) and combine them into a weighted composite variable (a wealth index). This approach can provide a convenient way to summarize an individual or
a household’s long-run economic status with a limited amount of data. The weights are determined by
the loading of each individual asset variable on the
main component in a principal components analysis
(PCA) including all asset variables. The PCA is the
most commonly used method to construct wealth
indexes even if it suffers from an underlying lack of
theory to motivate either the choice of variables or
the appropriateness of the weights. The wealth index
we constructed includes information on 16 individual asset variables.
Analyses
Baseline characteristics were compared across study
arms using chi-squared and t-tests. Factors associated with loss-to-follow-up were identified using
logistic regression; those at p<0.20 were used to
generate weighting estimates to adjust for loss-tofollow-up (N=135 (33%) were missing post-intervention; N=92 (23%) were missing at six months.
Mental Health and Functionality Outcomes
Intervention impact was calculated by comparing
average scores for women in CPT and IS villages at
each follow up. Analyses included all participants
accounting for loss-to-follow up through a weighting process. Missing values for any specific symptom or function item were imputed based on mean
values for other items in the scale. Random effects
models (xtmixed and xtmelogit) were used for all
impact analyses (Laird & Ware, 1982). As the data
were clustered within therapy groups, villages and
randomization block, multiple random effects were
evaluated. Models with and without the randomization block, compared using the Hausman test
(Hausman, 1978), were not significantly different
(p=.99) so the three-level model was used which
incorporated the individual study participant measured over 3 time points, the therapy group she participated in if in the CPT condition, and the village
in which the participant lived. Time and treatment
condition (CPT/IS access) were included as fixed
effects. All tests were two-sided with statistical significance set at p < 0.05.
Economic Outcomes
To estimate the effects of participation in CPT on
economic outcomes we used the standard specification below (McKenzie, 2012):
EOi,t=α+βEOi,0+ δCPTi+γBCi,0+εi (1)
With EOi,t being the economic outcome of interest
of woman (or household) I at time period t, EOi,0
woman (or household) i’s baseline value of the economic outcome of interest, CPTi an indicator variable for treatment status and BCi,0 a vector of baseline variables to correct for baseline imbalances.
Specification 1 was estimated with t=1 (the immediate post-assessment) and t=2 (the 6-month followup). This estimated the impact of CPT on economic
outcomes immediately after treatment and the longer-run impact six months after the treatment had
been completed, and shed light on the trajectory and
persistence of impacts. We also estimated specification 1 where the post intervention outcome value
is calculated as the average of both post-assessment
outcomes values. Given the variability of many eco-
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
21
nomic indicators, averaging over multiple (in our
case, two) post-intervention measurements can lead
to more precise estimates (McKenzie, 2011).
To take into account the fact that the randomization
was done at the block level (i.e., with villages clustered into blocks of 2-4 villages), block dummies
were added in the estimation of specification (1)
and standard errors were clustered at the level of the
CPT group.
Specification (1) was estimated by the standard
22
Ordinary Least Squares (OLS) method. Plotting
the economic outcomes, however, shows heavily
skewed distributions with fat tails. We therefore also
estimated specification 1 using quintile median regression (which is more robust to outliers and extremes).
All analyses were conducted using Stata version 12.
More specific information about the analyses can be
obtained by contacting the authors (jbass@jhsph.
edu for mental health analyses and Jeannie.annan@
rescue.org for economic analyses).
RESULTS
Description of participation
A total of 494 women provided informed consent
and were screened for eligibility (Figure 1). Of
these, 440 (89%) met inclusion criteria; seven who
were excluded for severe suicidality (as determined
through a high risk protocol, Appendix E) received
immediate assistance by PSAs and IRC staff. Of
the 433 eligible women, 402 (93%) agreed to participate in the study. An additional four women who
did not meet the symptom cut-off criteria were mistakenly recruited in one of the CPT villages and are
included in the analysis. After dropping one CPT
participant due to paperwork errors, the final study
population included 405 women.
Fifty-three women (13.1%) were unable to be reassessed at either the post-intervention or 6-month
follow-up interview, 46 of whom lived in IS villages
and 7 in CPT villages. Eighty-two (20%) women
who missed the post-intervention assessment were
found and assessed at the 6-month follow-up. In total, 354 (87%) of the 405 women invited to participate in the study completed at least one assessment
(post-intervention, 6-month follow-up or both) and
231 women (57%) completed both. Factors associated with loss to follow-up included older age, being
in a IS village, being pregnant at baseline, and witnessing and experiencing a wider range of traumas.
The rate of follow-up differed by language that the
interview was conducted in. Problems with security and cases where the wrong women were interviewed reduced follow-up numbers.
In the CPT villages, 141 (89%) were considered
treatment completers, having attended at least nine
of the 12 treatment sessions; the nine sessions did
not need to be consecutive. Women in CPT groups
who missed a session were visited by PSAs to identify reason for absence and encouraged to rejoin.
Among the women who dropped out (i.e., attended
fewer than nine sessions) most cited family obligations and agricultural duties as reasons. One CPT
participant died near the end of the treatment due
to a violent incident in the community. In the IS villages, 182 (73%) study participants utilized at least
one session with the PSA, with 20 participants attended 1-2 sessions; 45 participants attended 3-4
sessions; 88 participants attended 5-6 sessions; 27
participants attended 7-8 sessions; and one participant attending nine and one participant attended
eleven sessions. Among those who utilized any of
the PSA services, the average number of sessions
was five. PSAs in IS villages actively invited women
to continue to engage in available services (if they
were currently a client) or invited them back to receive services (if they were a prior client) at the beginning of the study and were available throughout
the intervention period for women who sought their
services.
Despite regional instability, greater than two-thirds
of women were living in the same area where they
were born. Comparing women in the CPT and IS
villages at baseline identified some significant differences in the make-up of the treatment conditions
(Table 1). Demographically, the women in the CPT
villages were on average nearly three years older
and had a 16% greater prevalence of being married,
compared with women in the IS villages. In terms of
symptoms and functional impairment, the women
in IS villages on average reported more functional
impairment at baseline and more severe symptoms,
which resulted in a larger proportion meeting the
cut-off for clinically significant symptoms. Women
in the CPT villages reported greater variety in types
of different traumas experienced and witnessed
compared with women in the IS villages. There were
five different traumas a woman could have reported
experiencing and six different traumas a women
could have reported witnessing, thus the range of
scores could be 0-5 and 0-6, respectively. Tables 2
and 3 provide the differences in demographics and
total symptom and function scores separately by village.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
23
Figure 1. Flow chart of study participants
16 villages randomized for study
1 CPT village excluded because of
counselor capacity
Allocated to IS (n=8 villages)
273 women assessed for eligibility
248 Eligible women
invited to participate
25 non-eligible
7 non-survivors
14 low symptoms
or dysfunction
4 actively suicidal
Allocated to CPT (n=7 villages)
221 women assessed for eligibility
188 Eligible women
158 women invited to
participate
154 eligible +
4 ineligible
33 non-eligible
10 non-survivors
23 low symptoms or
dysfunction
3 actively suicidal
32 eligible women not
invited because group
size met
8 permanently lost to follow-up
1 id number not verified*
1 death
6 no information
156 (63%) completed
post-intervention
assessment
114 (73%) completed
post-intervention
assessment
175 (71%) completed 6month follow-up
assessment
138 (88%) completed 6month follow-up
assessment
248 included in analysis
129 (52%) completed postintervention and 6-month follow-up
assessments
73 (29%) only completed post-intervention
or 6-month follow-up assessments
46 (19%) completed only baseline
157 included in analysis
102 (65%) completed postintervention and 6-month follow-up
assessments
48 (31%) only completed post-intervention
or 6-month follow-up assessments
7 (4%) completed only baseline
25
* The sample was recruited from NGO clients lists serving sexual violence survivors we can assume 100% of the sample
experienced rape. However, given that not all women will want to share this information, it was not surprising that a small
proportion (N=22; 5%) reported witnessing but not experiencing rape.
** For one CPT participant treatment id could not be matched with a study id, therefore this participant could not be included in
any analysis.
24
Baseline demographic, mental health, and functioning characteristics of
the CPT and IS samples
Table 1. Study Sample Characteristics at Trial Baseline (n=405)
Variable
CPT
(n=157)
IS
(n=248)
Demographic characteristics
Age in years, Mean (SD)*
36.89 (13.44)
33.77 (12.43)
Years of education completed, Mean (SD)
1.76 (2.76)
2.25 (3.14)
Number of people living in home, Mean (SD)
7.41 (3.15)
6.81 (3.32)
Number of children responsible for, Mean (SD)
3.96 (2.67)
4.06 (2.76)
Single
20 (12.74)
35 (14.11)
Married
93 (59.24)
107 (43.15)
Divorced
1 (0.64)
11 (4.44)
Separated
19 (12.10)
43 (17.34)
Widowed
24 (15.29)
52 (20.97)
130 (82.80)
194 (78.23)
Average typesa traumas experienced, Mean (SD)*
3.91 (1.08)
3.36 (1.36)
Average typesa traumas witnessed, Mean (SD)*
5.20 (1.28)
4.06 (1.96)
1.66 (0.69)
2.48 (0.82)
1.91 (0.51)
2.20 (0.44)
Average HSCL score greater than 1.75, No. (%)*
110 (70.97)
208 (83.87)
Average PCL score greater than 1.75, No. (%)*
90 (58.06)
200 (80.65)
Food Expenditures per capita (CDR), Mean (SD)*
965.2 (91.4)
718.7 (73.9)
Score on Asset Index, Mean (SD)*
0.114 (0.09)
-0.204 (0.05)
Hours of Economic Work per Week, Mean (SD)*
24.4 (1.8)
17.9 (1.5)
Hours of Domestic Work per Week, Mean (SD)*
35.1 (2.2)
40.2 (1.6)
Marital Status, No. (%)*
Living in territory of origin, No. (%)
Trauma Exposure Data
Functionality Outcome
Average functional impairment score, Mean (SD)*
Baseline Symptom Scale Score
Average Total Symptom score, Mean (SD)*
Indicators of Clinical Significance
Economic Indicators
*Between arm difference significant at the 0.05 level
Respondents were asked whether they had personally experienced 5 different types of traumas and/or witnessed 6 different
types of traumas.
a
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
25
26
1.63 (2.97)
5.89 (2.85)
4.26 (1.91)
Years of education completed, Mean
(SD)
Number of people living in home,
Mean (SD)
Number of children responsible for,
Mean (SD)
0 (0.00)
5 (26.32)
8 (42.11)
Divorced
Separated
Widowed
Average Total Symptom score, Mean
(SD)
Baseline Symptom Scale Score
Average functional impairment, Mean
(SD)
2.00 (0.32)
2.29 (0.57)
5.63 (0.68)
Average different traumas witnessed,
Mean (SD)
Functionality Outcome
4.32 (0.82)
Average different traumas experienced,
Mean (SD)
Trauma Exposure Data
19 (100.00)
4 (21.05)
Married
Living in territory of origin, No. (%)
2 (10.53)
Single
Marital Status, No. (%)
35.11(13.2)
Age in years, Mean (SD)
Demographic characteristics
Village/Language/NGO
Buzunga
Kihavu
ADIF
(n=19)
2.44 (0.48)
2.64 (0.65)
5.34 (1.21)
4.49 (0.74)
31 (88.57)
9 (25.71)
13 (37.14)
1 (2.86)
0 (0.00)
12 (34.29)
2.66 (2.42)
5.46 (3.99)
3.86 (3.65)
24.89 (6.68)
Kiniezire
Kihavu
UEFA
(n=35)
1.90 (0.40)
1.15 (0.42)
4.16 (1.76)
2.88 (1.07)
24 (75.00)
8 (25.00)
1 (3.13)
5 (15.63)
15 (46.88)
3 (9.38)
5.56 (3.29)
7.56 (3.97)
2.09 (2.80)
41.41 (13.46)
Lusambo
Kibembe
PSVS
(n=32)
2.00 (0.40)
2.36 (0.66)
3.77 (1.87)
3.30 (1.29)
21 (70.00)
0 (0.00)
0 (0.00)
1 (3.33)
27 (90.00)
2 (6.67)
4.4 (3.06)
8.1 (3.38)
1.63 (3.20)
32.5 (7.52)
Makobola
Kifuliru
PSVS
(n=30)
2….10 (0.45)
2.47 (0.49)
4.27 (1.48)
3.13 (1.53)
23 (76.67)
2 (6.67)
4 (13.33)
0 (0.00)
22 (73.33)
2 (6.67)
3.4 (1.71)
6.37 (2.68)
1.23 (2.53)
37.47 (14.79)
Mulengeza
Kihavu
ADIF
(n=30)
2.36 (0.25)
3.09 (0.34)
2.64 (2.28)
4.03 (1.11)
22 (61.11)
6 (16.67)
4 (11.11)
4 (11.11)
9 (25.00)
13 (36.11)
2.94 (2.16)
6.97 (3.13)
3.86 (3.78)
27.22 (9.62)
Nyabibwe
Kihavu
UEFA
(n=36)
2.40 (0.34)
2.88 (0.80)
4.16 (2.06)
2.66 (1.24)
29 (76.32)
14 (36.84)
9 (23.68)
0 (0.00)
15 (39.47)
0 (0.00)
5.08 (3.11)
7.16 (3.06)
1.60 (2.38)
42.18 (11.83)
Runingu
Kifuliru
PSVS
(n=38)
Table 2. Study Sample Characteristics in Individual support Villages at Trial Baseline (n=248)
2.20 (0.50)
2.76 (0.69)
3.11 (1.79)
2.29 (1.15)
25 (89.29)
5 (17.86)
7 (25.00)
0 (0.00)
15 (53.57)
1 (3.57)
4.32 (2.37)
6.64 (2.44)
1.39 (2.17)
29.68 (7.92)
Sange
Kifuliru
PSVS
(n=28)
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
27
1.96 (2.08)
5.74 (2.77)
2.35 (2.14)
Years of education completed, Mean (SD)
Number of people living in home, Mean (SD)
Number of children responsible for, Mean
(SD)
0 (0.00)
4 (17.39)
3 (13.04)
Divorced
Separated
Widowed
Average Total Symptom score, Mean (SD)
Baseline Symptom Scale Score
Average functional impairment score, Mean
(SD)
1.58 (0.66)
1.54 (0.76)
4.87 (1.96)
Average different traumas witnessed, Mean
(SD)
Functionality Outcome
4.17 (0.94)
Average different traumas experienced,
Mean (SD)
Trauma Exposure Data
19 (82.61)
8 (34.78)
Married
Living in territory of origin, No. (%)
8 (34.78)
Single
Marital Status, No. (%)
26.87 (9.22)
Age in years, Mean (SD)
Demographic characteristics
Village/Language/NGO
Bishange
Kihavu
UEFA
(n=23)
1.86 (0.34)
1.33 (0.47)
4.74 (1.15)
3.47 (1.47)
16 (84.21)
3 (15.79)
4 (21.05)
0 (0.00)
6 (31.58)
6 (31.58)
3.11 (2.60)
8.42 (4.36))
4.16 (3.98)
31.16 (12.81)
Kiliba
Kifuliru
PSVS
(n=19)
1.76 (0.37)
2.03 (0.44)
5.63 (0.58)
3.92 (0.97)
22 (91.67)
5 (20.83)
0 (0.00)
1 (4.17)
18 (75.00)
0 (0.00)
4 (2.25)
7.25 (2.23)
0.79 ( 1.41)
34.88 (10.21)
Lushebere
Kihavu
ADIF
(n=24)
1.91 (0.35)
1.22 (0.54)
4.45 (1.30)
3.22 (1.27)
11 (52.38)
1 (4.76)
3 (14.29)
0 (0.00)
15 (71.43)
2 (9.52)
3.45 (2.18)
6.45 (2.81)
3.36 (3.32)
33.27 (10.27)
Luvungi
Kifuliru
PSVS
(n=22)
2.06 (0.51)
1.25 (0.37)
5.71 (0.46)
3.95 (0.92)
16 (76.19)
6 (28.57)
4 (19.05)
0 (0.00)
11 (52.38)
0 (0.00)
4.86 (2.41)
8.71 (2.85)
0.14 (0.65)
46.71 (10.68)
Mabingu
Mashi
ADIF
(n=21)
Table 3. Study Sample Characteristics in CPT Villages at Trial Baseline (n=157)
2.00 (0.46)
1.87 (0.60)
5.67 (0.70)
4.13 (0.80)
22 (95.65)
4 (17.39)
1 (4.35)
0 (0.00)
15 (65.22)
3 (13.04)
4.25 (3.19)
7.29 (2.79)
1.63 (2.70)
36.13 (14.98)
Mantu
Mashi
ADIF
(n=24)
2.18 (0.54)
2.15 (0.89)
5.21 (1.56)
4.38 (0.82)
22 (91.67)
2 (8.33)
3 (12.50)
0 (0.00)
19 (79.17)
0 (0.00)
5.54 (2.70)
8.25 (3.34)
0.71 (1.90)
48.5 (10.86)
Nyamukubi
Kihavu
ADIF
(n=24)
Mental Health Outcomes
Comparison of CPT to IS samples
Although there were differences across villages at
baseline across the two treatment conditions, the
evaluation team concluded, through a review of the
randomization process and discussion with interviewers and study staff, the differences were not due
to any systematic bias (i.e., decision on the part of
the program, researchers, or study interviewers to
specifically recruit and enroll participants different
from those in other communities). Thus comparing
women in the CPT to IS is possible with the longitudinal analytic methods accounting for baseline
differences across study conditions.
Table 4 below presents the comparison of women in
CPT and IS villages across all of the mental health
outcomes. For each outcome, average scores are
provided from the baseline and follow-up assessments of those who completed the follow-up. The
estimate of treatment effect is provided based on
the longitudinal regression analysis that adjusts for
differences in the treatment arms at baseline and
weights for loss to follow-up. The treatment effect
is the estimated difference in amount of average
change experienced by the women in CPT compared with women with access to IS participants, together with 95% confidence intervals. Confidence
intervals that include a value of 0.0 would imply that
the difference in average change between CPT and
IS was not statistically significant.
Table 4: CPT and IS symptom scores and impacts at each follow up*
Observed Score
% Change from baseline
Estimated
difference
CPT
IS
CPT
IS
(95% CI)**
Average Depression scores
Baseline
Post-Intervention
6-month follow-up
1.90
0.82
0.75
2.16
1.67
1.51
57%
61%
23%
30%
0.78 (0.45-1.12)
0.64 (0.28-1.02)
Average Anxiety scores
Baseline
Post-Intervention
6-month follow-up
2.04
0.80
0.73
2.23
1.67
1.52
61%
64%
25%
32%
0.93 (0.60-1.26)
0.83 (0.46-1.21)
Average Trauma scores
Baseline
Post-Intervention
6-month follow-up
1.85
0.75
0.70
2.21
1.67
1.53
59%
62%
24%
31%
0.96 (0.62-1.30)
0.84 (0.45-1.23)
Average Qualitative scores
Baseline
Post-Intervention
6-month follow-up
1.94
0.75
0.71
2.22
1.68
1.52
61%
63%
24%
32%
0.88 (0.55-1.21)
0.75 (0.40-1.11)
Average HSCL-25 scores
Baseline
Post-Intervention
6-month follow-up
1.97
0.81
0.74
2.20
1.67
1.52
59%
62%
24%
31%
0.86 (0.53-1.19)
0.74 (0.38-1.11)
Average Total Symptoms
Baseline
Post-Intervention
6-month follow-up
1.91
0.75
0.71
2.20
1.65
1.50
61%
63%
25%
32%
0.86 (0.53-1.19)
0.74 (0.38-1.11)
*Data presented based on observed rates; probable caseness was defined using cut-off scores of 1.75 on the HSCL-25
**Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly
different comparing women in CPT with women in IS villages at baseline and related to change in symptoms over time: age,
pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in
the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village,
treatment group within village, and the individual participant level indicators.
28
Based on the results above (Table 4), CPT participants had significantly greater change in average
symptoms across all outcomes compared with those
with access to IS. At the post-intervention assessment, the percent change was twice as great among
CPT participants compared with the percent change
among those with access to IS across all outcomes.
At the 6-month follow-up, the difference was reduced a very small amount, indicating that initial intervention effects were maintained. The results for
the HSCL combined depression and anxiety scales
and the trauma symptoms as measured using the
PCL measure are presented graphically in Figure 2.
Table 5 presents a comparison of women in CPT
with IS villages on percent of probable caseness for
depression/anxiety and PTSD. This analysis represents an alternate way to examine the data compared
with the previous analysis of change in symptom severity. In this analysis, we are looking specifically
Figure 2 : Average scores on the combined depression/anxiety scales using the Hopkins
Symptom Checklist (HSCL-25) and the trauma scale using the PTSD Checklist (PCL) across
the trial assessment points. Average scores on the HSCL-25 and PCL range from 0 to 3
with scores higher than 1.75 consistent with clinically significant levels and depression/
anxiety and PTSD
Legend
Dark Blue: 2IS Depression/Anxiety
Light Blue: CPT Depression/Anxiety
Dark Purple: IS Posttraumatic Stress
Light Purple: CPT Posttraumatic Stress
Table 5: Probable cases of depression/anxiety and PTSD and impacts at each follow up*
Relative Risk
CPT
IS
(95% CI; p-value)**
Probable Depression/Anxiety cases
Baseline, N (%)
Post-intervention, N (%)
6-month follow-up, N (%)
111 (70.7)
11 (9.7)
12 (8.7
206 (83.1)
82 (52.6)
73 (41.7)
7.3 (3.4 - 16.8; <0.001)
4.6 (2.1 - 11.1; <0.001)
Probable PTSD cases
Baseline, N (%)
Post-intervention, N (%)
6-month follow-up, N (%)
94 (59.9)
9 (7.9)
12 (8.7)
205 (82.7)
85 (54.5)
73 (41.7)
12.3 (5.2 - 30.5; <0.001)
5.5 (2.5 - 13.2; <0.001)
* Data presented based on observed rates; probable caseness was defined using cut-off scores of 1.75 on the HSCL-25
(depression/anxiety cases) and on the PCL trauma measure (PTSD cases).
**Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly
different comparing women in CPT with IS villages at baseline and related to change in symptoms over time: age, pregnancy
status, marital status (married yes/no), language, range of time living in this village, total number of people living in the home,
number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village, treatment
group within village, and the individual participant level indicators.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
29
0
Scale Score
1
2
3
Figure 3 - Box plot of HSCL and PCL scores with the dark horizontal line
indicating the 1.75 cut-off*
Control
CPT
1 hscl
1 trauma
2 hscl
2 trauma
3 hscl
3 trauma
*1 hscl and 1 trauma reference the baseline HSCL-25 and PCL scores by treatment arm (IS/CPT). 2 hscl and 2 trauma reference
the respective scores at the post-intervention follow-up. 3 hscl and 3 trauma reference the respective scores at the 6-month
follow-up assessments.
at the rate at which participants in each group who
met our criteria for a clinical case of disorder (i.e.,
had scores of greater 1.75) went into remission –
which basically means they no longer met criteria
as a clinical case. For both outcomes, women with
access to IS were at significantly greater risk of remaining a probable case of Depression/Anxiety and
PTSD compared with those in the CPT arm at the
post-intervention assessment and at the 6-month
follow-up. Figure 3 further shows that the remission
rates are not due to cases simply ‘dipping’ below the
cut-off score of 1.75; rather, a review of the box plots
shows that among the CPT participants, the majority have had their symptom severity scores significantly reduced.
30
Function and Social Resource
Outcomes
Comparison of CPT to access to IS women
Table 6 below presents the results of the analysis
comparing average functional impairment scores of
women in CPT villages with women in access to IS
villages. Functional impairment was assessed with
a series of 20 tasks and activities of daily living. As
with the symptom outcomes above, the women in
CPT villages showed significantly greater improvement compared with women in the access to IS villages.
Table 7 presents a comparison of CPT to IS samples
across 2 domains of social resources: participation
Table 6: CPT and IS function scores and impacts at each follow up*
Observed
Average Function scores
Baseline
Post-Intervention
6-month follow-up
% Change from baseline
Effect Estimate
CPT
IS
CPT
IS
(95% CI)*
1.65
0.82
0.88
2.48
1.92
1.77
50%
47%
23%
29%
1.08 (0.63-1.53)
0.90 (0.41-1.39)
* Data presented based on observed rates.
**Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly
different comparing women in CPT with women in IS villages at baseline and related to change in symptoms over time: age,
pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in
the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village,
treatment group within village, and the individual participant level indicators.
Table 7: CPT and IS social resource ratings and impacts at each follow up*
Observed
% Change from baseline
Effect Estimate
CPT
IS
CPT
IS
(95% CI)*
Average number of groups
participating in
Baseline
Post-Intervention
6-month follow-up
3.04
3.68
3.96
2.69
3.23
2.85
21%
30%
20%
06%
0.09 (-1.18, 1.35)
0.88 (-0.28, 2.05)
Average frequency of visiting
with others**
Baseline
Post-Intervention
6-month follow-up
1.20
1.69
1.72
1.14
1.43
1.34
41%
43%
25%
18%
0.11 (-0.37, 0.58)
0.24 (-0.19, 0.66)
* Data presented based on observed rates. The range of possible numbers of groups is 0-9; frequency of visitation value is based
on reporting the average frequency of visiting others/having others visit you: 0=never, 1=rarely, 2=sometimes, 3=often
**Regression analyses used all available data and incorporated adjustment for variables that were statistically significantly
different comparing women in CPT with women in IS villages at baseline and related to change in symptoms over time: age,
pregnancy status, marital status (married yes/no), language, range of time living in this village, total number of people living in
the home, number of children responsible for, range of traumas witnessed and experienced, as well as random effects for village,
treatment group within village, and the individual participant level indicators.
in community groups and frequency of visiting with
others. There were no statistically significant differences between the treatment conditions, though
the trends show greater increases among women in
the CPT compared with women in the access to IS
arms.
Economic Outcomes
As with the mental health outcomes, the randomization of villages into CPT and IS conditions did
not produce a good balance on baseline economic
variables. As shown in Table 1 above, the economic
situation of CPT women at baseline was on average
better than that of IS women: Per capita expenditures on food were higher for treatment (CDF 965.2
or 2.17 PPP USD10) than for IS women (CDF
718.7 or 1.61 PPP USD) and their score on the asset
index-a composite indicator of household wealthwas substantially higher. In line with this, treatment
women performed on average more economic work
(24.4 hours per week) than IS women (17.9 hours
per week). Women in the IS villages on average per-
10 We used the last purchasing power parity conversion factor
available for private consumption: $444.84 in 2008. Source: http://
data.worldbank.org/indicator/PA.NUS.PRVT.PP
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
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Table 8: Baseline Characteristics for lost to follow-up and completed at least one
follow-up interview
Loss to follow-up
(N=53)
Completed follow-up
(N=352)
Mean Diff
Food Expenditures per Capita
(CDF), Mean (SD)
961.3 (280.3)
792.3 (51.4)
-169 (170.9)
Score on Asset Index, Mean (SD)
-0.107 (0.104)
-0.076 (0.050)
-0.03 (0.135)
Hours of Economic Work
(Week), Mean (SD)
15.8 (2.8)
21.1 (1.3)
-5.3 (3.4)
Hours of Domestic Work
(Week), Mean (SD)
40.2 (3.7)
38 (1.4)
2.2 (3.9)
formed more domestic work.
Table 8 below shows the baseline economic characteristics for women who were re-interviewed after
the intervention and women who were not (lost
to follow-up). We did not see any significant differences regarding their economic outcomes. Baseline
per capita food expenditures were somewhat higher
for women who did not complete a follow-up interview than for women who completed a least one
post-intervention assessment, asset holdings of lost
to follow-up women were somewhat lower at baseline and these women also performed fewer hours of
economic work. None of the differences is however
statistically significant.
It is also important to examine whether attrition
among CPT participants differs systematically from
attrition among the IS participants, which would
jeopardize the comparability of the randomized
groups. To highlight the patterns of attrition, Table
9 shows baseline characteristics of CPT and IS lost
to follow-up. The seven CPT lost to follow-up women were better off in economic terms than were the
IS lost to follow-up women: their average per capita
food expenditures (CDF 1,810 or 4.1 PPP USD)
were more than double than those of the IS lost to
follow-up (CDF 832.2 or 1.87 PPP USD) and their
score on the asset index was higher (statistically significant at p<0.05).
The observation that participants lost to follow-up
in the CPT condition were better-off than IS lost to
follow-up may point to a possible underestimation
of CPT’s economic impact. Since wealthier women
dropped out of the CPT group, the remaining CPT
32
participants may represent a less privileged part of
the original CPT sample. Exploring baseline differences between CPT and IS women after loss to
follow-up, however, suggests that this is unlikely to
be a problem, as the CPT group is still better-off
than the IS group even considering loss to followup. Women in the CPT group had higher food expenditures, a higher score on the asset index, and
performed more hours of economic work and less
hours of domestic work.
Table 10 shows the means of the economic outcomes at baseline, post-intervention and 6-month
follow-up for the CPT and IS participants. Between
baseline and post-intervention, the hours of economic work performed (both paid and unpaid) increased for CPT women and stayed approximately
the same for IS women. At the 6-month follow-up
however, economic work in the CPT group had
fallen back to baseline levels. Per capita food expenditures increased in both the CPT and IS groups.
The magnitude of the increase was exactly the same
for CPT and IS women (average increase of 66%).
While the score on the asset index (a standardized
variable) dropped for CPT women, it increased for
IS women. These descriptive statistics give us a first
sense of the evolution of economic outcomes in
both groups but a proper empirical analysis is needed to provide a rigorous impact assessment.
Table 11 shows the estimated impact of CPT on the
different economic outcomes (estimates of
in
specification 1) compared with IS. The first row in
Table 12 reports the estimates of the immediate impact (at post-intervention), the second row presents
the longer-run impact (at 6-month follow-up) and
Table 9: Baseline Characteristics of CPT and IS Lost to Follow-Up
CPT Lost to FollowUp
(N=7)
IS Lost to Follow-Up
(N=46)
Mean Diff
Food Expenditures per Capita
(CDF), Mean (SD)
1810 (1087)
832.2 (279)
977.8 (824.8)
Score on Asset Index, Mean (SD)
0.524 (0.321)
-0.203 (0.104)
0.727 (0.294)**
Hours of Economic Work
(Week), Mean (SD)
21.3 (5.0)
15 (3.1)
6.3 (8.3)
Hours of Domestic Work (Week),
Mean (SD)
40.1 (10.5)
40.2 (3.9)
-0.1 (10.9)
** indicates significance at the 0.05 level.
the third row reports the estimated impacts using
the average of the two post intervention assessments
as unique follow-up measurement. The analysis reveals positive impacts of CPT participation on the
number of hours of economic work performed per
week (both paid and unpaid). At the post-intervention assessment CPT women performed on average
6.3 hours more paid economic work and 7.7 hours
more unpaid economic work per week than IS women. The estimates are statistically significant at the
1% level. We also find a positive impact on per capita expenditures on food11. At the post-intervention
assessment median food consumption expenditures
were 354 CDF (or 0.8 PPP USD) higher for CPT
than for IS women. Finally, we find a small negative
effect on assets; however, the magnitude is insignificant from both an economic and statistical point of
view.
11 the coefficient is only statistically significant when using quintile
regression (which estimates the conditional median instead of the
conditional mean)
Focusing on the 6-month follow-up, we find that all
effects had become smaller or had subsided. We still
find a statistically significant effect on the number
of hours of paid economic work per week (three extra hours for the CPT women compared to the IS
women), though the impact on unpaid economic
work is small and insignificant. The positive impact
on per capita food expenditures is still observed at
the 6-month follow-up. The estimated coefficients
are smaller compared to the immediate post-intervention assessment but still significant when using
quantile regression. The difference in asset holdings
is not statistically significant. The last row in table
11 presents the estimates using the average of the
post-intervention assessments as unique post measurements. Overall the estimates suggest a modest
positive economic impact of CPT compared to IS.
Overall, we find a positive impact of CPT compared
to IS on economic work and to a lesser extent on
food expenditures. However, these effects decrease
or disappear after 6-months.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
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Table 10: Descriptive Statistics for CPT and IS Participants at Baseline and Follow-Ups
CPT
SI
Baseline (SD)
14.66 (16.37)
10.81 (17.52)
Post-Intervention (SD)
15.74 (12.93)
8.66 (9.54)
6-month follow-up (SD)
13.78 (13.77)
8.71 (9.87)
Baseline (SD)
10.67 (13.49)
7.37 (13.29)
Post-Intervention (SD)
14.75 (11.86)
8.57 (11.86)
6-month follow-up (SD)
12.33 (9.97)
9.96 (9.98)
Baseline (SD)
25.26 (23.91)
17.91 (23.37)
Post-Intervention (SD)
30.48 (20.41)
17.05 (15.99)
6-month follow-up (SD)
25.24 (17.96)
18.87 (14.71)
Baseline (SD)
35.1 (27.8)
40.2 (25.5)
Post-Intervention (SD)
37.7 (19.8)
54.9 (28.0)
6-month follow-up (SD)
38.6 (21.1)
46.1 (26.8)
Baseline (SD)
965.2 (1144.7)
718.7 (1161.8)
Post-Intervention (SD)
1148.1 (1923.4)
728.7 (1000.5)
6-month follow-up (SD)
1604.4 (1609.3)
1193.6 (1251.9)
Baseline (SD)
0.114 (1.11)
-0.204 (0.75)
Post-Intervention (SD)
0.013 (1.05)
-0.024 (0.96)
6-month follow-up (SD)
0.043 (0.99)
-0.063 (1)
Average Hours Paid Economic Work
Average Hours Unpaid Economic Work
Average Hours Total Economic Work
Average Hours Domestic Work
Per Capita Food Expenditures
Score on Asset Index
Note: All regressions control for baseline demographic variables such as age, age-squared, years of education, household size,
and marital status. Analyses also include dummy variables for identifying the village block used for randomization.
34
Table 11: Estimated Impact of CPT on Economic Outcomes
Paid Economic Work
Unpaid Economic
Work
Food
Expenditures
Asset Index
N
OLS
6.3***
7.7***
494.5
-0.044
270
[SD]
[1.54]
[1.05]
[360.3]
[0.153]
QR
5.7***
8.8***
354.4***
-0.065
[1.73]
[1.7]
[86.6]
[0.142]
OLS
2.9**
1.0
362.2
0.103
[SD]
[1.3]
[1.4]
[239.3]
[0.117]
QR
2.7*
1.9
260.2**
0.108
[1.4]
[1.4]
[125.5]
[0.125]
OLS
4.9***
3.4***
388.0*
0.049
[SD]
[1.3]
[1.1]
[225.7]
[0.116]
QR
5.0***
3.4***
292.0***
0.040
[1.2]
[1.2]
[100.3]
[0.104]
Post Intervention
270
6-month Follow-Up
311
311
Average Follow-Up
350
350
Note: ***, **, and * indicate significance at the 1, 5, and 10 percent levels respectively. Two specifications are presented for each of
the three rows: Ordinary Least Squares (OLS) and Quintile Median Regression (QR).
Qualitative follow-up results
Qualitative interviews
The sample of CPT participants interviewed during
the post-intervention qualitative study spoke about
positive and negative changes in the free list exercise. The most commonly mentioned changes in the
lives of participants across all three sites were having harmony with others and having strength. Some
changes were mentioned more frequently in one or
two sites but not all three. While some participants
in Bishange mentioned having no more fear and not
having a lot of thoughts, more people in Luvungi
and Lushebere mentioned these two changes. In
Luvungi and Bishange, participants spoke about
changes in poverty status (positively and negatively)
as well of the problem of lack of mutual comprehension with family members. Participants in Lushebere and Bishange spoke about not being ashamed,
not being discriminated against anymore and feeling
free, but these changes were not mentioned in the
Luvungi site. Participants in Lushebere mentioned
how they are no longer abandoning themselves.
They used this term to refer to how they now care
for themselves and their children. Participants in
Lushebere also spoke about how they reestablished
their physical state, don’t hate men, don’t underestimate themselves, and have power now.
When asked about changes specifically due to the
program, participants mentioned many of the same
changes that they had identified in the prior question and some new changes. Being in harmony with
others was the most commonly mentioned change
and was mentioned in three field sites. In Luvungi,
participants spoke about having stability or peace.
In Luvungi and Bishange, participants mentioned
not having fear and reduced poverty in relation to
participating in the program, even though in general they did say it was a problem in response to
the first question. In Lushebere, participants spoke
about not being discriminated against, being ill, hav-
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
35
Table 13. Report of amount of change from baseline to post-intervention
Post-Intervention
IS (n=155)
CPT (n=114)
Worse
Same
Better
Worse
Same
Better
G1 Harmony with husband
30%
5%
32%
12%
7%
48%
G2 Harmony with children
23%
12%
62%
7%
8%
77%
G3 Harmony with neighbors
23%
15%
61%
5%
11%
86%
G4 Harmony with family
21%
23%
53%
2%
8%
89%
G5 Strength to do work
34%
21%
44%
9%
7%
83%
G6 Strength to go to market
26%
18%
49%
12%
9%
76%
G7 Having good thoughts
30%
15%
53%
9%
5%
85%
G8 Not ashamed in front of others
32%
19%
47%
5%
4%
88%
G11 Peaceful environment in home
34%
16%
49%
4%
3%
93%
G12 Peaceful environment in
community
28%
30%
50%
5%
2%
93%
G9 Hatred against men
39%
20%
37%
19%
8%
68%
G10 Discriminated against by others
32%
21%
45%
6%
4%
83%
G13 Wearing clean clothes and shoes
29%
28%
43%
10%
18%
72%
G14 Taking baths
20%
11%
69%
4%
6%
88%
G15 Wearing makeup
25%
12%
36%
7%
15%
67%
G18 Thinking about how food affects
your body
25%
27%
41%
12%
32%
63%
G16 Making sure your children look
clean
20%
12%
66%
3%
6%
87%
G17 Cooking food for family
19%
14%
65%
4%
8%
88%
G19 Thinking of having more children
33%
17%
29%
26%
18%
32%
Harmony:
Strength:
Positive feelings:
Negative feelings:
Care of self:
Care for family:
* data are presented as percentages; results may not sum to 100% due to missing data and/or responses indicating that the
questions were not relevant.
36
Table 14. Report of amount of change during maintenance period
6-month Follow up
IS (n=175)
CPT (n=138)
Worse
Same
Better
Worse
Same
Better
G1 Harmony with husband
25%
7%
27%
13%
8%
43%
G2 Harmony with children
21%
9%
70%
4%
12%
81%
G3 Harmony with neighbors
22%
12%
66%
7%
10%
83%
G4 Harmony with family
25%
13%
61%
15%
9%
76%
G5 Strength to do work
37%
12%
51%
14%
9%
76%
G6 Strength to go to market
29%
15%
53%
12%
15%
70%
G7 Having good thoughts
32%
19%
49%
9%
5%
86%
G8 Not ashamed in front of others
29%
18%
53%
2%
7%
91%
G11 Peaceful environment in home
27%
14%
59%
6%
9%
75%
G12 Peaceful environment in
community
22%
16%
62%
6%
6%
88%
G9 Hatred against men
37%
18%
45%
12%
7%
77%
G10 Discriminated against by others
33%
18%
48%
7%
11%
82%
G13 Wearing clean clothes and shoes
28%
19%
52%
10%
12%
76%
G14 Taking baths
18%
9%
74%
2%
2%
96%
G15 Wearing makeup
20%
21%
42%
12%
10%
77%
G18 Thinking about how food affects
your body
25%
26%
45%
25%
15%
59%
G16 Sure your children look clear
19%
10%
70%
3%
4%
88%
G17 Cooking food for family
21%
10%
68%
3%
12%
85%
G19 Thinking of having more children
45%
23%
28%
33%
22%
33%
Harmony:
Strength:
Positive feelings:
Negative feelings:
Care of self:
Care for family:
* data are presented as percentages; results may not sum to 100% due to missing data and/or responses indicating that the
questions were not relevant.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
37
ing many thoughts and death. In both Luvungi and
Lushebere, participants spoke about being cured. In
Bishange, participants spoke about feeling free.
Preliminary analysis of quantitative items
from items added based on qualitative
study
Based on the frequently mentioned changes from
the qualitative study, a series of additional questions
were added to the quantitative interview to reflect
possible unexpected changes due to participation in
CPT. By including them in the interview and asking the questions to both CPT and IS participants,
we can explore whether these differences may be
due to the CPT program or to factors common to
both groups (CPT and IS). For each type of change
(e.g., harmony with family), we asked participants
38
to reflect on whether they felt this had gotten worse
over the prior six months (a score of 0 ‘a lot worse’
or 1 ‘a little worse’), whether they felt this had not
changed at all (a score of 2), or whether they felt this
had gotten better over the prior six months (a score
of 3 ‘a little better’ or 4 ‘a lot better’). Tables 13 and
14 present the results in terms of the percent of respondents reporting changes. Across all outcomes
and both follow-ups, the majority of CPT participants reported that these outcomes had gotten better. For what is listed in the table as negative feelings
it should be understood that respondents were not
saying that they felt them more often, but rather that
these feelings got better. That is, the CPT participants reported high rates of feeling less hatred and
discrimination, or their hatred and discrimination
were less strong, compared with IS participants.
DISCUSSION
Mental health Outcomes
This study found that while the average symptom
scores improved over time in both treatment conditions, CPT was more effective in improving
function and reducing symptoms of distress regardless of how it was assessed (i.e., depression, anxiety,
trauma, combined depression/anxiety and PTSD)
compared with individual support alone among
female survivors of SV with high levels of mental
health symptoms in eastern DRC. The benefits were
large and maintained six months post-intervention.
CPT participants were significantly less likely to
meet criteria for probable depression/anxiety and
PTSD. Our findings are consistent with trials in
high-income countries of cognitive behavioral interventions generally (Olatunji, 2010) and of CPT
specifically (Resick, 2002; Cloitre, 2010) for studies
among SV survivors.
Prior research has suggested short-term therapies
may not be effective for populations exposed to
ongoing or multiple severe traumas (Cloitre, 2010;
Dorrepaal, 2010). In this study, all villages reported
at least one major security incident during the trial
including attacks, displacement due to fighting, and
robbery by armed groups. There were also suggestions that providing therapy to mostly illiterate
clients would be challenging. Our findings suggest
that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective.
Differences in how CPT and IS were provided may
affect our conclusions. Since CPT, but not IS, was
provided in groups, it is unclear how much of the
impact was due to group context. The difference
in how study participants were motivated to participate in sessions also differed by study arms. CPT
participants were also actively encouraged to come
to ongoing sessions while IS participants were invit-
ed to come to as many sessions as they themselves
wanted. PSAs in the CPT condition may also have
been more motivated and engaged than those in IS
because they were implementing a new service and
reported high satisfaction with the treatment manual and guidance provided through the supervision
system set up for this trial.
From the program perspective, in a review of their
experience, while the CPT PSAs acknowledged the
importance of some of the non-content differences
between CPT and IS for achieving these outcome
results (such as group vs. individual, or fixed dates
vs. meeting as needed), they also felt that the content of the therapy was essential in achieving these
results. The PSAs reported that the CPT training
provided them with useful tools and guidance to address deeper issues in clients’ thoughts and feelings
that current case management does not address. The
PSAs also noted that it provided them with a more
structured and organized system of therapy with a
clear end, which made offering effective services
easier for the PSAs with less experience, intuition,
or capacity, compared to case management, where
services are provided based on the client’s needs and
which depends heavily on the capacity and skills of
the PSA to engage with the client in identifying and
addressing these specific needs.
The level of supervision the CPT PSAs received was
greater than that for IS counselors due to the nature
of introducing a more specific manualized program
(CPT) that required significant (i.e., weekly) supervision because of the minimal mental health
background training of the PSAs. Prior studies have
found increased quality and quantity of clinical supervision can explain some treatment effect (Sholomskas 2005; Stewart 2009). CPT participants also
had on average a greater number of treatment sessions compared with IS participants. Overall CPT
effects must therefore be taken as program effects,
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
39
which include the therapy itself, number of sessions,
group process and supervision systems.
Individuals who are illiterate have traditionally been
excluded from research trials of trauma-focused
cognitive behavioral therapies. To deal with the literacy issues, modifications to CPT (see Appendix
C for a complete list of treatment modifications)
were made to simplify treatment materials and rely
on memorized rather than written homework. This
suggests that trauma-focused interventions may be
able to be used with populations that have traditionally been excluded from care where literacy or access
to written materials is problematic.
