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Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq
UMass Worcester Prevention Research Center Publications
  • J. F. Magidson, Harvard Medical School
  • C. W. Lejuez, University of Maryland
  • T. Kamal, University of Sulaimani, Iraq
  • E. J. Blevins, University of Maryland
  • L. K. Murray, Johns Hopkins Bloomberg School of Public Health
  • J. K. Bass, Johns Hopkins Bloomberg School of Public Health
  • P. Bolton, Johns Hopkins Bloomberg School of Public Health
  • Sherry L. Pagoto, University of Massachusetts Medical School
UMMS Affiliation
UMass Worcester Prevention Research Center; Department of Medicine, Division of Preventive and Behavioral Medicine
Publication Date
Document Type

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 (Bolton et 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 (Bolton et al.2014a), informed by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing (ADAPT-ITT) framework for intervention adaptation (Wingood and 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.

  • Adaptation,
  • behavioral activation,
  • depression,
  • task shifting,
  • trauma
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Copyright © The Author(s) 2015.
DOI of Published Version
Glob Ment Health (Camb). 2015 Dec;2. pii: e24. Link to article on publisher's site
Related Resources
Link to Article in PubMed
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Creative Commons License
Creative Commons Attribution 4.0
Citation Information
J. F. Magidson, C. W. Lejuez, T. Kamal, E. J. Blevins, et al.. "Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq" Vol. 2 (2015) ISSN: 2054-4251 (Linking)
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