title: Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq.
abstract: BACKGROUND
  Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Boltonet al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq.
  
  
  METHODS
  This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Boltonet al.2014a), informed by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing (ADAPT-ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting.
  
  
  RESULTS
  Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT-ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility.
  
  
  CONCLUSIONS
  BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.
authors.affiliation: Department of Psychiatry, Massachusetts General Hospital (MGH)/Harvard Medical School, Boston, MA, USA.
authors.forename: J F
authors.initials: JF
authors.lastname: Magidson
authors.affiliation: Department of Psychology, Center for Addictions, Personality, and Emotion Research (CAPER), University of Maryland, College Park, MD, USA.
authors.forename: C W
authors.initials: CW
authors.lastname: Lejuez
authors.affiliation: Fine Arts Institute, University of Sulaimani, Kurdistan Region, Iraq.
authors.forename: T
authors.initials: T
authors.lastname: Kamal
authors.affiliation: Department of Psychology, Center for Addictions, Personality, and Emotion Research (CAPER), University of Maryland, College Park, MD, USA.
authors.forename: E J
authors.initials: EJ
authors.lastname: Blevins
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: L K
authors.initials: LK
authors.lastname: Murray
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: J K
authors.initials: JK
authors.lastname: Bass
authors.affiliation: Center for Refugee and Disaster Response and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: P
authors.initials: P
authors.lastname: Bolton
authors.affiliation: Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: S
authors.initials: S
authors.lastname: Pagoto
keywords: Adaptation; behavioral activation; depression; task shifting; trauma