Some service providers and researchers assume that
populations exposed to multiple severe traumas
such as refugees, survivors of child sexual abuse,
or those exposed to ongoing war either cannot tolerate or will not respond to short-term trauma-focused cognitive behavioral therapies (Cloitre et al.,
2010; Dorrepaal et al., 2010). Insecurity continued
in CPT and IS sites during the implementation of
trial. Of the seven CPT sites, all reported at least
one incident of insecurity during the intervention
period. Reports of general attacks and pillage on the
whole village occurred in two villages, and outbursts
of military fighting in three, causing displacement of
populations into the forest. In three villages, there
were reports of specific attacks and robbery by military or bandits at individual homes, a commercial
truck, religious convents, a health center and one
of the ‘listening centers’. Our findings suggest that
despite exposure to extensive previous trauma, as
well as ongoing conflict, treatment of mental health
symptoms can be both well-tolerated and effective.
The group format of treatment has several advantages over individual treatment that were considered in
selecting this model of intervention. Group can be
more resource-efficient; a single therapist can treat
more women in the same period of time (Beck, Coffey, Foy, Keane, & Blanchard, 2009). This is an especially vital benefit when working in settings where
specially trained professionals and resources are limited. Another advantage to group treatment is that
it can potentially provide a means of reducing internalized stigma around rape itself and around mental
health symptoms (Classen, et al., 2011), as women
40
are exposed to other survivors struggling with similar experiences. CPT may also have provided a way
of building self-efficacy for participants as they
helped each other acquire skills through listening
to group members discuss practice assignments,
participating actively in the group and helping each
other generate alternative cognitions.
The task-sharing model utilized in this trial was
based on an apprenticeship model (Murray et al.,
2011) of service provision with lay-level counselors
receiving brief (2-week) training (experiential and
didactic) and then ongoing supervision through a
multi-tiered support system of local and international mental health staff. Although the initial training
was important, the majority of learning for the CPT
PSAs occurred during the pilot phase and throughout the implementation of the trial. The regular and
consistent supervision from both local IRC supervisory staff and US-based expert trainers was essential
in ensuring uptake and fidelity to the treatment. This
was evidenced by documented notes of challenges
and questions by local staff requiring input from the
supervisory structure on the implementation of the
therapeutic model. IRC-based supervisors (CTs)
and the US-trained clinical social worker were able
to get support from the US-based CPT experts for
both ongoing and complex questions regarding the
treatment and to then provide real-time feedback
and support directly to the PSAs in the field.
Function and Social Outcomes
On average, the CPT participants reported significantly less difficulty in engaging in their daily tasks
compared with IS participants. Unlike many function assessment instruments, ours did not differentiate between functional impairment specifically
related to health problems versus dysfunction due to
any cause (including lack of resources or assistance).
This is important in contexts where dysfunction is
common and due to multiple causes. Moreover,
the tasks assessed were those identified by women
similar to those in the study as being particularly important to them. Therefore a large improvement in
the ability to do these tasks could significantly affect
community welfare and development.
We did not find any significant differences in two
social resource indicators we analyzed: number of
groups participating in or amount of visiting with
others. This may an artifact of there being a limited
number of groups in each village (i.e., not all types of
groups existed in each village). Further analysis on
data collected related to participation in the groups
is warranted in order to determine whether there
are more nuanced differences. For the frequency of
visiting the trends show CPT participants reporting
somewhat greater average frequency compared with
IS, though the differences were not statistically significant. Regardless, the average frequency of participation was relatively low across both groups, with
both groups staying between the rarely and sometimes amount of visitation.
Although results of the questions added to the questionnaire based on the post-intervention qualitative
assessment showed consistent improvements across
all the domains of family and community comparing CPT to IS participants, initial analysis of a few of
the social resource outcomes did not find as clear results. Further exploration of this data is needed. For
example, there may be a limited number of groups
available in certain communities, limiting the upper
threshold for this measure, or it may be the quality of
group participation (being more active in the same
groups) or visits (having longer visits) that changed,
rather than the number of groups or visits. Further
analysis will explore potential changes in social resources through other measures.
Economic Outcomes
Relative to IS women, women who participated
in the CPT sessions performed more paid and unpaid economic work per week. Taken together, CPT
women spent about one day more per week than IS
women on economic work (adding the coefficients
of paid and unpaid economic work results in an overall impact of eight hours, about a day’s work). We
also find a positive impact on per capita food expenditures, weakly statistically significant (at the 10%
level) using OLS and strongly using quantile regression. We do not find impacts on assets.
These economic results add to the limited evidencebase that mental health programs can have secondary benefits on economic functioning. The preliminary results show that the strongest impacts were in
the immediate post-intervention period, which may
indicate an important time-period for introducing
economic services that can support the women’s
increases in work hours and economic potential.
Where the social drift hypothesis states that increases in mental health problems can place individuals
at risk for ‘drifting’ into poverty, the preliminary results from this trial provide initial evidence that this
trend can be reversed; improving individual’s mental
health and thereby improving their economic outcomes.
However, it needs to be recognized that our evaluation is limited by our lack of information on standards for each community and changes that may have
occurred at the community level over the course of
the trial. Climate and conflict-related factors should
be explored at the macro level to determine whether
there were village-level issues that may have impacted economic outcomes (i.e. reductions in agricultural production, changes in purchasing power, access
to economic activities).
Limitations
Limitations include symptom severity differences
across study arms that may limit comparability. Randomization was done within blocks of 2-4 villages
grouped together based on language and proximity,
with the assumption that villages close to one another would be similar; however this assumption was not
empirically confirmed. The small number of village
clusters (n=6) made randomization less likely to result in comparability. The recruitment process relied
on PSAs in the villages reviewing their files to identify women that were currently under treatment or
who had previously been in treatment they thought
might be appropriate for the intervention trial based
on the criteria we gave them (i.e., significant trauma
symptoms and impairment in tasks of daily living).
There may have been biases in recruitment that resulted in higher average symptom scores in IS villages because PSAs recruiting patients knew ahead
of time whether they would be providing CPT or IS.
To assess if higher IS baseline scores biased results,
we performed sensitivity analyses restricted only to
women with baseline HSCL-25 scores greater than
2.0 (CPT N=84; IS N=171), and found effect sizes
remained greater than 1.0.
An additional limitation is the lack of locally-validat-
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
41
ed measures for specifically identifying depression,
anxiety, and posttraumatic stress disorder. Data
from the preliminary qualitative study indicated
that rather than specific disorders, SV survivors in
these villages experienced more generalized distress, presenting with symptoms from all three disorders (depression, anxiety and PTSD), as well as a
range of other symptoms of distress unrelated to any
one specific disorder. A brief validation study confirmed these results, with our study team either finding women with lower levels of symptoms or higher
levels of symptoms, but not women meeting specific
criteria for any one of these disorders. This may help
explain why the results using the HSCL-25 and the
PCL are quite similar. That is, it may be that while
we have separated the measures into different disorder constructs, the reality in the field is that they are
42
both measuring the same underlying distress.
A final limitation is use of measures of unknown
validity for identifying clinical cases of combined
depression/anxiety and PTSD. Since symptoms of
these disorders could be nonpathological reactions
to extreme circumstances, it is unclear what proportions of participants actually meet clinical criteria. While the clinical meaning of standard cut-off
scores is therefore uncertain, the score itself can still
be meaningfully interpreted: 1.75 means women are
reporting that symptoms occur, on average, nearly a
‘moderate’ amount of the time (a score of 2.0). CPT
participants’ scores dropped, on average, to lower
than ‘a little bit’ for the average response (a score of
1) while IS participants’ scores remained closer to a
‘moderate amount’.
CONCLUSIONS AND
RECOMMENDATIONS
T
his trial provides evidence of effectiveness of a
mental health intervention for SV survivors in
a low-income conflict setting. The results indicate that with appropriate training and supervision,
psychotherapeutic treatments such as cognitive
processing therapy can be successfully implemented and show impact in settings with few specially
trained mental health professionals. To meet the
goal of identifying low-cost and scalable interventions for this population and context, a cost-impact
analysis is needed. As the supervision costs for this
trial, in terms of human and economic resources,
were relatively high, it may also be beneficial to determine the level of ongoing supervision needed for
PSAs to continue to implement CPT once they have
been trained and completed several groups.
CPT may be used with populations that have traditionally been excluded from care where literacy or access to written materials is problematic.
Individuals who are illiterate or who are potentially
exposed to ongoing violence have traditionally been
excluded from research trials of trauma-focused cognitive behavioral therapies. To deal with the literacy
issues, modifications to CPT were made to simplify
treatment materials and rely on memorized rather
than written homework. Based on our findings these
factors did not limit the impact of CPT.
CPT may be used with populations exposed to
multiple severe traumas and who are exposed
to ongoing trauma. There is often an assumption
that populations exposed to multiple severe traumas
such as refugees, victims of child sexual abuse, or
those exposed to ongoing war either cannot tolerate
or will not respond to short-term trauma-focused
cognitive behavioral therapies (Cloitre et al., 2010;
Dorrepaal et al., 2010). Our findings suggest that
despite the high degree of trauma experienced by
many of the study women and the context of ongoing conflict, treatment of mental health symptoms
with this type of therapy can be both well tolerated
and effective.
The group format of treatment has several advantages over individual treatment that were considered in selecting this model of intervention.
Group can be more resource-efficient; a single therapist can treat more women in the same period of
time. This is an especially vital benefit when working
in settings where specially trained professionals and
resources are limited. Another advantage to group
treatment is that it can potentially provide a way of
reducing internalized stigma around rape itself and
around mental health symptoms, as women are
exposed to other survivors struggling with similar
experiences. CPT may also have provided a way of
building self-efficacy for participants as they helped
each other acquire skills through listening to group
members discuss practice assignments, participating actively in the group and helping each other generate alternative cognitions.
This study demonstrates that with a task-sharing
approach, which includes training and supervision structures that support the counselors and
local supervisors, evidence-based treatments
such as CPT can be implemented with fidelity.
The task-sharing model utilized in this trial was
based on an apprenticeship model (Murray et al.,
2011) of service provision with lay-level counselors
receiving brief (2-week) didactic training and then
ongoing supervision through a multi-tiered support
system of local and international mental health staff.
Although the initial training was important, the majority of learning for the CPT counselors occurred
during the pilot phase and throughout the implementation of the trial. The regular and consistent supervision from both local IRC-supervisory staff and
US-based expert trainers was essential in ensuring
uptake and fidelity to the treatment. IRC-based supervisors and the US-trained clinical social worker
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
43
were able to get support from the US-based trainers
for both ongoing and complex questions regarding
the treatment and to then provide real-time feedback and support directly to the counselors in the
field.
PSAs from CPT sites expressed that they were initially worried that CPT would be too difficult for
them to implement, though with the help of support
from the CTs, they adapted to using CPT and found
that it was not as difficult as they initially expected.
One possibility for potential future CPT interventions may be to integrate CPT and case management
skills to ensure that PSAs can still offer services to
women who cannot participate in CPT, and be able
to refer safely and appropriately to other services as
per the case management model.
Increased costs related to the initiation and implementation of CPT are comparable to those
associated with a randomized controlled trial.
The costs associated with implementing CPT in this
study were in part due to the nature of introducing a
new program, particularly one with a learning curve
that requires weekly supervision in a region where
logistics, for example getting to villages on a weekly
basis, can be quite difficult and sometimes impossible because of security issues. But in considering
the costs, one needs to also consider the reduction
in costs that is realized once the counselors are
more fully trained and experienced. In the case of
this study, once the trial was complete, the counselors continued to provide services to new groups of
women and received monthly, rather than weekly,
supervision from the IRC-based supervisors. This
monthly supervision is in line with standard practices for many NGO-based psychosocial services
and thus does not add additional costs relative to
standard services.
Next steps include a cost-impact analysis and a
mapping of mental health services in the region.
The cost-impact analysis is being planned jointly by
44
JHU and the IRC to further inform the discussion
about the initial and continued costs of the program
in relation to the outcomes. JHU is also working
independently on a situational analysis to map the
NGO, UN, Ministry of Health and other agency
programs that provide mental health and psychosocial services in the region. This will inform further
recommendations of how CPT could be integrated
into existing systems of care.
Recommendations
Program recommendations
In DRC:
• The strong findings that CPT was successful
in reducing symptoms and increasing functioning suggests that CPT should be made
more widely available for women survivors
of SV with high levels of symptoms and impaired functioning within eastern DRC.
• An integrated model of CPT delivered in tandem with other services (such as case management, health and other SV services) should
be developed and tested in order to better
understand whether combining systems of supervision and program monitoring can reduce
human and economic resource costs.
Globally:
• CPT can be used with populations that have
traditionally been excluded from care where
literacy or access to written materials is problematic. It can also be used with populations
who have been exposed to multiple severe
traumas, including SV. Given that this is the
first evaluation showing CPT works with
these populations, future programs should
still be accompanied with rigorous evaluations
to measure effectiveness.
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APPENDICES
Appendix A: Design Framework
Appendix B: Questionnaire
Appendix C: Adaptation of CPT
Appendix D: Intervention
Monitoring Forms
Appendix E: High Risk Protocol
Appendix A
Design Framework
Impact Evaluation Framework
An evaluation of the impact of community-based initiatives to promote improved
functioning among survivors of sexual violence in South Kivu, Eastern DRC: assessing
mental health and social-economic programming
Jeannie Annan, Ph.D.
Director, Research & Evaluation, IRC
Judy Bass, Ph.D.
Assistant Professor, Johns Hopkins University
Dalita Cetinoglu, M.A.
Director, GBV Programs IRC-DR Congo
Gabrielle Cole, B.A.H.
VSLA Manager, IRC-DR Congo
Karin Wachter, M.Ed.
Senior Technical Advisor, IRC
Revised – Oct 2011
50
Appendix A: Design Framework
Introduction
S
exual violence has grave physical and psychological consequences, including injuries, poor reproductive health, mental health and psychosocial problems, and associated dysfunction. In communities affected by armed conflict, women may be exposed to both violent conflict and violence in the home and
the neighborhood, and consequences can be compounded when sexual violence by armed groups results in
rejection from families and communities.
Much remains unknown about how to prevent violence against women and how to treat its various mental
health and psychosocial effects. This applies to all forms of violence, including sexual violence resulting from
armed conflict, by other community members and intimate partner violence in places where gender inequity
is pervasive and where social norms and barriers to justice sustain violence against women. In areas where
survivors of sexual violence are also faced with extreme poverty and bear the burden of social stigma, there
is currently little information on effective interventions for alleviating psychological symptoms, increasing
social capital and improving economic status.
The International Rescue Committee (IRC) implements programming to respond to violence in the Democratic Republic of Congo (DRC) and is committed to growing the evidence-base about what programs are
the most effective, why they work, and for whom. Eastern Congo is still embroiled in conflict with armed
groups committing high rates of sexual violence and survivors often facing significant stigma within their own
families and the wider community. IRC also observes increases in reported incidents of violence perpetrated
by civilians and that minors constitute a substantial percentage of the survivors seeking services.
The overall objective of the evaluation is to identify effective and scalable interventions for the response to
sexual violence in areas affected by armed conflict by evaluating innovative approaches to socio-economic
programs. The project in DRC will evaluate the impact of both a savings and loans association and a mental
health intervention on improving the mental, social, physical and economic functioning of survivors of sexual
violence. This evaluation offers a significant contribution to the field of gender-based violence programming.
Background and significance of the evaluation
The Democratic Republic of the Congo (DRC) has become synonymous with sexual violence by armed
groups within the last 2 decades. Reportedly, tens of thousands of women and girls have been raped, sexually
assaulted, attacked and abducted in Eastern Provinces including North and South Kivu, targeted by armed
groups with unparalleled levels of brutality. Renewed hostilities between armed groups led to a spike in violence in late 2008 with fighting taking place in both North and South Kivu. The breakdown of the security
system in the region, combined with societal attitudes toward women and the absence of a functioning judicial system, have created conditions in which violence against women and girls persists with alarming frequency after periods of active fighting have ended.
Access to services in North and South Kivu—both emergency and longer term care—remains a major challenge. Limited services as well as the potential stigma of seeking services mean that many survivors have
never received adequate care. Results of a preliminary study by the IRC and Johns Hopkins University found
many survivors have substantially reduced ability to function, including reduced ability to perform basic tasks
and activities related to earning, self care, caring for family, and contributing to their communities. These
survivors also describe high rates of mental health and social problems including mood disorders, anxiety,
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withdrawal, and stigmatization and rejection by family and community. The rates of mental problems and
dysfunction are significantly higher than those found in other violence-affected populations in other parts of
Africa and elsewhere.
With IRC’s training and support, case managers from local NGOs have been providing psychosocial services to these survivors and preliminary study results show that psychosocial care is associated with increased
functioning and decreased mental health symptoms. However, case managers report the need for more skills
to address the large number of clients and their multiple needs. In other areas, community-based programs
have been providing social support and advocating for women at village level; however, they have no viable
options for referring clients who have more severe symptoms and need to higher level care. Across communities and services, IRC has also seen the great need for increased access to economic resources for women
who have been sexually assaulted because of their reduced function and frequent alienation from family and
community.
While social and economic development in conflict affected areas like DRC relies on populations who are
ready and able to work, the psychological effects of conflict may mean that a percentage of the population
living in these low-resource areas are less able to engage in economic opportunities even when they are available. However, there is little data on the best strategy to deal with this. One approach is to treat mental health
problems in order to reduce symptoms and improve functioning with the hope that people will then seek
out and take advantage of opportunities. Another option is to provide new ways to encourage participation
in economic activities as a way of addressing both mental health issues and dysfunction and thereby consolidating continued participation. A third option is to combine the two approaches: first providing a mental
health intervention and then providing new economic opportunities. Currently, it is not known which of
these approaches is the most effective, since little is known about how improvements in mental health impact
economic development, and conversely, how economic programs impact mental health.
IRC GBV Programming
IRC is introducing two new and innovative programs for survivors of sexual violence in South Kivu who have
high symptoms of distress and who are having difficulty with daily functioning:
1. Economic Program: The Village Savings and Loan Associations (VSLA) model was developed to
provide a system of community savings for people who cannot access banks or microfinance institutions. Self-selected groups of 15-25 members form independent associations where each member
saves and contributes to a common pool of money. Members can apply for loans from the pool and
pay back with interest. At the end of a cycle (usually about 1 year), group members cash out and receive their savings plus interest earned. IRC has implemented VSLAs in several programs and have
found the results promising. A model based on trust among the members, IRC sees VSLAs as an
important tool with which to promote solidarity and social cohesion amongst women and contribute to the social reintegration of survivors This evaluation will investigate its potential for providing
socio-economic support and improving the mental health and functioning of survivors of sexual
violence, which has not been done previously.
2. Mental Health Program: Group Cognitive Processing Therapy (CPT), a structured group therapy
that research has shown to be effective used to assist trauma survivors and can improve a variety
of symptoms related to depression, anxiety and posttraumatic stress disorder, will be adapted to
fit the cultural context. Local Psychosocial Assistants (PSAs) will be trained by expert US-based
CPT trainers and will provide the therapy to groups of 6-8 women. The PSAs will be provided with
direct supervision and assistance with problem solving as issues arise, with remote supervision and
quality assurance provided by the US-based CPT trainers. This evaluation will investigate the fea-
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Appendix A: Design Framework
sibility and impact of implementing CPT by local counselors for improving the mental health and
functionality of survivors of sexual violence.
Impact Evaluation
The central evaluation questions include:
1. What is the impact of a mental health intervention on social, psychological, physical and economic functioning?
2. What is the impact of a socio-economic intervention on social, psychological, physical and economic functioning?
3. What is the combined impact of a mental health intervention followed by a socio-economic
program on social, psychological, physical and economic functioning?
Based on these questions, the evaluation has the following objective and aims:
Study Objective: To identify cost effective and scalable interventions that demonstrate improvements in
the psychological, social, physical and economic functioning of survivors of sexual violence living in Eastern
DRC.
Specific Aims:
1. What is the impact of IRC’s mental health intervention (Cognitive Processing Therapy- CPT)
on social, psychological, and economic functioning?
2. What is the impact of IRC’s socio-economic intervention (Voluntary Savings and Loans Associations – VSLA) on social, psychological, and economic functioning?
Exploratory Aims:
What is the sequential impact of IRC’s mental health intervention followed by a socio-economic program on social, psychological, and economic functioning?
Does improving mental health prior to implementing an economic program improve the uptake
and utilization of the economic program?
Evaluation hypotheses
The proposed research project is based on the hypothesis that participation by survivors of sexual violence
with high levels of psychological symptoms and functional impairment in VSLA groups or in CPT groups
will lead to an increase in psychological, social, physical and economic functioning compared to similar women (controls) who did not participate in these interventions.
The specific hypotheses of the evaluation are:
VSLA Study
1. Women participating in the VSLAs will have increased household assets and consumption compared to control.
2. Women participating in the VSLAs will report improved social support compared to control.
3. Women participating in VSLAs who report improved social support and increased assets will report
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decreased psychological symptoms compared to control.
Mental Health Study
4. Women participating in the CPT intervention will report improved social support compared to
control.
5. Women participating in the CPT intervention will report decreased psychological symptoms compared to control.
6. Women participating in the VSLA program after first having participated in the CPT intervention
will have increased household assets and consumption compared to women who only participated
in CPT or in the control condition.
Both Studies
7. Women participating in the mental health intervention and/or the VSLA program will have an increase in their functionality, as assessed through measures of daily functioning, compared to control
women.
Program and Evaluation Strategy
The study will be two parallel randomized impact evaluations to investigate the impacts of the different intervention strategies.
The first study will focus on the impact of the VSLA compared to a wait-control sample. The VSLA impact
evaluation study will be conducted in communities served by 9 IRC’s CBO partners.
The second study will focus on the impact of the mental health intervention followed by the VSLA program
compared to a wait-control sample. This study will be conducted in communities served by 3 of IRC’s NGO
partners currently providing psychosocial support. The design of this second study will allow us to look at
the independent impact of the CPT intervention and to explore the effect of receiving the CPT intervention
on the rates of retention in VSLA and the impact of the VSLA program.
Phase 1: Formative Research
During the first phase, qualitative research will be conducted among 3 major language groups (Swahili, Mashi,
Kifuliro) in South Kivu, to learn how the psychological and social problems resulting from sexual violence
vary in their presentation and impacts. This information will be used to refine existing measures from a previous study and design a suitable instrument for use across these populations to assess these problems and their
effects on functioning. Once developed, this assessment tool will be validated in 2 communities among 2 different language groups and cut-off scores determined for identifying women with high rates of mental health
problems and functional impairment. This cut-off score will be used to determine eligibility for both studies,
along with the more general criteria of being exposed to sexual violence and being over age 18. Exclusion
criteria will include very low functioning (cut off determined during phase 1), high suicidality, and substance
dependence. Participation in all phases of the studies will be completely voluntary.
Phase 2: Training, Recruitment and Program Implementation
VSLA Study
In 9 areas with community based organizations, trained interviewers will work with CBOs to identify communities most affected by GBV and violence. Within these communities, the CBO management committee
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Appendix A: Design Framework
and members of other local NGOs who work with survivors of GBV will assist IRC in identifying women to
be screened for eligibility into the study. These women will also be asked to identify other women who have
similar problems, using a snowball sampling method to identify eligible women.
The women who meet criteria in the screening will be invited to an introductory meeting in which the VSLA
methodology will be described and they will be encouraged to return to a second meeting along with 2-3
friends they would be interested in joining a group with. At the end of the meeting, participants would be
asked to go out and form into groups of 15-25 women interested in being a part of VSLA. A third meeting
would be held with all the potential groups, and at this time groups would submit their membership lists as
an application. IRC staff will review all of the applications and select those groups that contain approximately
6-8 women who meet the study eligibility. These applications will then be randomized into treatment and
wait-list control conditions. The aim in each community is to have eight VSLA groups—4 treatment groups
and 4 waitlist control. All of the groups will be formed at the same time, but the control groups will not receive VSLA training until year 2, when the intervention group has completed the program.
As per standard practice, the selected groups will meet on a weekly basis during the first several months to
learn about the process through 7 IRC led modules, make decisions as to how they want to implement the
savings program, and select a management committee to assist with the running of the program and start the
savings activities. The next period (approximately months 3-12) will cover the actual running of the savings
and loans program, when members save money on a weekly basis and apply for loans. The first round of the
program is complete when the share-out is provided, typically starting in months 9-11. The waitlist control
applications will then be invited to participate in the VSLA program, with the training being provided by
women from the initial VSLA groups.
Mental Health followed by VSLA Study
Training for the adapted mental health intervention will be done at the beginning of Phase 2. There are 16
psychosocial assistants (PSAs) working with the 3 collaborating NGOs. Each PSA provides services at a
designed office that serves several villages. The 16 PSAs will be randomized to either receive training in the
CPT intervention or to continue providing treatment as usual. At the end of the study, if CPT is found to be
effective, the control PSAs will receive training in order to be able to provide it to the control participants.
Recruitment for participation in the study will be the same whether the PSA is an intervention or control
service provider. A variety of methods will be used to identify eligible participants including:
• PSAs will review their old beneficiary files and identify women who did not significantly improve
from their usual services and who may still be in need of additional services and these women will be
invited to be screened for the study;
• PSAs will invite current beneficiaries to be a part of this new activity and these women will be invited
to be screened for the study;
• The community educators (CEs) that are paired with each PSA will adopt a community education
messaging for a period of time, focusing it more on symptoms that survivors might be experiencing
that are indicative of higher distress. The messaging will include an invitation to be screened for possible eligibility into the program. Care will be taken to not mobilize more women than the PSAs can
accommodate to mitigate any negative effects on the NGOs reputation.
In the 8 locations designated to receive the adapted mental health intervention, the PSAs will put eligible
women into 3 groups of up to 8 women. The women will be grouped by where they live to minimize the
distance they have to travel for the weekly sessions. The treatment will include two introductory individual
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meetings followed by 12 regular weekly meetings. The total treatment will last approximately 4 months,
followed by a maintenance period during which PSA will meet with study participants as requested by the
participant. During this time period, the PSAs in the CPT and control communities will monitor any services used by the study participants. This maintenance period will allow us to evaluate whether there is any
post-intervention sustenance of any initial reduction in symptoms and improvement in functioning.
After the maintenance period is complete, the CPT participants will be invited to participate in a VSLA program. Similar to the VSLA study described above, the women will be invited to an introductory meeting in
which the VSLA methodology will be described and they will be encouraged to return to a second meeting
along with other community members who they would like to join their VSLA group. At the end of the second meeting, the women will be asked to submit their membership lists, each including 15-25 women, as an
application. IRC staff will review all of the applications and select those groups that contain approximately
6-8 women of the treatment participants. As per standard practice, the selected groups will meet on a weekly
basis during the first several months to learn about the process through 7 IRC led modules, make decisions as
to how they want to implement the savings program, and select a management committee to assist with the
running of the program. The next period (approximately months 3-12) will cover the actual running of the
savings and loans program, when people give money on a weekly basis and apply for loans. The program is
complete when the pay-out is provided, typically starting in months 9-11.
The PSAs who did not originally receive the adapted mental health training and who provided services to the
waitlist control condition will be provided with the training once the maintenance data has been reviewed.
After receiving the training, any control study women who still want services will be invited to participate in
the group therapy.
Data Collection
There are 4 designated data collection points:
1. Baseline Quantitative Assessment – prior to initiation of any of the intervention strategies. If we
assume that approximately 75% of the women assessed will meet eligibility criteria and will agree
to participate in the study, we will assess approximately 500 women within the 16 PSAs areas and
480 women in the 9 VSLA locations. This will allow us to meet our goal of 360 study women in the
VSLA program (40 women per location; 180 intervention; 180 control) and 380 study women in
the mental health program (24 women per PSA; 180 intervention; 180 control).
2. Qualitative Post-program – after approximately 10-11 months, following the pay-out period for the
VSLA program and the end of the treatment period for the mental health treatment, a brief qualitative assessment will be done to identify any unexpected outcomes. The study questionnaire will
then be amended to include questions related to these unexpected outcomes.
3. First Mental Health Quantitative Follow up – approximately 1 month following completion of the
CPT intervention, all intervention and control participants will be assessed with the amended assessment tool, to allow for investigation of immediate intervention effects.
4. First VSLA Quantitative Follow up – approximately 2-4 weeks after the pay-out period is complete,
all women who were eligible and originally agreed to participate in the VSLA programming will be
assessed with the amended assessment tool.
5. Second Mental Health Quantitative Follow up – after the 6-7 month maintenance period is complete, and before the VSLA program is initiated in the CPT communities, all intervention and control participants will again be assessed with the amended assessment tool to allow for investigation
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Appendix A: Design Framework
of longer term treatment effects.
6. Second VSLA Quantitative Follow up – approximately 8-10 months after the first round of VSLA
groups are completed, a final assessment will be conducted of all study participants to investigate
longer term maintenance of the VSLA program.
7. Third Mental Health Quantitative Follow up - approximately 2-4 weeks after the pay-out period is
complete for the VSLA program in the CPT communities, all women who were eligible and originally agreed to participate in the VSLA programming will be assessed with the amended assessment
tool. This will allow us to explore the impact of the combined CPT and VSLA program.
Outcomes and measures
The primary outcomes of interest include the psychological, social, physical and economic functioning of the
women involved in the programs. To assess these domains, the study will use the assessment tool developed
in phase 1 to assess mental health and functioning. The function assessment will cover both social and economic functioning, including indicators of social capital, social cohesion, and income/consumption. The
measures will be developed to capture outcomes at the level of the individual, family and community. Assessments will be conducted at baseline and at regular intervals described above.
Primary Outcomes
• Psychological Well-Being
• Physical and Social Functioning
• Economic functioning
Secondary Outcomes
• Family Functioning
• Cost effectiveness
Monitoring
Over the course of the implementation of both the VSLA and mental health program, IRC will systematically
monitor the outputs and outcomes of each program. We will monitor progress of the project on two levels:
individual-level and group-level.
1. VSLA Program: IRC staff will make regular monitoring visits to each VSLA group. During these
visit they will collect the following quantitative data for monitoring purposes: attendance rate, dropout rate, accumulated value of savings, number and value of current loans, and the value of cash
not in circulation. This data will be inputted and analyzed in the standard VSLA Monitoring Information System. The frequency of monitoring visits will be determined by the phase of the VSLA.
During the intensive phase, groups will be monitored on a weekly basis at every meeting. After a
period of approximately 4 months, each group will be evaluated and, if successful, will progress to
the development phase where monitoring visits will be reduced to every 2-3 weeks. Four months
after this, another evaluation will take place and the group will progress to the maturity phase. During this 4-month phase, groups may only be monitored 3-4 times before the end of the cycle.
2. Mental Health Program: The CPT therapy groups will meet weekly. Following each session, the
PSAs will fill out a monitoring form for each group participant as well a form summarizing what
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57
was covered during the group session and any challenges that may have arisen. These forms will be
reviewed weekly with an IRC supervisor who will in turn review each group, and each client, with a
Mental Health technical advisor and US-based trainers.
The control PSAs will maintain monitoring forms for all control participants indicating if/when a
participant came to see them and what services were provided. IRC supervisors will contact control
PSAs monthly to review monitoring procedures and ensure forms are being filled out.
During the maintenance period, when the CPT program is complete, the CPT PSAs will fill out the
standard monitoring form (same one used by control PSAs) any time a study participant visits them
for additional services. The control PSAs will continue to fill out the monitoring forms on control
study participants during this period as well.
Evaluation Outputs
The formative research and program evaluation will be carried out over the three years of the project. Below
are the projected dates for key outputs which will be developed and led by the JHU team, with collaboration
from IRC.
Outputs
Timeline
Qualitative study and situation analysis report – complete draft
August 31, 2010
Instrument development and validation – complete draft
November 31, 2010
Baseline Quantitative data analysis – complete draft
December 15, 2011
Qualitative Post-program analysis for Mental Health and VSLA programs
– complete draft
May 31, 2012
First Mental Health and VSLA quantitative assessment and monitoring
– complete draft
April 30, 2012
Second Mental Health and VSLA quantitative assessment and
monitoring – complete draft
April 30, 2013
Preliminary impact evaluation report – based on completion of first
round
April 15, 2012
Final Quantitative and impact evaluation report submitted to World
Bank
June 30, 2013
Output Descriptions
The JHU team will have primary responsibility for generating each of these reports, with collaboration from
IRC.
Qualitative study report: The data from the qualitative studies and the additional situation analysis information will be summarized to provide a picture of the relevant psychosocial problems and functional impairments currently experienced by the target population, GBV survivors. The report will also highlight any
differences identified across the three language groups in which the qualitative studies were done.
Instrument development and validation report: This report will provide information on the selection,
adaptation and validation of the mental health and psychosocial assessments and will present the complete
instrument to be used for all subsequent quantitative data collections.
Baseline Quantitative data report: The baseline report will provide background characteristics of the women in the evaluation; detailed information about the pre-intervention status of the main outcomes that the
58
Appendix A: Design Framework
programs aim to improve and an analysis of whether or not there are systematic differences between treatment and control individuals.
Qualitative Post-program report: This report will provide data on any unexpected outcomes associated
with participating in the programs and information about how these outcomes will be incorporated into the
subsequent quantitative assessments.
First Mental Health and VSLA Quantitative report: This report will provide preliminary analyses of the
data from each intervention program (VSLA and Mental Health) comparing participants to waitlist controls
on the primary outcomes of interest.
Second Mental Health and VSLA Quantitative report: This report will provide preliminary analyses of
the maintenance data from each intervention program (VSLA and Mental Health) comparing participants to
waitlist controls on the primary outcomes of interest.
Preliminary impact evaluation report: This report will follow up the previous report by providing a more
in depth investigation and complete analysis as to the impact of each intervention program on the primary
and secondary outcomes.
Final Quantitative and impact evaluation report: The final report will provide a final analysis of the program impact, including data from the combined mental health and VSLA programs and longer-term follow
up of the VSLA only participants. The report will answer the main questions and hypotheses described in
this document.
Communication plan
Involvement of stakeholders at beginning of evaluation (see Annex for communication documents). IRC
will communicate the evaluation plan to the following stakeholders at multiple levels:
• Community: CBOs, NGO partners, GBV staff, INGOs for GBV, Provincial Commissioner, universities (IRB), local authorities, territorial-level authorities, psychiatric hospital, media
• National: social protection meeting subgroup, university (IRB), Ministry of Gender, and donors
community in DRC Ministry of Health, media
• International: current and potential donors, InterAction, GBV Area Of Responsibility, Harvard Humanitarian Initiative, Columbia University, Women’s Refugee Commission, media, academic and
practitioners forums
Dissemination of findings
Community-level: At the end of the evaluation, IRC will hold meetings with IRC GBV staff, partner NGOs
and CBOs to discuss preliminary findings and to engage them in discussions about the findings. These discussions will inform the final report. Final reports will also be provided to local government officials and other
community stakeholders.
National level: The results of the final evaluations will be disseminated to key stakeholders in the government, private sector and non-governmental agencies. IRC will hold presentations in Bukavu and Kinshasa
and disseminate copies of the reports.
International level: JHU researchers and IRC will present findings in New York and Washington, D.C. to donors, NGOs, UN agencies, and other international agencies working in microfinance and GBV programming.
The reports will also be widely disseminated. The evaluation will be published in both policy and academic
Addressing Sexual Violence Related Trauma
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journals for wide dissemination among both communities.
Ethical and Safety Considerations
Standard ethical procedures for data collection and research will be used to ensure that participation in the
study will minimize any potential distress or harm. The evaluation protocol and questionnaires will be reviewed by an external board at Johns Hopkins University and a Congolese review board at the Kinshasa
School of Public Health.
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Appendix A: Design Framework
Annex 1
Communication Points for the Impact
Evaluation of a Socio-Economic Program
and a Mental Health Program for Survivors
of Sexual Violence
• IRC is committed to providing good programming. We do this, in part, by designing programs based
on existing research and by conducting rigorous evaluations to figure out what is effective programming.
• We are introducing two new and innovative programs for survivors in South Kivu who suffer from
the psychological and social consequences of sexual violence (i.e. who have high symptoms of distress
and who are having difficulty with daily functioning):
1. Economic Program: The Village Savings and Loan Associations (VSLA) model was developed to
provide a system of community savings for people who cannot access banks or microfinance institutions. Self-selected groups of 15-25 members form independent associations where each member
saves and contributes to a common pool of money. Members can apply for loans from the pool and
pay back with interest. At the end of a cycle (usually about 1 year), group members cash out and
receive their savings plus interest earned. IRC has implemented VSLAs in several programs and
have found the results promising. A model based on trust among the members, IRC sees VSLAs
as an important tool with which to promote solidarity and social cohesion amongst women and
contribute to the social reintegration of survivors. This evaluation will investigate its potential for
providing socio-economic support and improving the mental health and functioning of survivors of
sexual violence, which has not been done previously.
2. Mental Health Program: Cognitive Processing Therapy (CPT) is a structured group therapy
that research has shown to be effective on the major problems and symptoms that were identified
through both program experience and qualitative research. The CPT group therapy will be adapted
to fit the cultural context.
• These programs will be implemented together with the national NGOs and CBOs that we work
closely with in South Kivu
• For the evaluation of both programs, we are partnering with Professor Judy Bass and Dr. Paul Bolton
from Johns Hopkins University Mental Health Department
• Through this evaluation, we will learn about the impact of both the group mental health intervention
and socio-economic program on the social, psychological and economic functioning of survivors.
Understanding the impact will help us to identify effective interventions.
• Funding for the evaluation is provided by the World Bank and the USAID Victims of Torture Fund
and IRC contributes through funding the program components.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
61
Appendix B
Questionnaire
Numero d’Enqeuteur ________
_________
Date du Jour DD/MM/YY:
Code du participant: ____ _____
Langue : _________________
Uko na miaka ngapi?
Quel est votre âge -What is your age:
Iyi Fasi unaishi sasa njo territoire
kwenye ulizaliwaka ? Est-ce que l’endroit
_______
Miaka Années/years
que vous habitez actuellement votre territoire d’origine?
- Is where you are living now your territory of origin?
Uko wa kabila gani? Quel est votre group
ethnique - What is your ethnicity
Ulishaka olewa?
matrimonial
Quel est votre statut
What is your Marital status
___Ndiyo Oui
___Apana Non
_____________ Kabila, Group ethnique - ethnicity
_____Haya olewa Single, Célibataire
_____Ameolewa Marrié Married
_____Wame acana Divorcé Divorced
_____ Wame tenganaSeparée Separated
Kama ulishaka olewa, izi siku
unaishi na bwana ko?Si Marrié, est ce
que vous habitez actuellement avec votre mari? If
married, currently living with husband
_____ MujaneVeuve Widowed
___Ndiyo Oui
___ Apana Non
Ulimalizaka miaka ngapi ku
masomo ? Combien d’années d’études avez- ____ Miaka Nombre d’annees number of years
vous terminé
How many years of education did you complete
Zaidi ya shule la msingi? Plus que le primaire?
More than primary education?
___Ndiyo Oui
62
Appendix B: Questionnaire
___ Apana Non
Kwa sasa,ni batu ngapi njo
___ Idadi ya watu nombre de personnes
banaishi mu mwako (mu nyumba
yako)? Combien de personnes vivent actuellement
dans votre propre maison , c’est à dire sous votre
proper toit- How many people are currently living in
your own house, by house we mean under your own
roof
Andika idadi kwa kila aina ya watu
Ecrire le nombre pour chaque type de personnes
Write in the number of each type of person
Una pashwa lea watoto ngapi ?
Vous avez la responsabilité de vous occuper
de combien d’enfants? How many children you
responsible for care of?
Uko muja muzito hizi siku ? Etes
vous enceinte actuellement - Are you currently
pregnant
___ (plus de 18 ans)
___ (plus de 18 ans) Wana
wake Femmes
___ (annees 12-17) Vijana Adolescents
___ (annees 4-11) Watoto Enfants
___ (annees 0-3)
bébés
____
___
Depuis combien de temps vous habitez ici ___
___
___
___
Watoto wacangaNourrissons
/
# (miaka /annees 0-17)
____ Ndiyo Oui
Ni tangu wakati gani unaishi
hapa ?
How long have you lived here
Wanaume Hommes
___ Apana Non
0 - 5 Mwezi mois
6 - 11 Mwezi mois
1 - 4 Mwaka années
5 – 9 Mwaka années
10 + Mwaka années
_____ Vita/Uasi Guerre/ Rebelles - Rebels/war
_____ Ndoa Marriage - Marriage
_____ Afia/kuwa
Kama ni cini ya miaka tano,
ulihamaka sababu gani ? (caguwa
moja).
karibu ya kituo ca
afiaSanté
_____ Mavuno mabaya Mauvaise récolte
_____ mengine Autre - Other
Si c’est moins de 5 années, pourquoi vous avez
déménagé (choisissez un) If less than 5 years, why
did you move (choose one):
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
63
SECTION A- Evaluation des Fonctions
Assessment of Function
Nita soma makazi fulani fulani. Ni kazi ambazo wengine wana wake ambao
wanaishi huku walituambiya ni za muhimu kufanya. Kwa kila kazi,nita
nitakuomba uniamabiye kiasi ya magumu unapataka kwa kuifanya.
Utaniambiya kama haupatake hata shida moja,ao shida kidogo,ao kiasi
ya shida kwa kadiri,ao shida nyingi,ao mara na mara shida ni nyingi hata
hauwezi kufanya ile kazi. Je vais lire une liste de tâches et d’activités. Ce sont des tâches et des activités
que d’autres femmes autour d’ici nous ont dit qu’il était important pour elles de pouvoir accomplir. Pour chaque tâche ou
activité, je vais vous demander comKbien de difficultés en plus vous rencontrez. Vous devriez me dire si vous avez aucune
difficulté, un peu de difficulté, un nombre modéré de difficulté, beaucoup de difficulté, ou vous ne pouvez souvent pas faire
cette tâche.
Kusudi uelewe vema zaidi,niko na picha,na kila picha inaonesha kiasi fulani
ya shida.
Pour rendre cela beaucoup facile à comprendre, j’ai une carte ici avec des images. Chaque image représente un bon
nombre de difficulté. Montrer au participant la carte illustrant les niveaux de difficultés. Pointez sur chaque image en même
temps que vous la décrivez.
Picha ya kwanza,inaonesha mutu ambaye hana shida yoyote. Picha ya
pili inaonesha mutu ambaye ana shida kidogo. Picha ya tatu inaonesha
mutu ambaye ana kiasi ya shida kwa kadiri. Picha ya ine inaonesha mutu
mwenye kuwa na shida nyingi na picha ya mwisho inaonesha mutu mwenye
kuwa na shida mingi na hata hawezi kufanya hiyo kazi. Kwa kila kazi ama
shurti,nitakuomba ushote kidole kwa kuonesha picha ambayo ina ambatana
na shida unayo kwa kufanya ile kazi ama shurti. La première image montre quelqu’un qui n’a
aucune difficulté. La deuxième image montre quelqu’un qui a un peu de difficulté. La troisième image montre quelqu’un qui
a un nombre modéré de difficulté. La quatrième image montre quelqu’un qui a beaucoup de difficulté et la dernière montre
quelqu’un qui a tellement de difficultés qu’il ne peut même pas faire la tâche. Pour chaque tâche ou responsabilité, je vais
vous demander de pointer sur l’image qui montre combien de difficultés vous avez en faisant cette tâche ou activité.
Tuseme sasa kama pamoja na nyuma ya kila kazi ama shurti: Munamo juma
mbili zilizo pita ,haukupata hata shida yoyote,shida kidogo, shida kwa kiasi
ya kadiri ,shida nyingi,ao ulipata shida nyingi hata huwezi kufanya hiyo kazi.
Wakati una shota kidole kwa kila picha na kusema hii maneno,uandike jibu
kwa nafasi ambayo ina ambatana na kila kazi ama shurti. Disons maintenant qu’avec
chaque tâche, et après chacune d’elle dire: Au courant des deux semaines passées, est ce que vous avez eu aucune
difficulté, un peu de difficulté, un nombre modéré de difficulté, beaucoup de difficulté, ou avez-vous autant de difficulté
que vous ne pouvez souvent pas faire la tache ?, En pointant sur chaque image en le disant. Enregistrez la réponse en
entourant le numéro dans la boite appropriée à côté de l’activité ou de la tâche dans le tableau ci-dessous.
64
Appendix B: Questionnaire
DRC GBV Psychosocial Evaluation Questionnaire
Pour chaque
tâche dites:
Swahili-French-English
February 9, 2012
Mu juma mbili zilizo pita ni shida za kiasi gani uli pata kwa kufanya hii
Pour chaque
tâche dites:
kazi____:
Mu juma mbili zilizo pita ni shida za kiasi gani uli pata kwa kufanya hii kazi____:
Dans les 4 dernières semaines, combien de difficulté avez-vous eu pour faire In the last 4 weeks, how much difficulty have you had doing
Dans les 4 dernières semaines, combien de difficulté avez-vous eu pour faire In the last 4 weeks, how much difficulty have you had doing
Kiasi ya shida kwa kufanya hiyo kazi
Quantité de difficulté en faisant la tâche/l’activité
Kazi
tâches/activités
tasks/activities
Hakuna
aucune
None
Kidogo
Un peu
Little
Amount of difficulty doing the task/activity
Kiasi ya
kadiri
Quantité
modérée
moderate
amount
Mingi
Beau
coup
a lot
Mara na mara
hata hawezi
kufanya ile kazi
Non applicable
not applicable
Souvent ne peut pas
faire
often cannot do
A01. Mulimo cultivation/agriculture -
0
1
2
3
4
9
A02. Ucuruzi ao ingine njia
ya kupata pesa/franka
0
1
2
3
4
9
A03. Kupiga cakula Cuisine –
Cooking
0
1
2
3
4
9
A04. Ku lea watoto
s’occuper des enfants looking after children
0
1
2
3
4
9
A05. Ku shauriya wengine
wana memba wa jamaa
0
1
2
3
4
9
0
1
2
3
4
9
A07. Kubadirisha mafikiri
na watu wengine échanger des
0
1
2
3
4
9
A08. Kufuga wa nyama
0
1
2
3
4
9
A09. Kazi zingine za
mikono Tout autre type de travail
0
1
2
3
4
9
A10. Kujiunga na wengine
wanamemba wa jamii kwa
kufanya kazi kwa faida ya
jamii S’unifier avec d’autres membres de
0
1
2
3
4
9
A11. Kujiunga na wengine
wanamemba wa jamaa kwa
kufanya kazi kwa faida ya
jamaa ’unifier avec d’autres membres
0
1
2
3
4
9
cultivating/farming
commerce ou autres moyens de gagner
l’argent - trading or other making money
Donner des conseils aux membres de la
famille - giving advice to family members
A06. Ku shauriya wengine
wana memba wa jamii
Donner des conseils aux autres membres
de la communauté giving advice to other
community members
idées avec les autres exchanging ideas
élever des animaux raising animals
manuel any other types of manual labor
la communauté pour accomplir des tâches
pour la communauté/uniting with other
community members tasks for community
de la famille pour accomplir des tâches pour
la famille - uniting with other family
members to do tasks for the family;
3
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
65
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
Kazi
tâches/activités
tasks/activities
Hakuna
aucune
None
February 9, 2012
Kidogo
Un peu
Little
Kiasi ya
kadiri
Quantité
modérée
moderate
amount
Mingi
Beau
coup
a lot
Mara na mara
hata hawezi
kufanya ile
kazi
Non applicable
not applicable
Souvent ne peut pas
faire
often cannot do
A12. Kujiunga na wengine
ndani ya jamii Socialiser avec les
0
1
2
3
4
9
A13. Kulomba/ku pokea
msaada kutoka watu ao
shirika wakati wa mahitaji
0
1
2
3
4
9
A14. Ku cukuwa uamzi
wenye muhimu kuhusu
maisha ya kila siku. Prendre
0
1
2
3
4
9
A15. Ku shiriki kwa kazi za
jamaa ao matukiyo prendre part
0
1
2
3
4
9
A16. Ku shiriki kwa kazi za
jamii ao matukiyo. Prendre part
0
1
2
3
4
9
A17. Ku jifunza ufundi ao
akili mpya Apprendre des nouvelles
0
1
2
3
4
9
0
1
2
3
4
9
0
1
2
3
4
9
0
1
2
3
4
9
autres dans la communauté - socializing
with others in the community.
Demander/Obtenir de l’aide des gens ou
des organisations quand vous en avez
besoin - asking/getting help from people or
organizations when you need it
des decisions importantes sur la vie
quotidienne Making important decisions
about daily life
aux activités familiales ou aux événements/
taking part in family activities or events
aux activités de la communauté ou aux
événements taking part community events
techniques ou du savoir learning new skills
A18.kujiusisha sana kwa
kazi ao mapashwa yako
Se concentrer sur ses tâches
responsabilités - concentrating on your
tasks/responsibilities
A19. Kujadiliana ao
kushirikiyana na watu
ambao haufahamuCommuniquer
ou établir une relation avec les gens que
vous ne connaissez pas interacting or
dealing with people you do not know
A20. Kwenda kanisani ao
muskitini kama kawaida
aller à l’église ou à la mosquée comme
d’habitude - attending church or mosque as
usual
Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo A01-A20 (Bila Kufanya
hesabu ya 9): Total_______
Sum up all the scores for
questions A01-A20 (Ignore the 9’s):
4
66
Appendix B: Questionnaire
TOTAL : _______
SECTION B: Instrument de symptômes Symptom Assessment Instrument
Nitasoma shida fulani fulani. Nita ku uliza mara ngapi kila shida Ili
kusumbuwa munamo juma ine zilizo pita hadi leo. Nina penda kuelewa kama
hiyo shida haiku kusumbuwa hata kidogo, kidogo, kwa kiasi ya kadiri ao
sana (Tuna weza uliza ivi: Munamo juma ine zilizo pita hadi leo, ni mara
ngapi uli lemewa na shida hiyo? Je vais vous lire une liste de problèmes. Pour chacun, je vais vous
demander combien ce problème vous a tracassé ces quatres dernières semaines, y compris aujourd’hui. Je veux savoir si
ce problème ne vous a pas dérangé du tout, un peu, d’une quantité modérée, ou beaucoup. (Alternativement, nous pouvons
demander : « Combien chacune des catégories suivantes a été un problème pour vous au courant de ces quatres dernières
semaines)
Rudilia kila maneno na mwisho ujiulize kama mutu unaye zungumuza naye
alijisikiyaka vile vile munamo juma ine zilizo pita. Déclarez chaque rapport, et après chacun,
se demander si le participant s’est souvent senti comme ca lors de ces quatres dernières semaines. Répétez les catégories
aprés chaque déclaration et laissez le participant en choisir une. Enregistrez la réponse en entourant le numéro dans la
boite appropriée à côté du symptôme.
Pour chaque symptome dites:
Munamo juma ine zilizo pita, ni kwa kiasi gani ulipata shida ya __________
Dans les 4 dernières semaines, à quelle fréquence avez-vous eu le problème de In the last 4 weeks, how often have you experienced the
problem of
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
February 9, 2012
Shida
Problèmes
Problems
B01. Kujisikiya hauna nguvu Sentir peu
Akuna
hata
siku
moja
Kidogo
Un peu
a little bit
Pas du tout
not at all
Kiasi ya
kadiri
Beaucoup
a lot
Une quantité
modérée
moderate amnt:
Mingi
0
1
2
3
B02. Kuji shitaki sababu ya mambo
fulani Se blamer pour des choses Blaming self for things
0
1
2
3
B03. Mwepesi kuliya/Kuliya kwepesi
0
1
2
3
B04. Kupoteza faida ao furaha katika
kitendo ca ndoa Perte d’intérêt ou de plaisir
0
1
2
3
B05. Kukosa hamu ya kula
0
1
2
3
B06. Shida kwa kupata busingisi ao
kubaki una lala Difficulté à s’endormir, à rester
0
1
2
3
B07. Kujisikiya mwenye kukosa
matumaini kuhusu maisha ya kesho
0
1
2
3
B08. Kujisikiya mwenye huzuni
Se sentir triste Feeling sad (H,Q)
0
1
2
3
B09. Kujisikiya unabaki peke yako.
Se sentir seul - Feeling lonely (H,Q)
0
1
2
3
B10. Kufikiriya ku ji uwa
Penser à se suicide - Thoughts of ending your life (H,Q,D)
0
1
2
3
d’énergie, au ralenti Feeling low in energy, slowed down (H)
(H,Q)
Pleurer facilement Crying easily (H,Q)
sexuel - Loss of sexual interest or pleasure (H)
Manque d’appétit - Poor appetite (H,Q,D)
endormi - Difficulty falling asleep, staying asleep (H,Q,D)
Se sentir désespéré au sujet du futur - Feeling hopeless
about the future (H, Q,D)
Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B01-B10 Total_______
Sum up all the scores for questions B01-B10:
TOTAL : _______
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In Eastern DRC with Cognitive Processing Therapy
67
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
February 9, 2012
Shida
Akuna
hata
siku
moja
Kidogo
Kiasi ya
kadiri
Beaucoup
a lot
0
1
2
3
B12. Kujiuzunisha sana sababu ya
vitu Trop s’inquiéter sur des choses - Worrying too much
0
1
2
3
B13. kusikiya kukosa faida ajili ya
vitu/faida kidogo ku elekeya kazi za
kila siku Sentir aucun intérêt pour des choses/ moins
0
1
2
3
B14. Kusikiya sawa ku fanya kila kitu
yoyote ni kujikaza Sentir que tout est un effort -
0
1
2
3
B15. Kujisikiya mwenye kukosa
mafia/maana Sentiment de dévalorisation/ avoir
0
1
2
3
bila sababu Soudainement
0
1
2
3
B17. Kujisikiya mwenye oga
0
1
2
3
B18. Uzaifu, kizungu zungu ao
uregevu Faiblesse, vertige ou fragilité - Faintness,
0
1
2
3
B19. Ukali ao kutetemeka
kindanindani Nervosité ou tremblement à l’intérieur
0
1
2
3
B20. Kuwa na moyo wa kupiga piga
Coeur battant ou palpitation Heart pounding or racing (H,Q)
0
1
2
3
B21. Kutetemeka
Trembler - Trembling (H)
0
1
2
3
B22. Kujisikiya mwenye kutetemeka
Se sentir tendu ou surexcité Feeling tense/ keyed up (H,Q)
0
1
2
3
B23. Maumivu ya kichwa
Maux de tête/Headaches (H,Q)
0
1
2
3
B24. Wakati wa woga sana
Moments de terreur ou de panique Spells terror/panic (H,Q)
0
1
2
3
B25. kujisikiya mwenye bisirani hata
hawezi kubaki fasi moja
0
1
2
3
Problèmes
Problems
B11. Kujisikiya ndani ya mtego ao ku
naswa. Se sentir piégé ou attrapé - Feeling of being
Un peu
a little bit
Pas du tout
not at all
trapped or caught (H)
about things (H,Q)
Une quantité
modérée
moderate amnt:
Mingi
d’intérêt pour les activités quotidiennes - Feeling no interest
in things/less interest in daily activities (H, P, Q, D)
Feeling everything is effort (H)
aucune valeur - Feelings of worthlessness- no value (H,Q)
B16. kujisikiya pale pale mwenye oga
effrayé sans aucune
raison - Suddenly scared for no reason (H)
Se sentir peureux - Feeling fearful (H,Q,D)
dizziness or weakness (H Q)
- Nervousness or shakiness inside (H)
Se senir nerveuxt, ne peut pas rester sur place - Feeling
restless, can’t sit still (H)
Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B11-B25
Sum up all the scores for Questions B11-B25: TOTAL: _______
7
68
Appendix B: Questionnaire
Total____
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
February 9, 2012
Shida
Kiasi ya
kadiri
Beaucoup
a lot
1
2
3
0
1
2
3
0
1
2
3
B29. Ku jisikiya mwenye kutengwa ao
kubaguliwa na wengine.
0
1
2
3
B30. Kujisikiya hauwezi sikiya
uwepo ndani Incapable de sentir des
0
1
2
3
B31. Kujisikiya mukali ,ku camuka ao
kuwaka upesi Se sentir nerveux, sursaute
0
1
2
3
B32. Magumu kuweka akili fasi moya.
0
1
2
3
0
1
2
3
0
1
2
3
B35. Kuepuka ma kazi zenye zina
weza kumbusha wakati mbaya mtu
alipitiyaka Eviter des activités qui rappellent les
0
1
2
3
B36. Kushindwa ku kumbuka vipindi
vya wakati ya magumu sana na ya
kuogopesha uliyo pitiya. Incapacité de se
0
1
2
3
Problèmes
Problems
B26. Mawazo iko inakurudilia ao
kukumbuka ile wakati ya mambo
mazito ao ya oga uliyo pitiya.
Pensées récurrentes ou des souvenirs des événements les
plus durs ou les plus terrifiants - Recurrent thoughts or
memories of the most hurtful or terrifying events (P, D, Q)
B27. Kusikiya sawa vile ungali ndani
ya ile wakati ya mambo mazito ao ya
oga uliyo pitiya Sentir comme si les événements
Akuna
hata
siku
moja
Kidogo
0
Un peu
a little bit
Pas du tout
not at all
Une quantité
modérée
moderate amnt:
Mingi
durs ou terrifiants se passent encore - Feeling as though
the hurtful or terrifying event is happening again (P)
B28. Ndoto mbaya za kurudiliya
Cauchemars récurrents (sur un événement) - Recurrent
nightmares (about the event) (P)
Se sentir détaché ou exclus des autres - Feeling detached
or withdrawn from others (P,Q,D)
émotions/Unable feel emotions (P)
facilement - Feeling jumpy, easily startled (P)
Difficulté pour se concentrer - Difficulty concentrating (P)
B33. Ku jisikiya sawa mwenye iko ku
zamu. Se sentir en garde - Feeling on guard (P)
B34. Mwepesi kwa kuwaka ao
kucamuka na bisirani sana
Se sentir irritable ou avoir des excès de colère - Feeling
irritable or having outbursts of anger (P,Q)
événements durs ou traumatiques - Avoiding activities that
remind of the traumatic or hurtful event (P, Q)
souvenir des parties des événements les plus durs ou
terrifiants - Inability to remember parts of the most traumatic
or hurtful events (P)
Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B26-B36 Total_______
Sum up all the scores for questions B26-B36:
TOTAL: _______
8
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In Eastern DRC with Cognitive Processing Therapy
69
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
February 9, 2012
Shida
Akuna
hata
siku
moja
Kidogo
Kiasi ya
kadiri
Beaucoup
a lot
0
1
2
3
B38. kuepuka mawazo yenye
kuamabatana na vipindi vigumu
ulivyo vi pitiya Eviter des pensées qui sont
0
1
2
3
B39. Vitendo vya mbiyo biyo/haraka
vya kimafikiri ao vya kimwili wakati
bana kukumbusha ile vipindi vigumu
sana uliyo pitiya.Réaction soudaine,
0
1
2
3
B40. Kujisikiya mwenye makosa.
0
1
2
3
B41.kuwa na boga ya kukamatika na
magonjwa. Avoir peur d’ être infecté par la maladie -
0
1
2
3
B42. Kujisikiya mwenye kutendewa
vibaya na wanamemba wa jamaa.
0
1
2
3
B43. Kujisikiya mwenye kutendewa
vibaya na wanamemba wa jamii.
0
1
2
3
B44. Kujisikiya haya.
0
1
2
3
B45. kujisikiya mwenye kutupiliwa na
watu wote. Se sentir rejeté par tout le monde -
0
1
2
3
B46. Kujisikiya mwenye kushotwa
vidole na kubaguliwa. Se sentir stigmatisé -
0
1
2
3
B47. Kuwaza sana ju ya mambo iliyo
kufikiya. Trop penser à ce qui t’est arrivé -Thinking too
0
1
2
3
Problèmes
Problems
B37. Kusikiya sawa hauna maisha ya
mbele/kesho Se sentir comme si vous n’avez pas
de futur Feeling as if you don’t have a future (P,Q)
associées aux événements durs ou traumatiques - Avoiding
thoughts of feelings associated with the traumatic or hurtful
events (P)
émotionnelle ou physique quand on n’est rappelé des
événements les plus durs ou les plus traumatiques - Sudden
emotional or physical reaction when reminded of most
hurtful/traumatic events (P)
Se sentir coupable - Feeling guilty (P,D)
Being afraid to be infected by disease (D,Q)
Se sentir maltraité par les membres de la famille
Feeling badly treated by family members (D,Q)
Se sentir maltraité par les membres de la communauté
Feeling badly treated by community member (D,Q)
Se sentir honteux - Feeling shame (D,Q)
Feeling rejected by everybody (D,Q)
Feeling stigma (D,Q)
much about what happened to you (D,Q)
Un peu
a little bit
Pas du tout
not at all
Une quantité
modérée
moderate amnt:
Mingi
Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B37-B47 Total_______
Sum up all the scores for questions B37-B47:
9
70
Appendix B: Questionnaire
TOTAL: _______
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
February 9, 2012
Shida
Akuna
hata
siku
moja
Kidogo
Kiasi ya
kadiri
Beaucoup
a lot
0
1
2
3
B49. kuwaza kujilumiza.
0
1
2
3
B50. kutafuta kuepuka watu wengine
ao kujifica. Vouloir éviter les autres gens ou se
0
1
2
3
B51. Mawazo mengi sana.
Trop de pensées - Too many thoughts (Q)
0
1
2
3
B52. Kuwa mwenye baridi
Etre froid/timide -To be cold/shy (Q)
0
1
2
3
B53. Kukosa amani
Elle manque de paix - She lacks peace (Q)
0
1
2
3
B54. Hasira ndani ya roho
Colère au Cœur - Anger in the heart (Q)
0
1
2
3
B55. Vidonda vya ndani
Blessures intérieures - Inward wounds (Q)
0
1
2
3
Problèmes
Problems
B48. kuwaza sana ju ya mambo
mengine iliyo kubabaisha.
Trop penser à d’autres choses qui t’ont bouleversé Thinking too much about other things that upset you (D,Q)
Penser à se blesser - Thinking about hurting yourself (D,Q)
cacher Wanting to avoid other people or hide (D, Q)
Un peu
a little bit
Pas du tout
not at all
Une quantité
modérée
moderate amnt:
Mingi
Fanya esabu ya ma jibu zote zime patikana Kwa ma ulizo B48-B55 Total_______
Sum up all the scores for questions B48-B55:
TOTAL: _______
TOTAL SCORES:
Fanya hesabu ya ma jibu zote za mashida za ki maisha kawaida(Page4)Total_____
Total Score for Function Problems (page 4) :
TOTAL : _______
Fanya hesabu ya ma jibu zote simepatikana ku husu vitendo vinavio onekane
kuwa shida kwa mtu (hesabu majibu za page 5-9) : Total : __________
Total Score for Symptom Problems (add up scores from bottom of pages 5-9) :
TOTAL : _______
10
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
71
SECTION C. Se Debrouiller et L’Usage des Services
Coping and service usage;
Tuna penda sasa kuelewa zaidi kuhusu mambo ambayo wana wake wanafanyaka
kwa kujisaidiya ku kuwa vema zaidi. Nitakuuliza maulizo fulani fulani ku husu
ma kazi mbali mbali, na tena nita kuuliza kwa kiasi gani unafanyaka zile kazi
ajili ya kujisaidiya wakati una jisikiya vibaya.Kwa kila kazi,uta tuambiya kama
hauyifanyake hata kidogo ,ao unaifanyaka mara haba,ao una ifanyaka saa
zimoja zimoja,ao una ifanyaka mara mingi kwa kujisaidiya kujisikiya vizuri
zaidi
Maintenant, nous voulons apprendre sur ce que les femmes font pour les aider à se sentir mieux. Je vais vous poser des
questions sur les différentes activités, et je vais demander à quelle fréquence vous faites ces activités pour s’en sortir lorsque
vous vous sentez mal. Pour chacune des activités, Dites-nous si vous ne le faites pas du tout, avez-vous a le faire rarement,
faites-vous quelquefois, ou faites-vous souvent pour vous aider à vous sentir mieux
Hata
kidogo
Pas du tout
Not at all
Mara
haba
Rarement
Rarely
Mara moja
moja
Mara
mingi
0
1
2
3
C02. Kuzungumuza kuhusu
magumu yangu pamoja na
wengine wa mama walio
pitiya shida ya ubakaji
0
1
2
3
C03. Kusali /kujihusisha
ndani ya kazi za kanisa.
0
1
2
3
C04. Kutumika
Travailler – Work
0
1
2
3
C05. Najifungiyaka mu
nyumba Je m’enferme dans la maison
0
1
2
3
C06. Kunywa pombe
Boire de l’alcool - Drink alcohol
0
1
2
3
C07. Kuimba
0
1
2
3
0
1
2
3
C01. Kuzungumuza ku husu
magumu ao shida zangu
pamoja na marafiki na wana
memba wa jamaa yangu.
Quelque fois
Sometimes
Souvent
Often
Discuter mes problèmes avec les amis ou
les membres de ma famille - Talk about your
problems with friends or family members
Discuter mes problèmes avec d’autres
femmes qui ont vécu des choses similaires
Talk about your problems with other women
who have experienced similar traumas
Prier/ Participer dans les activités de l’église
- Pray/ participate in church activities
I shut my self up in the house
Chanter – Sing
C08. Kubakiya na wengine
rester avec les autres - Spend time with
others
72
Appendix B: Questionnaire
Tunataka sasa kuelewa kwa jumla kuhusu ma kazi mbali mbali ambazo
mulitumika mu miezi sita (6) iliyo pita. Kwa kila aina ya kazi, nita kuuliza
kama muli ifanya mu miezi sita (6) iliyo pita. Maintenant, nous voulons apprendre plus
généralement sur les différents types de services que vous avez utilisés au cours des 6 derneir mois. pour chaque type de
service, je vais vous demander si vous l’avez utilisé dans les 6 derniers mois Now we want to learn more generally about
the different types of services you may have used in the past 6 months. For each type of service, I will ask whether you
have used it in the past 6 months
Apana
Ndiyo
0
1
0
1
Non
No
C09. Ulienda ku kituo ca afya sababu ya shida
za afya? Vous êtes allé à la clinique à cause de vos problèmes de santé.
Oui
yes
- Have you gone to the health clinic for your own health problems.
C10. Je,ulipataka musaada kimafikiri na kijamii.
Est –ce que vous avez reçu une assistance psycho-sociale - Did you recieve
psychosocial services
C10a. Kama ndio, ulipataka msaada wa aina gani na nani
alikusaidiyaka? Si oui, qu’est-ce que vous avez reçu et de qui? If yes, what did you
receive and from whom
C11. Je,ulipataka msaada usiyo kuwa wa pesa
(nyama za kufuga,vifaa vya mulimo) Est-ce que vous
0
1
C12. Je, uko na pesa zako binafsi zenye
unaweza tumikisha kama vile unataka ?
0
1
C13. Je, uko mwana memba wa vikundi vya
mikopo ? Participez-vous à des activités de prêt actuellement?
0
1
avez reçu une assistance non-monétaire (ex: animaux, matériel agricole) Have you received any non-money assistance (e.g. animal, farm materials)
C11a. Kama ndio,ulipataka nini?
Si oui, qu’est-ce que vous avez reçu? - If yes, what did you receive
Avez-vous de l’argent que vous pouvez utiliser à votre gré? Do you have any
money of your own that you alone can decide how to use?
Are you currently participating in any loan activities?
C13a.Kama ndiyo,ni tangu wakati gani uko ndani ya vikundi hivyo ?
Si oui,depuis quand participez-vous dans ces activités? If yes, how long have you been
participating in these activities?
_____ miezimois months _____ miakaannees years
C13b. kama ndio,ni mkopo wa kiasi ao samani gani ulipewa huu
mwaka? Si oui,quelle est la valeur total des prêts que vous avez eu cette annee? If yes,
what is the total value of the loans you have taken out this year
__ Cini ya $5
moins de
__ $5-$10
__ $10-$20
__ yulu ya $20
plus que
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
73
SECTION D. Groupes et Réseaux
groups and networks
Nita ku uliza sasa unizungumuziye kuhusu vikundi, shirika, na miungano
ambayo wewe ni mwanamemba. Inaweza kuwa ni shirika halali ao vikundi
vya watu wenye ku kusanyika karibuni kila mara kwa ajili ya kazi fulani ao
ajili ya kuzungumuza ku husu mambo mbali mbali. Nita soma aina za vikundi
mbali mbali na utaniambiya zile ambazo una shiriki kama vile mwanamemba.
Kama ndiyo, nita kuomba uni ambiye kama unakuwaka unashiriki kwa
kucukuwa uamzi ndani ya ile kundi. maintenant vous demander de me parler de groupes,
organisations et les réseaux auxquels vous appartenez. Ceux-ci peuvent être les groupes formellement organisés ou des
groupes de personnes qui s’assemblent régulièrement pour une activité ou pour parler de choses. Je vais vous lire une
liste des groupes et vous allez m’indiquer ceux-la auxquels vous appartenez. Si oui, dites moi si vous participez activement
à la prise de décision de ce groupe. - I am now going to ask you about groups, organizations and networks to which you
may belong. These could be formally organized groups or just groups of people who get together regularly to do an activity
or talk about things. As I read the list of groups, please tell me if you belong to such a group. If yes, please tell me if you
actively participate in the group’s decision making.
Aina ya shirika ao kundi
Type d’Organisation ou Groupe
Type of organization or group
Una
kuwaka
ndani ya
iyi kundi?
Mara ngapi unakuwaka una
shiriki ndani ya ile kundi?
0= Apana
Pendant la plupart des reunions
Appartenez-vous
à ce groupe
Non/no
1= Ndiyo
Oui/yes
Combien de fois participez-vous dans ce
groupe
3= Kila mukutano Chaque reunion
2= Kwa wingi wa mikutano
1= Mara moja moja ila si zaidi
Quelquefois, mais pas souvent
0= Hata moja Pas du tout
D01. Vikundi vya mulimo/
vikundi vya hakiba ao vingine
vya kuzaa matunda.Groupe Agricole/
1
0
3
2
1
0
1
0
3
2
1
0
1
0
3
2
1
0
1
0
3
2
1
0
1
0
3
2
1
0
1
0
3
2
1
0
D07. Vikundi vya kujifunza
kusoma na kuandika
1
0
3
2
1
0
D08. Vikundi visivyo kuwa vya
kutegemea serikali
1
0
3
2
1
0
coopérative ou d’autre groupe de production Farming cooperative or other production group
D02. Vikundi vya kuceza kiasili
Groupe de danse folklorique
Folkloric dance group
D03. Shirika za dini ao za
kiroho- Groupe religieux ou spiritual
Religious or spiritual group
D04. Vikundi ao shirika za mila
Groupe ou association culturel - Cultural group or
association
D05. Muungano wa afya
Mutuelle de santé - Health groups
D06. Vikundi vya kusaidiyana
Groupe mutuelle de solidarité,
Solidarity group
Groupe d’alphebetisation/Education
Groupe ONG/OCB/ou autre groupe civique NGO
or other civic group3
74
Appendix B: Questionnaire
D09. Miungano ya wana wake.
Association de femmes. Women’s group
1
0
3
D10. Je,una shirikianaka na wana memba wa jamaa
yako,hata ile jamaa yako ya inje? Ëtes-vous régulièrement en
2
1
0
ApanaNon
NdiyoOui
0
1
contact avec les membres de votre famille, y compris la famille élargie? - Are you in
regular contact with members of your family, including extended family?
Si le répondant dit oui, continuez. Si le répondant dit non, passez à la partie
D14.
If respondent says yes, continue on. If respondent says no, go to next section (D14).
Nita ku uliza maulizo ku fuatana na ushirika kati yako na wanamemba
wa jamaa yako ya inje. Ninge hitaji uniambiye kama masemi haya mara
mingi,wakati moja moja,ao mara haba,ao hata kamwe ni ya kweli.
Je vais vous posez des questions à propos des relations que vous entretenez avec les membres de votre famille élargie.
J’aimerai que vous me disiez si les déclarations suivantes sont vraies souvent, parfois, rarement, ou jamais - I am going to
ask you about relationships with extended family members. I’d like you to tell me if these things are true often, sometimes,
rarely, or never
UShirika na wanamemba wa jamaa ya
inje
Relations avec les membres de votre famille élargie
Extended Family Relationships
Hata
kamwe
Mara
haba
Wakati Mara
moja mingi
moja Souvent
Often
Jamais
never
Rarement
rarely
D11. Ni mara ngapi una kuwaka mu
mangovi /fujo na wana memba wa jamaa
yako ya inje?À quelle fréquence avez-vous des disputes
0
1
2
3
D12. Ni mara ngapi una cangiyaka
mawazo na manunguniko yako na
wanamemba wa jamaa yako ya inje?
0
1
2
3
D13. Ni kwa kiasi gani wanamemba wa
jamaa yako ya inje wana kusaidiyaka,kwa
mufano wakati wa magonjwa,wakati
wa shida za watoto,wakati hauko
nyumbani,ao kwa kazi za shamba?
0
1
2
3
avec, ou de l‘hostilité envers un (des) membre(s) de votre famille
élargie? – How often do you have quarrels or hostility with
member(s) of your extended family?
À quelle fréquence partagez-vous vos pensées et vos soucis avec
les membres de votre famille élargie? - How often do you talk with
extended family members about your thoughts and troubles?
À quelle fréquence les membres de votre famille élargie vous
aident-ils par example, quand vous êtes malade, avec les enfants,
Parfois
sometimes
quand vous êtes absente, ou avec les travaux champetres ? How often do you receive practical help from your extended family,
like help when you are sick, child care when you are away, or help
with garden work?
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
75
Nina taka ku ku uliza kuhusu ushirika wako na wanamemba wa jamii (wale
wasiyo kuwa wanamemba wa jamaa yako) Je vais vous posez des questions à propos des
relations que vous entretenez avec les membres de votre communauté (qui ne font pas partis de votre famille). I am going to
ask you about relationships with people in the community who are not in your family.
Hata
kamwe
D14. Katika mwezi uliyo pita,ni kwa
kiasi gani watu wali kutembeleya ?
Pendant le mois dernier, à quelle fréquence est-ce que les
gens vous ont rendu visite chez-vous? In the last month, how
often have people visited you in your home?
D15. Katika mwezi uliyo pita,ni
kwa kiasi gani uli tembeleya watu
nyumbani kwao? Pendant le mois dernier, à quelle
fréquence avez-vous rendu visite aux gens chez-eux ? In
the last month, how often have you visited people in their
home?
Mara
haba
Wakati
moja
moja
Mara
mingi
Jamais
Never
Rarement
Rarely
0
1
2
3
0
1
2
3
Quelque fois
Sometimes
D16. Kama una pata hitaji ya pesa kidogo haraka haraka,kwa
mufano pesa ya kusaidiya jamaa yako muda wa juma moja,ni watu
wangapi wa roho mwema una weza kimbiliya kuomba ile pesa? Si
tout d’un coup vous avez besoin d’une petite somme d’argent, par example, assez pour soutenir votre
foyer pendant une semaine, vous aurez recours à combien de personnes de bonne volonté pour demander
cet argent? - If you suddenly needed a small amount of money, for example like enough to pay for your
household for one week, how many people could you turn to who would be willing to provide?
D17. Kama mara moja una jikuta ndani ya hitaji ya mbiyo mbiyo
tena ya kudumu,kama vile kilio,mavuno mabaya,una weza
kimbiliya watu ngapi wa roho mwema na ambao wata kuwa tayari
ku kutolea msaada? Si tout d’un coup vous vous retrouvez face à une urgence à long terme,
comme, telle qu’un décès ou une mauvaise récolte; vous aurez recours à combien de personnes de bonne
volonté qui seront prêtes à vou aider? - If you suddenly faced a long-term emergency, such as a family
death or harvest failure, how many people could you turn to who would be willing to assist?
76
Appendix B: Questionnaire
souvent
Often
Idadi
Nombre
Number
Idadi
Nombre
Number
16
1
Ndiyo
1
Oui (►3)
0
Apana
Non
Oui
Ndiyo
Apana
(►E05)
Avez-vous fait un travail
salarié pendant les 12
derniers mois ? (i.e
travailler pour quelqu’un
qui vous paye un salaire
ou qui vous paye en
nature)
Je, ulifanya
kazi ya kulipwa
mushahara
munamo miezi
12 iliyo pita ?
(kutumikiya
mutu na kisha
akulipe
mushahara wa
pesa ao vitu)
E02.
0
Non
Avez-vous fait un travail
salarié pendant les 7
derniers jours (i.e
travailler pour quelqu’un
qui vous paye un salaire
ou qui vous paye en
nature)
Je, ulifanya
kazi ya kulipwa
mushahara
munamo siku
saba 7 zilizo
pita
(kutumikiya
mutu na kisha
akulipe
mushahara wa
pesa ao vitu) ?
E01.
L’EMPLOI SALARIE
SECTION E. Economics
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
Saa/HEURES
/
Dans les 7 derniers
jours, combien d’heures
avez-vous travaillé en
tant que employée
salariée (payée en
nature ou en espèces)?
Munamo siku 7
zilizo pita, uli
tumika saa
ngapi kama vile
mutu mwenye
kutumikiya
mushahara wa
pesa ao vitu ?
E03.
February 9, 2012
4
3
2
1
DEMI-JOURNE
Kiasi ya Pesa/MONTANT
Siku JOUR
Juma SEMAINE
(entre 4-5 heures)
Saa HEURE
Nusu ya siku
6
5
Muda
PERIODE DE REFERENCE
Mwezi MOIS
Miezi tatuTRIMESTRE
7 Miezi sita SEMESTRE
8 Mwaka AN
Quelle est (était) la valeur des paiements que vous avez recu pour ce travail ?
Spécifiez la période de référence ! [si le répondent est payé en nature, demandez au
répondent d’estimer la valeur de ces paiements en nature;en cas de paiement en
espèce et en nature, demandez au répondent d’estimer la valeur du paiement en
nature et de l’ajoutez au paiement en espèce]
Malipo uli lipiwaka kwa ile kazi ni ya samani gani ?
Na muda wa ile kazi ni wakati gani?
[Kama ulipewaka vitu kama vile malipo, ao ulipewaka
franka na vitu pamoja, ufanye jumla ya yote pamoja.
E04.
SECTION E. Economics
L’EMPLOI SALARIE
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
77
78
Appendix B: Questionnaire
17
1
Ndiyo
1
Oui (►7)
on
0
ApanaN
Oui (►8)
Ndiyo
Non (►11)
Apana
Avez-vous exploité
une entreprise/
commerce ou effectué
une activité
génératrice de
revenus pour le
compte de votre
propre ménage
pendant les 12
derniers mois, autres
que cultiver vos
champs?
Je,ulitumika
ndani ya
shirika /ao
ulifanya
biashara ao
kazi ingine ya
kupata faida
kwa jamaa
yako pekee
munamo
miezi 12 iliyo
pita, zingine
kazi kuacha
kulima ?
E06.
0
Avez-vous exploité
une
entreprise/commerce
ou effectué une
activité génératrice de
revenus pour le
compte de votre
propre ménage
pendant les 7 derniers
jours, autres que
cultiver vos champs?
Je,ulitumika
ndani ya
shirika /ao
ulifanya
biashara ao
kazi ingine ya
kupata faida
kwa jamaa
yako pekee
munamo siku
7 zilizo pita,
zingine kazi
kuacha
kulima ?
E05.
L’EMPLOI INDEPENDENT
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
Heures
Saa
Dans les 7 derniers
jours, combien
d’heures avez-vous
travaillé dans cet
entreprise /
commerce / activité
génératrice des
revenus ?
Munamo
siku 7 zilizo
pita,ni saa
ngapi
ulitumika
ndani ya
shirika
/ucuruzi/kazi
zingine za
ku leta
faida ?
E07a.
February 9, 2012
Francs
Dans les 7 derniers
jours, combien d’argent
avez-vous gagne a
travers des activites de
cet entreprise/
commerce/ activité
génératrice des
revenus ? SVP essayez
d’estimer le benefice de
cette activite dans les 7
derniers jours.
Muda ya siku
saba zilizo pita,
franga ngapi
uliweza pata
kupitiya kazi za
uchumi, ma
kazi ya kuzala
franga ?
Tafazali,
unaweza
kudirisha faida
za ile kazi mu
muda za siku
saba zilizo pita.
E07b.
Munamo miezi
12 iliyo pita ,ni
muda wa miezi
ngapi njo
ulifanya hiyo
kazi ? (Idadi ya
miezi iyo kazi ili
endeshwa)
E09.
Si plusieurs
personnes, notez
deux codes en
maximum :
Mois
Miezi
Si le répondent ne sait
pas, notez « 99 »
Mimi/ Moi
Combien de mois au
des 12 derniers
Mume wangu/ Mari cours
mois avez-vous exploité
Baba/ Pere
cette entreprise ?
(Nombre de mois
Mama/ Mere
l’entreprise était en
Kaka/ Frere
activité)
Dada/ Soeur
Mwanangu/ Fils Kama mutu
wengine/ Autres unaye
zungumuza
(a preciser)
naye hajuwi,
andika «99 »
1
2
3
4
5
6
7
9
Qui dans le ménage est
propriétaire de cette
entreprise?
Ndani ya
jamaa,ni nani
ndiye mwenyeji
wa kazi hiyo ?
E08.
Francs
Franka
Si le répondent ne sait
pas, notez « 99 »
Kama mutu
unaye
zungumuza
naye hajuwi,
andika «99 »
Quel était le REVENU
TOTAL NET (le bénéfice)
de votre entreprise(s)
pendant les 12 derniers
mois ?
JUMLA YA
FAIDA ya kazi
ulizo zi fanya
munamo miezi
12 iliyo pita ni
ngapi ?
E10.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
79
18
Ndiyo Oui
1
(►13)
Apana Non
0
Etiez-vous disponible et
prête à travailler pour un
salaire ou un profit
pendant les 7 derniers
jours?
Je ,ulikuwa tayari
kufanya kazi ya
kulipwa
mushahara ama
yenye kuleta
faida munamo
siku saba (7)
zilizo pita ?
E11.
Chomage
Réponse Question 1 :
Miaka kidogo sana/ Trop jeune
Kuzeheka sana/ Trop âgée
Magonjwa/kuumia/
Magonjwa ya kichwa /Maladie
Ulemavu/ Handicapée
Mengine / Autres (à préciser)
3
4
5
6
7
9
mentale
(►14)
Maladie/blessure physique
taches ménagères
Masomo/ A l’école
Kufungwa na kazi za
nyumbani /Trop occupée par les
1
2
Pourquoi n’étiez-vous pas disponible et prête à
travailler pendant les 7 derniers jours?
|___|
1
Ndiyo Oui
0 Apana Non
Avez-vous essayé de trouver un
travail rémunéré pendant les 4
dernières semaines ?
Je, ulijaribu kutafuta
kazi ya kulipwa
mushahara munamo
juma ine (4) zilizo
pita ?
E13.
Réponse Question 5 :
February 9, 2012
Ni sababu gani hauku kuwa na
muda na kuwa tayari ku tumika
munamo siku saba(7) zilizo
pita ?
E12.
|___|
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
_____
_____
Mwaka
Mwezi
Annee
Mois
[Marquez '0 / 0' si le répondent n’a jamais travaillee pour un
salaire/un profit]
Quand est la dernière fois ou vous avez travaillé pour un
salaire ou pour un profit ?
Ya mara mwisho ulitumikia
mushahara ao faida fulani ilikuwa ni
wakati gani ?
E14.
Si les deux réponses sont “Non” (0),
continuez avec question 11. Sinon,
continuez avec question 15.
80
Appendix B: Questionnaire
19
Saa
Heures
[SI AUCUNE, NOTEZ '0']
[Kama hakuna
,andika 0]
Dans les 7 derniers jours,
combien d’heures avez-vous
travaillé en tant que
travailleur non-rémunéré
dans une entreprise nonagricole ?
Munamo siku
saba (7) zilizo pita
,ni muda wa saa
ngapi ulitumika
sawa vile
mutumishi asiye
kuwa na
mushahara katika
kampuni /shirika
lisilo kuwa la
mulimo ?
E15.
TRAVAIL NON-REMUNERE
Saa
Heures
[SI AUCUNE, NOTEZ
'0']
[Kama hakuna
,andika 0]
Dans les 7 derniers
jours, combien
d’heures avez-vous
consacré (nonrémunéré) aux
activités agricoles du
ménage (travail sur les
champs), y compris
l’élevage et la pêche?
Heures
Saa
Minutes
Heures
Minutes
Dakika
[SI AUCUNE, NOTEZ '0']
[Kama hakuna,
andika 0]
[NOTEZ LE TEMPS ALLERRETOUR]
Combien d’heures avez-vous
consacré
hier aux autres taches ménagères,
comme nettoyer la maison,
prendre soin
des enfants, etc...?
Ni saa ngapi
ulitumiya kwa zingine
kazi za nyumbani
jana, sawa vile ku
safisha nyumba,
kushugulikiya
watoto,… ?
E20.
SaaHeures
Minutes
Dakika
[ANDIKA MUDA WA [Kama hakuna,
KWENDA NA
andika 0]
KURUDI]
[SI AUCUNE, NOTEZ '0']
Combien d’heures avez-vous
consacré hier à la collecte de
l’eau pour le ménage ?
Ni saa ngapi
ulitumiya kwa
kushota maji kwa
faida ya jamaa
jana ?
E19.
Dakika SaaHeures
Minutes
[SI AUCUNE, NOTEZ '0']
Dakika Saa
[SI AUCUNE, NOTEZ '0']
[Kama hakuna,
andika 0]
Combien d’heures avezvous consacré hier à la
collecte de bois pour la
cuisine (ou des autres
combustibles)
Combien d’heures avezvous consacré hier à la
cuisson- préparation de la
nourriture pour le
ménage ?
[Kama hakuna,
andika 0]
Ni saa ngapi
ulitumiya kwa
kutafuta kuni za
kupiga cakula
jana ?
E18.
Ni saa ngapi
ulitumiya kwa
kupiga cakula ya
nyumba yako
jana ?
E17.
February 9, 2012
Munamo siku
saba (7) zilizo
pita ,ni muda
wa saa ngapi
ulitumika (bila
kulipwa) kazi
za mulimo
kwa faida ya
nyumba yako
(kazi
shamabani),uf
ugo na uvuvi
pamoja
E16.
DRC GBV Psychosocial Evaluation Questionnaire
Swahili-French-English
BIENS ET BETAIL
E21.Je, wewe ao mwengine
mwanamemba wa nyumba yako,muna
kuwaka na :
Est-ce que vous ou un autre membre du ménage
possède:
[A]RADIO/Une Radio
Kama ndio,
Kama Apana ao
HAJUWI, endelea na kitu ngapi
(wanamemba
inayo fuata. Si Non ou NSP,
continuez avec le prochain bien
0 = Apana Non
1 = Ndio Oui
8 = Hajuwi NSP
wote wa
nyumbani)?
Si Oui, combien
(tous les membres
du ménage) ?
[B] simu ya mukononi/Une téléphone
portable
[C] SAA YA
KU KIBAMBAZI Pendule
KINGA/Une Bicyclette
[E] PASI/Un Fer a Repasser
[D]
[F] MASHINI YA
Machine a Coudre
KUSHONA/Une
E22. PAA YA NYUMBA YAKO
/Majani ya mingazi/
mugomba Chaume feuille de palmier
principal matériel de toit de votre maison ?
2 Mbao Planches de bois
3 Manjanja Tôles
9 Mengine Autre (à préciser)
E23. VIBAMBAZI VYA NYUMBA
1 Udongo/Matope Terre/boue
YAKO VINA JENGWA NA NINI ?
2 MbaoPlanches de bois/shingles
Quel est le principal matériel des murs de
3 Matofali Briques
votre maison ?
9 Mengine Autre (à préciser)
E24. NYUMBA AMBAYO UNAISHI NDANI,JE NI
0 Apana Non
YAKO PEKEE ? Est-ce que vous êtes propriétaire de la
1 Ndio Oui
maison ou vous habitez ?
8 Hajuwi NSP
E25. WEWE AO MWENGINE MWANAMEMBA
0 Apana Non
NDANI YA NYUMBA YAKO, MUNA MASHAMBA ZA
1 Ndio Oui
KULIMA ? Est-ce que vous ou un autre membre du ménage
8 Hajuwi NSP
INAJENGWA NA NINI ? Quel est le
1 Nyasi
possède des terres pour cultiver?
E26. JE , NYUMBANI MWAKO MUNA MIFUGO
IFUATAYO ? Est-ce que le ménage possède le bétail suivant?
Si oui, notez le nombre de têtes. Si non, notez « 0 »
IDADI YA MIFUGO
Nombre de têtes
[A]NGOMBE Bovins
[B] KONDOO/MBUZI Moutons/Chèvres
[C]NGURUWE/Porcins
[
D] KUKU/ Volaille
[E]
SUNGURA/ Lapin
[F] DENDE/ Cobailles
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
81
82
Appendix B: Questionnaire
BUNGA YA MIHOGO
MIHINDI/MAIS
B
C
D
E
F
MAZIWA/LAIT
M
0. ApanaNon
1. Ndio Oui
8. HajuwNSP
ACHETE
(PRODUIT)
PENDANT LES 7
DERNIERS
JOURS?
LE MENAGE A-T-IL
F02 JAMAA,
ILI NUNUA
MUNAMO
SIKU 7 ZILIZO
PITA ?
DANS LES 7 DERNIERS JOURS,
Si le répondent ne Si Non ou NSP,
sait pas, notez
continuez avec le
« 99»
prochain produit
A. Unite B. Quantite
Francs Congolais
Si le répondent ne sait pas,
notez « 99»
Munamo franka za
kikongomani
MARCHE LOCAL LA QUANTITE DU
(PRODUIT) MENTIONNEE DANS
QUESTION F05, COMBIEN AURAIT-IL
REÇU ?
MENAGE AURAIT VENDU SUR LE
F05 MUNAMO SIKU 7
F06 KAMA JAMAA INGE
ZILIZO PITA , NI KIASI UZISHA MAVUNO AMBAO
GANI YA MAVUNO
INA ANDIKWA KWA ULIZO
(MAVUNO BINAFSI YA 1.7 INGE PATA PESA/
JAMAA)JAMAA ILI
FRANKA NGAPI KU SOKO
TUMIYA ?
YA HAPA MJINI ? SI LE
QUELLE QUANTITE DE
(PRODUIT) (QUI VIENT DE LA
QUI A ÉTÉ RÉCOLTÉ PAR LE PROPRE PRODUCTION) LE
MENAGE A-T-IL CONSOMME ?
MÉNAGE (PROPRE
NOTEZ UNITE ET QUANTITE !
PRODUCTION)?
DANS LES 7 DERNIERS
JOURS, AVEZ-VOUS
CONSOMMÉ DE (PRODUIT)
F04 MUNAMO SIKU
7 ZILIZO PITA, MULI
TUMIA VITU
AMBAVYO
VLIVUNWA NA
JAMAA (MAVUNO
YENU PEKEE)
Munamo franka 0. ApanaNon
za kikongomani 1. Ndio Oui
francs congolais
8. Hajuwi NSP
VOUS PAYÉ POUR
L’ACHAT DE
(PRODUIT) PENDANT
LES 7 DERNIERS
JOURS ?
COMBIEN AVEZ-
F03 MULI LIPA
NGAPI KWA
KUNUNUA
VITU MUNAMO
SIKU 7 ZILIZO
PITA ?
LITRE...............2 PANIER..............3 REGIME..............4
PIECE...............6 NAMAHA..............7 PETITE BOUTEILLE....8
GOBELET.............10 BUMBA..............11 PLANTE DE MANIOC...12
GUIGOZ.............14 MORCEAU............15 AUTRES (PRECISEZ)..99
Si Non ou NSP,
Si Non ou NSP,
continuez avec le continuez avec
prochain produit q.F4
0. Apana Non
1. Ndio Oui
8. Hajuwi NSP
LE MENAGE A-T-IL
CONSOMME
(PRODUIT)
PENDANT LES 7
DERNIERS JOURS?
F01 JAMAA ,
ILI TUMIA
MUNAMO
SIKU 7 ZILIZO
PITA ?
KILOGRAMME..........1
TAS.................5
GRANDE BOUTEILLE....9
VERRE..............13
UNITES LOCALES 21
AUTRES POISSONS
ZINGINE SAMAKI/
DAGAA –
MBICHI/SAMBAZA FRAIS
SECHE/
KAVUSAMBAZA
DAGAA
NYAMA/VIANDE
NDIZI/BANANES
POMMES DE TERRE
VIAZI/BIRAI
MAHARAGI/HARICOTS
VIAZI/PATATES DOUCES
MCHELE/RIZ
FARINE DE MANIOC
L
K
J
H
I
G
MIHOGO
A
MANIOC TUBERCULE
PRODUIT
Ligne
F. CONSOMMATION ALIMENTAIRE – 7 DERNIERS JOURS
F. CONSOMMATION ALIMENTAIRE – 7 DERNIERS JOURS
Sasa tunataka kuuliza ma swali fulani fulani ku husu namna gani una tosheka
na vitu mbali mbali vya maisha yako. Ni kwa kiasi gani una tosheka na tena
kwa kiasi gani hautosheki ku husu Maintenant, nous aimerions vous poser quelques questions sur
votre niveau de satisfaction avec les différents composants de votre vie Quel est votre niveau de satisfaction-insatisfaction
concernant
Hautosheki
sana
Hautosheki
kidogo
Très
insatisfait
Un peu
insatisfait
Hakuna
kutosheka
na hakuna
kuto
kutosheka
Kutosheka
kidogo
Un peu
satisfait
Kutosheka
sana
Très
satisfait
Ni satisfait
ni
insatisfait
F07.
Afia yako
0
1
2
3
4
0
1
2
3
4
F09.
Nyumba
0
1
2
3
4
F10.
Maisha yako
kwa jumla
0
1
2
3
4
Votre santé
F08.
Hali yako
kiucumi/
Pesa
Votre situation
financière
Votre logement
Votre vie en général
Section G
Please tell me whether these feelings have gotten worse, gotten better or stayed the same in the last 6 months
Svp dites nous quels des ces sentiments ont empirés, sont améliorés ou sont restes les
mêmes dans les derniers 6 mois.
Tafazali una weza ku tu eleza vitendo gani avikubadirika, zile zili badirika,
wala zila zilibaki vilele kisha mwezi 6 kupita
Now I am going to ask you about any changes you have made in some behaviors in the last 6 months. For each one,
please tell me if you are now doing it less often, about the same, or more often than you were doing it 6 months ago.
Maintenant nous allons vous demander a propos de tout changements dans vos
comportement produits dans les derniers 6 mois. Pour chacun svp dites moi si vous le
faites moins souvent, également ou plus souvent que vous le fassiez il y a 6 mois.
Sasa tuta sumuliya ku usu ma badiriko yote ku usu namna yako ya ku ishi
mu mwezi sita zilizo pita. Na kwa kila moja tafazali u tueleze kama una ifanya
sana ao mara kwa mara wala ku ifanya mara mingi kwa ngisi ili zoweya ku i
fanya mu mwezi sita
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
83
In the past 6 months, have any of the following happened to you:
Dans le derniers 6 mois, quelqun de ces faits vous est-il arrive?
Kwa mwezi sita ku pita ku na kitu kili ku fikiya ?
Got a lot
worse
Beaucoup
empire
MAGUM
U ZAIDI
Got a little
worse
Un peu
empiré
MAGUM
U KIASI
G01. Feeling harmony with your
No change
Pas de
changemen
t
HAKUN
A
MABADI
LIKO
Got a little
better
Un peu
améliore
Got a lot
better
Beaucoup
amélioré
MABADIL MABADIL
IKO KIASI IKO ZAIDI
Not
Applicable
Non
applicable
HAIKU
HUSU
husband
Se sentir en harmonies avec
son Mari
0
1
2
3
4
9
0
1
2
3
4
9
0
1
2
3
4
9
0
1
2
3
4
9
0
1
2
3
4
9
0
1
2
3
4
9
Kujisikiwa kuwa sawa
na bwana yako
G02. Feeling harmony with your
children
Se sentir en armonie avec les
enfants
Kuji sikiya kuwa sawa
na watoto?
G03. Feeling harmony with your
neighbors
Se sentir en harmonie avec
les voisins
Kuji sikiya kuwa sawa
na majirani?
G04. Feeling harmony with your
family
Se sentir en armonie avec sa
propre famille
Kuji sikiya kuwa sawa
na jama yako?
G05. Having strength to do work (go
to the field, harvest, other)
avoir la force pour travailler
(aller au champ, faire la
récolte, autre)
Kuwa na ngufu ya ku
tumika (kuenda ku
shamba, ku vuna na
mengine)
G06. Having strength to go to the
market
Avoir la force pour aller au
marche
Kuwa na ngufu ya ku
enda ku soko
23
84
Appendix B: Questionnaire
G07. Having good thoughts
avoir des bonnes pensées
0
1
2
3
4
9
N’avoir pas honte devant
d’autres personnes
0
1
2
3
4
9
G09. Feeling hatred against men
Sentir de la haine envers les
hommes
0
1
2
3
4
9
Sentir de la discrimination de
la part d’autres personnes
0
1
2
3
4
9
G11. Feeling a more peaceful
environment in the home
Sentir une ambiance de paix
a la maison
0
1
2
3
4
9
G12. Feeling a more peaceful
environment in the community
Sentir une ambiance de paix
dans sa propre communauté
0
1
2
3
4
9
Kuwa na mawazo
mazuri
G08. Feeling not ashamed in front of
people
Kuto kuwa na haya
mbele ya watu wangine
Ku sikiya chuki kwa ku
ona wanaume
G10. Feeling discriminated against by
other people
Ku sikiya ku ku
baguliwa na mengine
Ku jisikiya kuwa na
amani nyumbani
Kujisikiya kuwa na
amani ndani ya jamaa
24
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
85
A lot less
often
G13.Wearing clean clothes and shoes
Porter des habits et des
chassures propres
A little less
often
Beaucou
p moins
souvent
ZAIDI
MARA
KIDOGO
Un peu
moins
souvent
MARA
MOJA
MOJA
About the
same
A peu pres
le meme
KARIBUNI
SAWA
VILE
A little more
often
Un peu
plus
souvent
KIDOGO
KILA
MARA
A lot more
often
Beaucoup
plus
souvent
MARA
MINGI
ZAIDI
Not Applicable
Non
applicable
HAKUNA
JIBU
0
1
2
3
4
9
G14.Taking baths
Prendre un Bain
0
1
2
3
4
9
G15 Wearing makeup
Vous maquiller
0
1
2
3
4
9
Faire attention a que les
enfants soient propres
0
1
2
3
4
9
G17. Cooking food for your family
Préparer la nourriture pour la
famille
0
1
2
3
4
9
G18. Thinking about what you
eat and how it affects your body
Penser a propos de ce que
vous mangeait et quel effet
ceci a sur votre corps.
0
1
2
3
4
9
4
9
Ku vaa mavazi na viato
vyaku takata
Ku koga
Ku ji podowa
G16. Making sure your children look
clean
Kufanya angalisho ju ya
usafi ya watoto
Ku piga chakula ju ya
watoto
Ku waza ju chakula una
kula na madiriko gani
una leta mwilini mwako
G19. Thinking about having more children
Penser d’avoir plus d’enfants
Kuwaza kuzala watoto
mingi
0
1
2
3
Yes
Oui
Ndiyo
1
G20. Had a baby
Avoir un bebe
Ku zala mtoto
G21. Lost a baby or child died
Avoir fait un avortement ou avoir perdu son propre fils ou fille
ku toka wala ku fisha
25 Mimba
G22. Had a seriously ill child
Avoir un enfant très malade?
mtoto wako bi nafsi
Kuwa na mototo mugonjwa ?
86
Appendix B: Questionnaire
Non
No
Hapana
0
1
0
1
0
G23. Had a close family member die
Avoir le décès d’un parent très proche?
1
0
G24. Had a close friend die
Avoir le décès d’un ami intime?
1
0
G25. Been seriously ill yourself
Etre serieusement malade vous même?
1
0
G26. Had a seriously ill family member
Avoir un membre de la famille gravement malade?
1
0
G27. Been seriously injured yourself
Etre gravement blesse (vous même)?
1
0
G28. Had a seriously injured family member
Avoir un membre de la famille gravement blessé
1
0
Kufisha mzazi wa karibu ?
Ku fisha rafiki wa karibu ?
Kuwa mgojwa sana ?
Kuwa na mtu wa jama ?
Ku lumiya sana?
Kuwa na mtu wa jama mwenyi kuwa mgonjwa ?
SECTION T: Experiences Traumatiques
Tuna penda kuelewa aina za vitendo ao vipindi vya hatari na vya kuogopesha
ambavyo ulivipitiya kwa jumla. Nita kuambiya aina mbali mbali tulisikiya kwa
wanawake wenye wali pitiya shida zile. Ina wezekana ulipitiya shida zimoja
zimoja wewe binafsi ao uliona mutu mwengine ana zipitiya. Kama vile ingine
maulizo, uki jisikiya haupendi ao haufurahishwi kujibu izi maulizo,tuna weza
zirudiliya wakati mwengine ao unaweza kataa kuzijibu zote. Kwa kila aina
ya shida,nita kuuliza kama uli ipitiya binafsi ao uliona mutu mwengine ana
ipitiya.
Nous voulons comprendre quels sont les types d’expériences traumatiques générales que vous avez vécues ? Je vais vous
citer les différents types d’expériences que nous avons entendu des femmes qui ont été victimes. Vous pouvez avoir vécu
certains des eux personnellement ou que vous avez vu quelqu’un d’autre l’expérience de ce traumatisme. Comme avec
toutes les questions, si vous ne vous sentez pas à l’aise de répondre à ces questions, nous pouvons y revenir plus tard ou
vous pouvez convenir de ne pas répondre à toutes. Pour chaque type de traumatisme, je vous demanderai de me dire si
vous avez vécu le traumatisme ou vu cela se produire à quelqu’un d’autre.
Dans les 6 derniers mois….
Je,hiyo shida
ilikufikiya binafsi/
wewe mwenyewe?
Avez-vous personnellement
vécu - Have you personally
experienced
T01. Ubakaji
Violence sexuelle - Sexual violence
T02. Mauwaji
Meurtre – Murder
0 apana
Non
1 ndiyo
Oui
Je, ulionaka ile
shida ina fikiya mtu
mwengine?
Avez-vous vu cela arriver a
quelqu’un d’autre - Have you seen
this happen to someone else
0 apana
Non
0 apana
Non
1 ndiyo
Oui
1 ndiyo
Oui
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
87
T03. Kushambuliwa na
budunki, mupanga ao zingine
silaha ao ingine ujehuri kali
kama vile kupigwa.
Attaque par fusil, machete ou autre munitions
ou autre violence severe comme etre tabasseAttack with a gun, machete or other weapon or
other severe violence like beatings
Non
T04. Kunyanganywa/ Kuporwa ao
kulunguziwa manyumba ao vitu
vingine.
0 apana
T05. kuachiliwa/kufukuzwa
0 apana
Pillage ou bruler les maisons ou autre propriete
Looting or burning of home or other property
Abandon/chassée - Abandoned/thrown out
T06. Kubebwa (mahali pasipo
julikana). Etre enleve - Being abducted
88
0 apana
Appendix B: Questionnaire
Non
Non
0 apana
Non
1 ndiyo
Oui
1 ndiyo
Oui
1 ndiyo
Oui
1 ndiyo
Oui
0 apana
Non
0 apana
Non
0 apana
Non
0 apana
Non
1 ndiyo
Oui
1 ndiyo
Oui
1 ndiyo
Oui
1 ndiyo
Oui
Appendix C
Adaptation of CPT
Text S4: Cognitive Processing Therapy Adaptation Process
We adapted the existing Cognitive Processing Therapy group manual and training materials (Resick, Monson, & Chard, 2008; Chard, Resick, Monson, & Kattar, 2008) to be both culturally appropriate and useable
by local psychosocial assistants. The adaptation process was guided by the local context, which included:
therapists with little to no training in cognitive behavioral treatments or group interventions; a client population with low levels of literacy; and specific beliefs and structures of cultural groups within the Democratic
Republic of Congo. The adaptation process was iterative, allowing us to benefit from feedback from multiple
constituencies including the project research team from Johns Hopkins (LM, JB, & PB), the hosting nongovernmental organization (International Rescue Committee), NGO-based psychosocial staff, and the psychosocial assistants.
The first phase of the adaption process consisted of the US trainers (DK and SG), along with assistance from
Cognitive Processing Therapy group trainer Carie Rogers, editing existing Cognitive Processing Therapy
training materials and the treatment manual to replace technical terms and American idioms with standard,
simple English terms and phrases. In addition, more information regarding providing group psychotherapy
and managing group process was added to the manual. Review of the simplified materials was done in the US
by members of the research team experienced in training persons with limited previous training and experience in mental health care (PB, JB, & LM). The resulting materials were translated into French by professional translators based in Democratic Republic of Congo. Materials were reviewed by a bilingual US-trained
clinical social worker dedicated to the project for clarity and cultural appropriateness.
Adaptation continued in the Democratic Republic of Congo during the two-week training of the psychosocial assistants, NGO-based psychosocial staff, and the bilingual US-trained clinical social worker. Feedback
from the trainees was solicited on a daily basis throughout the training and used to further adapt the manual
and training materials for subsequent training days. The field-based adaptation process focused on continuing to (1) improve clarity of all written materials; (2) increase the cultural fit of materials; (3) adjust client
materials to be accessible for those who are illiterate; and (4) reduce barriers to implementation inherent in a
low resource environment.
Prior to initiating the trial, the adapted Cognitive Processing Therapy treatment was piloted by the psychosocial assistants and the clinical supervisor, allowing for additional feedback as they implemented the therapy
for the first time. Minor changes were made to materials during this period. At the end of the study, a debriefing meeting was held with the psychosocial assistants and clinical supervisors to solicit any additional feedback regarding the training, materials, supervision and implementation of the therapy. Based on this feedback, a final set of materials was prepared for the psychosocial assistants and supervisors to use as reference
material as they continue to provide the therapy as part of an ongoing mental health service program.
Therapy Adaptation
The structure of Cognitive Processing Therapy and essential elements were retained in the modified treatment, however some aspects were simplified. The main changes to the manual involved reducing technical
Addressing Sexual Violence Related Trauma
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89
jargon, decreasing the emphasis on underlying theories of PTSD, including more information on specifics of
group therapy and managing group interactions, including more scripts of therapy content in lay language,
adding more group specific clinical case examples relevant to the experiences of sexual violence survivors in
the Democratic Republic of Congo, and modifying homework assignments for non-literate clients.
Structural considerations
Literacy. Cognitive Processing Therapy relies on homework as a way to facilitate emotional processing and
to teach how to recognize and change maladaptive beliefs that maintain symptoms of PTSD and depression.
It was not possible in the Democratic Republic of Congo to use written homework, therefore materials were
simplified to be easier to understand and to memorize. We monitored the success of these modifications
throughout the implementation process and also debriefed the psychosocial assistants about the modifications during the final project meeting.
In order to make Cognitive Processing Therapy accessible for low literacy and illiterate clients, the US trainers
reduced the complexity of written materials and incorporated changes to help with retention of information.
Skills taught to clients were simplified, both in terms of the language used and in terms of the number of items
used for the skill. For example, one of the homework sheets is called ‘Challenging Questions.’ The standard
skill has 10 questions, but for simplicity, the number was reduced to four. We retained questions that were
the least abstract and were easiest to memorize, while still retaining enough breadth across the questions.
Clients Worksheets were also modified to use pictures as cues to help illiterate clients remember the worksheet instructions and/or skill. Thus the psychosocial assistants would teach the skill related to the worksheet
during the group, and patients could refer back to the pictures on the worksheet as reminders of each step of
the skill while doing the homework. Through brainstorming discussions with the psychosocial assistants we
also developed a plan to help clients use exercises to memorize skills. For example, one of the sheets is called
the ‘ABC sheet,’ which used a picture of a person standing as a cue for the “Activating event”, a picture of a
person thinking as a cue for the “Belief ”, and pictures of people with various facial expressions as a cue for the
“Consequence” or emotion column. Clients were also encouraged to tap their heads as a reminder to notice
the belief and touch their hearts as a reminder to notice the related emotion. Lastly, we removed one cognitive
skill, to identify overarching patterns of cognitive distortions (called patterns of problematic thinking). Due
to the need for skills to be memorized rather than written down this skill was deemed too abstract for clients
to memorize and practice.
Efforts were also made to increase the chances that patients would practice the skills daily, regardless of their
literacy level. The psychosocial assistants suggested that clients practice the therapy skills as part of their daily
routine. Group members would also meet with each other between group sessions to help each other with
practicing their homework.
An additional adaptation was the removal of two behavioral assignments in session 10 of the treatment. The
first skill encourages patients to complete one nice thing for oneself daily, and the second is to practice giving
and receiving compliments. The removal of these activities was simplified the protocol for both patients and
therapists. The modified Cognitive Processing Therapy protocol thus focused on the clients mastering skills
related to identifying thoughts and feelings, challenging their own thoughts, and generating alternative ways
of viewing the situation, all core skills of Cognitive Processing Therapy. Each session therapists would teach
the new skill and review several examples within the group to help with memorization and consolidation of
skills.
Novelty of talk therapy. In addition to considerations regarding literacy, there were also important considerations related to the fact that there was not strong tradition of talk therapy or mental health treatment in the
Democratic Republic of Congo. Based on suggestions from the local supervisors we added an additional in-
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Appendix C: Adaptation of CPT
dividual therapy session to describe mental health symptoms, describe the rationale for talk therapy, discuss
what group treatment will be like, and to answer client questions and concerns.
Cultural considerations
Consideration of cultural factors was vital to adapting Cognitive Processing Therapy for use in the Democratic Republic of Congo. The identification of these factors was a collaborative process, involving the US-based
trainers, the study investigators, local and international staff at International Rescue Committee, and the Congolese supervisors, psychosocial assistants, and interpreter, all of whom were born, raised, and currently live
in the region. Some factors were identified before the training began (by means of a preliminary qualitative
study), whereas others emerged during the training and/or implementation of Cognitive Processing Therapy.
Cultural factors that needed to be addressed included factors related to specific beliefs about social status,
rape, and language differences.
With respect to beliefs about social status, psychosocial assistants and supervisors noted that many patients
beliefs that rape would mean that women’s social status was permanently changed. These beliefs can make
cognitive restructuring challenging. Consistent with traditional Cognitive Processing Therapy treatment, the
psychosocial assistants were trained to use Socratic dialogue to identify, within the client’s own cultural and
religious beliefs, those places where there is room for cognitive flexibility. For example, several female clients
reported concerns about reduced social status due to being raped – e.g., “I have no voice in my home because
I was raped.” “My family is ashamed of me because I was raped.”). To work with those beliefs, a strategy of using Socratic questions to identify possible exceptions was used. In the former example, therapist explored in
what ways the client could have a say in her household and whether this was true of all people or all the time.
In the latter case, exploration centered on whether all of the family felt ashamed and how the client came to
that conclusion.
Language differences also necessitated some adaptations to Cognitive Processing Therapy. Some key concepts such as the distinction between thoughts and feelings did not readily translate into Swahili. We worked
closely with the psychosocial assistants to identify ways to explain these concepts within the local languages.
The concept of homework did not translate directly and was instead translated as “small works you do at
home.” The concept of extreme words was translated as “heavy words.” Lastly, the name of the therapy “cognitive processing therapy” did not translate to Swahili and was instead named “mind and heart” therapy.
The final session order is listed below:
Session 1: Introduction to therapy (individual)
Session 2:Introduction to Cognitive Processing Therapy
Session 3: Meaning of the Event
Session 4: Identification of Thoughts and Feelings
Session 5: Identification of Stuck Points (maladaptive beliefs)
Session 6: Challenging Questions
Session 7: Challenging Beliefs
Session 8-12: Cognitive Modules: Safety, Trust, Power/Control, Esteem, Intimacy
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92
Problem Review - How much was this a problem for each survivor over the last week? Please put client number in each box.
Not a problem
A little problem
A medium problem
0
1
2
Feeling sad
In Swahili
In Mashi
In Kihavu
Feeling lonely
In Swahili
In Mashi
In Kihavu
Thoughts of ending your life
In Swahili
In Mashi
In Kihavu
Worrying too much or feeling fearful
In Swahili
In Mashi
In Kihavu
Spells of terror or panic
In Swahili
In Mashi
In Kihavu
Recurrent thoughts/memories of the worst
trauma
In Swahili
In Mashi
In Kihavu
Feeling on guard
In Swahili
In Mashi
In Kihavu
Session number: _____
Site ____________________
Duration of Group: _______
Group number: ____________
Date ____________
CPT SYMPTOM CHECKLIST
PSA Name: ________________________________
A very big problem
3
Appendix D
Intervention Monitoring Forms
Appendix D: Intervention Monitoring Forms
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Problem Review - How much was this a problem for each survivor over the last week? Please put client number in each box.
Not a problem
A little problem
A medium problem
0
1
2
Feeling sad
In Swahili
In Mashi
In Kihavu
Feeling lonely
In Swahili
In Mashi
In Kihavu
Thoughts of ending your life
In Swahili
In Mashi
In Kihavu
Worrying too much or feeling fearful
In Swahili
In Mashi
In Kihavu
Spells of terror or panic
In Swahili
In Mashi
In Kihavu
Recurrent thoughts/memories of the worst
trauma
In Swahili
In Mashi
In Kihavu
Feeling on guard
In Swahili
In Mashi
In Kihavu
Session number: _____
Site ____________________
Duration of Group: _______
Group number: ____________
Date ____________
CPT SYMPTOM CHECKLIST
PSA Name: ________________________________
A very big problem
3
94
Appendix D: Intervention Monitoring Forms
Avoiding activities that remind you of the
traumatic or hurtful event
In Swahili
In Mashi
In Kihavu
Nightmares about the worst trauma
In Swahili
In Mashi
In Kihavu
Avoiding thoughts or memories about the
traumatic or hurtful event
In Swahili
In Mashi
In Kihavu
Feeling guilty or ashamed
In Swahili
In Mashi
In Kihavu
PSA Name: ________________________________
PSA Name: ________________________________
Supervisor Name: _________________________________ APS Name:
____________________________________
Pilot Group (ID#______)
Session #_____
the group?
________
Were any clients late?
Y
N
Were any clients in crisis (suicidal/homicidal/other risks)
Y
N
What was done to manage or address that problem?
How many clients attended
Did the APS complete all TPC session components?
Y
N
If no, please discuss which were addressed, which were missed, and what the challenges
were:
Group #1 (ID#______)
Session #_____
the group?
________
Were any clients late?
Y
N
Were any clients in crisis (suicidal/homicidal/other risks)
Y
N
What was done to manage or address that problem?
How many clients attended
Did the PSA complete all TPC session components?
Y
N
If no, please discuss which were addressed, which were missed, and what the challenges
were:
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PSA Name: ________________________________
Name: _________________________________ APS Name:
____________________________________
Group #2 (ID#______)
Session #_____
the group?
________
Were any clients late?
Y
N
Were any clients in crisis (suicidal/homicidal/other risks)
Y
N
What was done to manage or address that problem?
How many clients attended
Did the APS complete all TPC session components?
Y
N
If no, please discuss which were addressed, which were missed, and what the challenges
were:
Group #3 (ID#______)
Session #_____
the group?
________
Were any clients late?
Y
N
Were any clients in crisis (suicidal/homicidal/other risks)
Y
N
What was done to manage or address that problem?
How many clients attended
Did the APS complete all TPC session components?
Y
N
If no, please discuss which were addressed, which were missed, and what the challenges
were:
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Appendix D: Intervention Monitoring Forms
PSA Name: ________________________________
Group #4 (ID#______)
Session #_____
the group?
________
Were any clients late?
Y
N
Were any clients in crisis (suicidal/homicidal/other risks)
Y
N
What was done to manage or address that problem?
How many clients attended
Did the APS complete all TPC session components?
Y
N
If no, please discuss which were addressed, which were missed, and what the challenges
were:
Rate the APS’s knowledge of TPC and delivery of TPC content (being able to
explain it, respecting the steps, assigning the right homework) this week from 1-6:
______________
1 (unacceptable), 2 (barely acceptable, several problems), 3 (acceptable but some problems), 4 (very good,
only minor problems), 5 (excellent, very few if any problems)
Rate the APS’s skills in group leadership (managing group members, getting people
to show up, encouraging participation, getting group members to help each other,
not being timid, finding common topics to draw group members together) this week
from 1-6: ______________
1 (unacceptable), 2 (barely acceptable, several problems), 3 (acceptable but some problems), 4 (very good,
only minor problems), 5 (excellent, very few if any problems)
What strategies were used to evaluate PSA skills this week (circle all that apply)?
Case report
play
Live observation
Quiz
Role
Note general impression of APS:
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PSA Name: ________________________________
What TPC skills are they using well this week (e.g. open questions, explaining
homework, teaching new skills)?
o Checking symptoms
o Teaching about caring stuck thoughts
o Reviewing correct homework
o Teaching how to identify thoughts and feelings &
using ABC skill
o Identifying stuck thoughts about the trauma
(hindsight bias, self-blame, minimizing, outcome
based reasoning)
o Teaching the Thinking Questions skill
o Identifying and addressing avoidance in group
members (no showing, not speaking, being late,
not doing homework, avoiding outside of group)
o Teaching about trauma problems
o Teaching about TPC and how it will help
o Teaching the Changing Thinking and Feeling
skill
o Teaching about avoidance
o Using gentle, open ended questions to help the
group challenge stuck thoughts
o Leading group discussion about the trauma
impact statement (session 3 and session 12)
o Assigning correct homework
o Leading group discussions (managing conflict,
managing quiet and dominating members)
o Looking for common themes or stuck thoughts
in the group.
o Teaching about safety stuck thoughts
o Teaching about trust stuck thoughts
o Teaching about power stuck thoughts
o Teaching about esteem stuck thoughts
What TPC skills are they struggling with this week?
o Checking symptoms
o Teaching about caring stuck thoughts
o Reviewing correct homework
o Teaching how to identify thoughts and feelings &
using ABC skill
o Identifying stuck thoughts about the trauma
(hindsight bias, self-blame, minimizing, outcome
based reasoning)
o Teaching the Thinking Questions skill
o Identifying and addressing avoidance in group
members (no showing, not speaking, being late,
not doing homework, avoiding outside of group)
o Teaching about trauma problems
o Teaching about TPC and how it will help
o Teaching the Changing Thinking and Feeling
skill
o Teaching about avoidance
o Using gentle, open ended questions to help the
group challenge stuck thoughts
o Leading group discussion about the trauma
impact statement (session 3 and session 12)
o Assigning correct homework
o Leading group discussions (managing conflict,
managing quiet and dominating members)
o Looking for common themes or stuck thoughts
in the group.
o Teaching about safety stuck thoughts
o Teaching about trust stuck thoughts
o Teaching about power stuck thoughts
o Teaching about esteem stuck thoughts
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Appendix D: Intervention Monitoring Forms
PSA Name: ________________________________
TPC SESSION NOTE
Date ____________
APS Name: ________________________________
Group number: _______
Session number: _______
Survivor ID: ________________
1.
Client’s sum of symptoms (add up from symptom checklist but still attach symptom
checklist): ___________
Which symptoms have changed (improved or worsened)?
2.
One stuck point this client has is:
3.
Any challenges or problems in therapy for this client (homework completion, attendance,
participation in group, changes in symptoms, crises)?
Survivor ID: ________________
1.
Client’s sum of symptoms (add up from symptom checklist but still attach symptom
checklist): ___________
Which symptoms have changed (improved or worsened)?
2.
One stuck point this client has is:
3.
Any challenges or problems in therapy for this client (homework completion, attendance,
participation in group, changes in symptoms, crises)?
TPC SESSION NOTE
Date ____________
Site ____________________
Duration of Group: _______
Group number: ____________
Session number: _____
1. What questions do you have for CT, Janny, Debra, and Shelly this week? 2. What did you do in session with your group? (Check all that apply) o Checked symptoms
Taught a skill:
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PSA Name: ________________________________
o Reviewed homework
o identify thoughts and feelings &
using ABC sheets
What homework did you review? ____________________
_________________________________________________
o identifying stuck thoughts
Provided education about:
tool
o trauma problems
o using the Thinking Questions
o using the Changing
and
Feelings tool
o TPC and how it thinks about trauma
o Listened for and talked about stuck
thoughts with the group
o TPC and how it will help
o Used gentle, open ended questions to
help the group
challenge stuck thoughts
o avoidance
o Discussed the trauma impact statement
o safety issues
o Assigned homework:
What did you assign? _______________
_________________________________ o trust issues
o power issues
o esteem issues
o caring issues
3. Please refer to the TPC Checklist at the beginning of the session in the manual.
Did you complete all items on the checklist for the session you did with your group?
o No
o Yes
If you did something differently from the check list, why did you do so? (check all that apply)
100
o A client was late to session
o I was late to session
o I accidently forgot to do a section
o Clients didn’t complete homework
o Talked with group about avoidance
o Talked with group about coming to sessions
o Didn’t have enough time
o A client had a crisis
o Clients had trouble doing homework
o Other: ____________________________________
o Other: ____________________________________
o Other: ____________________________________
Appendix D: Intervention Monitoring Forms
regularly
Appendix E
High Risk Protocol
Clinical Crisis Flow Developed
for Use with International Rescue
Committee’s High Risk
Participants in Psychosocial Programming
in South Kivu Province, DRC
Developed by:
Laura Murray: [email protected]
Stephanie Skavenski: [email protected]
Johns Hopkins Bloomberg School of Public Health
Catherine Poulton: [email protected]
International Rescue Committee
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English Version:
Clinical crisis flow for DRC
Initial responses by the APS
• The APS finishes the checklist of symptoms form, and the follow-up form. Asks questions directly to
the client with suicidal or homicidal ideation, with psychosis, or who is abusing substances.
• If the client indicates suicidal ideas….
Further evaluate:
a. “Have you ever tried to end your life?”
b. “Are you thinking about ending your life?”
c. “Do you have a plan to end your life?”
d. “Do you have access to that plan, in order words, do you have the means to execute your plan?”
If the client answers YES to questions c or D, call your supervisor immediately (CT), please!
If the client answers YES to questions A and/or B, please move on to the review of steps at the end of
this document.
Talk to your supervisor while the client is still working with you. Decide, or agree on a plan BEFORE the
client leaves.
• If the client indicates homicidal ideas…
Further evaluate:
a. “Have you ever tried to end someone’s life/ hurt someone before?”
b. “Are you thinking about ending someone’s life/ hurting someone?”
c. “Do you have a plan to end someone’s life/ hurt that person?”
d. “ Do you have access to that person, in order words, do you have the means to execute your plan?”
If the client answers YES to questions c or D, call your supervisor immediately (CT), please!
If the client answers YES to questions A and/or B, please move on to the review of steps at the end of
this document.
Talk to your supervisor while the client is still working with you. Decide, or agree on a plan BEFORE the
client leaves.
• If the client indicates psychotic symptoms or an intensification of substance use, for example alcohol
or marijuana…
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Appendix E: High Risk Protocol
Further evaluate:
a. “How frequently do you use these substances?”
b. “What substances are you using?”
c. “What are the psychotic symptoms that you experience?” Here, the APS will evaluate if the client has
hallucinations or delusions” (the hallucinations and delusions de
Call your supervisor immediately!
Talk to your supervisor while the client is still working with you. Decide, or agree on a plan BEFORE the
client leaves.
If the client answers “yes” to any of these questions, call your supervisor at the end of the session. Here
are certain things to do during the session:
A. Did the client give her “security word” (verbal agreement by the client to keep herself safe).
• “We want to be assured that you are safe. I understand that this can be difficult. Can you promise me
to keep yourself safe for a short period – at least until tomorrow?”
B. Establish a “security guard”
• “We want to help you stay safe. At times, we use family members to help us keep you safe. Can you
think of someone in your family who could stay by your side?”
• “Can we work together to get that family member to agree to stay by your side in order to keep you
safe?”
• If the APS does not succeed in getting in contact with her supervisor (CT), in this specific case, she
will contact immediately her supervisor within the ASBL, and it will be the responsibility of ASBL to
get in contact with Claudine or Maria.
Response of the CT and at the management level once the APS has identified a crisis
• The APS contacts the CT immediately if a crisis situation is identified (see above for initial responses
by the APS)
• The CT checks that the APS developed a plan of action before the client leaves, and makes sure that
Claudine has been notified. Maria should be contacted if it concerns a TPC village.
• The CT contacts the technical supervisors within the partner ASBL for an update on the continuous
delivery of services.
• The CT collects all information concerning the client’s crisis situation
ˏˏ
Client code
ˏˏ
Crisis
ˏˏ
Suicidal
•
Homicidal
•
Psychosis
•
Substance use
ˏˏ
Report on the client’s responses to the evaluation (see the initial questions by the APS)
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ˏˏ
Plan of action (till then) by the APS
• The CT contacts Claudine or Maria (depending on who is reachable at that moment) to communicate the collected information. Maria should be contacted if it concerns a TPC village.
• Claudine informs IRC of the report and the following steps
• The US-based trainers (for the TPC villages) and Judy should be informed via email as soon as all of
the information has been collected.
• Maria, Claudine, CT and Judy (if available) discuss the risks and the action plan
ˏˏ
•
The action plan could include, asking the APS to:
Ask the client to promise verbally to keep herself safe
■■
•
•
“We want to be assured that you are safe. I understand that this can be difficult. Can you
promise me to keep yourself safe for a short period – at least until tomorrow?”
Establish a “security guard”
■■
“We want to help you stay safe. At times, we use family members to help us keep you safe.
Can you think of someone in your family who could stay by your side?”
■■
“Can we work together to get that family member to agree to stay by your side in order to
keep you safe?”
And/ or contact SOSAM or Maltezer for additional support or hospitalization
• It is the responsibility of CT to communicate the action plan to the APS
• It is Maria’s responsibility to share the report (evaluation and action plan) with Judy
• Maria, Claudine and the CT develop an action plan to communicate to the APS
• Claudine makes a report for the IRC of the results of the plan, and provides any other report or feedback that the IRC may require. These reports are shared with the ASBL partners.
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Appendix E: High Risk Protocol
French Version:
Flux de Crises Cliniques pour la RDC
Réponses Initiales par les APS
• L’APS termine les fiches sur le Check-list des Symptômes et celles de Suivi. Pose directement des
questions au sujet du suicide, homicide, psychose et l’usage des substances.
• SI la cliente indique des idées suicidaires…
Evaluer davantage
a.
“Avez-vous déjà essayé de mettre fin à votre vie?”
b. “Pensez-vous à mettre fin à votre vie ?”
c.
“Avez-vous un plan afin de mettre fin à votre vie ?”
d. “Avez-vous accès à ce plan ; c.à.d. avez-vous des moyens pour exécuter ce plan ?”
Si la cliente repond OUI aux questions c ou d, appelez immédiatement votre superviseur (CT) s’il
vous plait !
Si la cliente repond OUI aux questions a et/ou b seulement, passez s’il vous plait à la revue des étapes
à la fin de cette fiche/feuille.
Parlez avec votre superviseur pendant que la cliente est encore avec vous .Décidez ou mettez-vous d’accord
sur un plan AVANT que la Survivante ne parte.
• SI la cliente indique des idées homicides …
Evaluer davantage
a. “Avez-vous déjà essayé de mettre fin à la vie de quelqu’un/ lui faire du mal avant ?”
b. “Pensez-vous à mettre fin à la vie de cette personne/lui faire du mal ?”
c. “Avez-vous un plan afin de mettre fin à la vie de quelqu’un /ou faire du mal à cette personne ?”
d. “Avez-vous accès à cette personne ; c.à.d. avez-vous les moyens d’exécuter ce plan ?”
Si la Cliente repond OUI aux questions c ou d, appelez immédiatement votre superviseur s’il vous
plaît !
Si la Cliente repond OUI aux questions a ou b seulement, passez s’il vous plait à la revue des étapes à
la fin de cette fiche/feuille.
Parlez avec le Superviseur pendant que la cliente est encore avec vous. Décidez ou mettez-vous d’accord sur
un plan AVANT que la cliente ne parte.
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105
• SI la cliente indique des symptômes de psychose ou d’intensification de l’abus de substances, par
exemple alcool, chanvre, …
Evaluer davantage
a.
“A quelle frequence utilisez-vous ces substances ?
b. “Quelles sont les substances que vous utilisez ?’’
c.
“Quels sont les symptômes liés à la psychose qui se présentent ? Ici l’APS évaluera par exemple si
la survivante présente des hallucinations, et des délusions’’ (les hallucinations et les délusions ne
font pas partie des symptômes spécifiques du traumatisme tels que les flashbacks et les phobies. “
Appelez votre superviseur immédiatement !
Parlez avec votre superviseur pendant que la cliente est encore là avec vous. Mettez vous d’accord ou décidez
sur un plan avant que la cliente ne parte.
Si la cliente dit oui à n’IMPORTE quelles questions, appelez votre superviseur à la fin de la séance.
Voici certaines choses à faire pendant la séance :
A. Est-ce que la cliente a donné son mot de sécurité (accord verbal par la cliente de se garder en sécurité)
• “Nous voulons nous rassurer que vous êtes en sécurité. Je sais bien que ceci puisse être difficile.
Pouvez-vous me promettre que vous vous garderez en sécurité pour une courte période-juste au courant du jour suivant ?”
B. Mettre en place un garde de sécurité
• “Nous voulons vous aider à vous maintenir en sécurité. Plusieurs fois, nous utilisons les membres de
la famille pour le faire. Pouvez-vous m’aider à penser de quelqu’un de votre famille qui puisse être
à vos cotés?”
• “Pouvons-nous travailler ensemble pour amener ces membres de famille à pouvoir se mettre d’accord
qu’ils seront avec vous pour que vous soyez en sécurité ?”
• Si l’APS ne reussit pas a entrer en contact avec son superviseur (CT) , dans ce cas précis elle contacte
immédiatement son superviseur au sein de l’ASBL et il appartiendra à ce dernier de contacter à son
tour soit Claudine ou Maria
Réponse du CT et du niveau de la Gestion une fois qu’une APS a identifié une Crise
• L’APS contacte immédiatement la CT si une situation de crise est identifiée (voir ci-haut les réponses initiales par l’APS)
• La CT se rassure que l’APS n’a pas laissé la cliente partir avant qu’il n’y ait un plan d’action qui est mis
en place et Claudine soit été notifiées. Maria doit être contactée si c’est un village TPC.
• Les CT contactent les superviseurs techniques au niveau des ASBLs partenaires pour une mise à jour
par rapport à la livraison continue des services
• La CT collecte toutes les informations autour de la situation au sujet de la crise
ˏˏ
106
Code de la Cliente
Appendix E: High Risk Protocol
ˏˏ
Crise
•
Suicidaire
•
Homicidaire
•
Psychose
•
Usage intense des substances
ˏˏ
Rapport de la cliente sur les questions d’évaluation [voir les questions aux réponses initiales par
l’APS]
ˏˏ
Actions prises jusque là par l’APS
• La CT contacte Claudine ou Maria(selon la personne qui est joignable à ce moment-là) pour communiquer les informations collectées. Maria doit être contactée si c’est un village TPC.
• Claudine informe IRC du rapport et des étapes suivantes.
• Les formateurs du coté des USA (pour les villages TPC) e et Judy doivent être informé en leur envoyant des e-mails aussitôt que toutes les informations sont collectées.
• Maria, Claudine, CT et Judy (si disponible) discutent les risques et le plan d’action.
ˏˏ
•
Le plan d’Action pourra inclure ; demandez aux APS de :
Demandez à la cliente de promettre verbalement qu’elle se gardera en sécurité.
■■
•
•
“Nous voulons nous rassurer que vous soyez en sécurité. Je sais que cela puisse paraître difficile. Pouvez-vous me promettre verbalement que vous veillerez sur vous au moins jusque
demain ?”
Mettre en place un garde de sécurité
■■
“Nous voulons vous aider à vous maintenir en sécurité. Plusieurs fois nous utilisons les membres de famille pour faire cela. Pouvez-vous m’aider à penser de quelqu’un de votre famille
qui puisse rester à vos cotés ?”
■■
“Pouvons-nous travailler ensemble pour amener ces membres de famille à pouvoir se mettre
d’accord qu’ils seront avec vous pour vous aider à rester en sécurité?”
Et /ou contacter SOSAM ou Maltezer pour un appui supplémentaire ou hospitalisation
• Il appartient au CT de communiquer à la suite le plan d’action à l’APS.
• A Maria de faire suivre le rapport (y compris l’évaluation et le plan d’action) , a Judy
• Maria Claudine et les CT développent un plan de suivi à communiquer aux APS
• Claudine fait rapport à l’IRC des résultats du plan et produit n’importe quel rapport dont l’IRC pourrait avoir besoin et partage le même rapport et autre feedback nécessaire avec les ASBLs partenaires.
Addressing Sexual Violence Related Trauma
In Eastern DRC with Cognitive Processing Therapy
107
THE WORLD BANK
1818 H, Street N.W.
Washington, D.C. 20433
www.logica-wb.org