Research Efforts in South Africa

Donnie W. Watson, Ph.D., Rick Rawson, Ph.D., Professor S. Rataemane, M.D.

FRI, Inc.,UCLA ISAP/Medical University of South Africa/University of Limpopo

ABSTRACT

R01DA019063-01: The goal of this project is to assess the efficacy of three (3) training approaches on Republic of South Africa (RSA) clinicians’ ability to adhere to the core elements of a research based model for individual Cognitive Behavioral Therapy that is adapted for use in RSA. Thus, 150 RSA clinicians at 30 treatment centers in a 12-session CBT intervention adapted from the Carroll CBT model will randomized to: 1) An in-vivo (IV) CBT training and supervision program in which clinicians receive approximately 84 hours of training and supervision with CBT from a South African Professional who will be trained in the United States (US) by an Expert Trainer; 2) A distance learning only (DLO) training and supervision approach, in which RSA clinicians will receive 84 hours of training and supervision via a teleconferenced and interactive broadcast originating in South Africa with a South African Professional who will be trained in the US by an Expert Trainer; and 3) A self instructional manual only approach (MO).

Key Personnel  Watson, D.W.                   Friends Research Institute               Principal Investigator

Brecht, M.L. UCLA ISAP Co-Investigator

Castro, F.                         Arizona State University                  Collaborating Scientist

Freese, T. UCLA ISAP Collaborating Scientist

Hawken. A. UCLA ISAP Co-Investigator

Morgenstern, J                  Mount Sinai School of Medicine     Collaborating Scientist

Obert, J.                           Matrix Institute                               Collaborating Scientist

Parry, C. Medical Research Council (RSA) Collaborating Scientist

Rataemane, S.                   Medical University of South Africa       Co-PI

Rawson, R.                       UCLA Integrated Substance Programs  Co-PI

Crucial Issue/Tech Transfer our knowledge base remains limited in identifying effective ways to

bridge the gap between research and the use of evidence-based behavioral treatment in the community

Lamb et al. (1998) determined that despite the availability of a number of efficacious behavioral treatments, these established treatments have not been systematically integrated into community and clinical practice. Methods for training and supervising community-based providers are needed.

one of the few studies to systematically examine how CBT knowledge and skills could be taught, Morgenstern et al. (2001) trained 20 counselors in CBT, while 9 counselors served as a control group . sum score of the CBT items revealed that this training was successful (adherence: r = .57, p < .01; skillfulness; r = .71, p < .01). Counselors rated their enthusiasm for the value of CBT as high and there did not appear to be substantial conflict between CBT techniques and other background counseling ideologies.

Specific Aims The specific aims of this project are: Aim 1- to

develop and pilot test an evidence-based, 12-session CBT protocol (Carroll, 1998) for use by clinicians in RSA.; Aim 2- to evaluate, via a randomized clinical trial, methods for clinician training in the 12 session CBT intervention to determine whether different modalities of training result in varying levels of CBT knowledge and competence in the delivery of CBT. Aim 3- to calculate the cost of the three training methods in order to determine the relative efficacy of the training method vis-à-vis cost.

CBT also has HIV risk reduction session (RSA?)

Background &Significance Growing body of literature supports the usefulness of

distance learning technologies for training substance abuse treatment providers in clinical methods.

These technologies are efficient and cost-effective. While the use of distance-based delivery systems in the substance treatment field is in the early stages, video conferencing, teleconferencing represent viable cost effective options.

The transfer of an empirically supported approach for the treatment of cocaine use disorders to clinicians in RSA is a timely and important challenge.

CBT demonstrated effective with US stimulant users

DEMOGRAPHICS OF SOUTH AFRICA Population (‘97 estimate): 42,327,458 Density (‘97 estimate): 35 people/sq km (90 people/sq mi) Urban/Rural Breakdown: 60% Urban, 40% Rural Largest Cities (‘91 census): Cape Town 854,616

Durban 715,669

Johannesburg 712,507

Pretoria 525,583 Largest Metropolitan Areas (‘91 census):

Cape Town 2,350,157

Johannesburg 1,916,063

Durban 1,137,378

Pretoria 1,080,187

DEMOGRAPHICS cont’dEthnic Groups: 75.2% Black African - including Zulu, Xhosa,

Tswana, and Sotho

13.6% White - including Afrikaners and British

8.6% Coloured (mixed race)

2.6% Asian – mostly Indian

DEMOGRAPHICS cont’d

Official Languages: Afrikaans, Tsonga, English, Ndebele,

Sesotho, Sesotho sa Lebowa, Swazi, Tswana, Venda, Xhosa, Zulu

Other Languages: Portuguese, German, Dutch and other

European languages, Gujarati, Hindi, Urdu, and other Asian languages

DEMOGRAPHICS cont’d

Religions: 17% Traditional African religions 16% Dutch Reformed Protestantism 13% African Christianity 11% Methodism 9% Roman Catholicism 7% Anglicanism 27% Other, including other Christian

denominations, Hinduism, Islam, and Judaism

DEMOGRAPHICS cont’d

Provinces (i.e., States): Eastern Cape Free State Gauteng KwaZulu-Natal Mpumalanga Northern Cape Limpopo Northwest Province Western Cape

DRUGS OF ABUSE IN SOUTH AFRICA Alcohol and Cannabis Mandrax: typically consists of a mixture of

Methaqualone (the active ingredient) and antihistamine

Cannabis or cannabis smoked with Mandrax are the most common primary illicit drugs of abuse for patients in treatment centers

Increases observed for Crack Cocaine and Injection Drug Use (Heroin) and Meth (tik)

12 ctrs (same as current study) 6 month period revealed that 1,109 out of 3,968 patients reported cocaine/crack use as part of their primary presenting complaint (Dec.03)

Research Design This 5-year study will compare the efficacy and

efficiency of 3 methods of training South African drug abuse clinician-counselors in a 12-session cognitive behavioral therapy (CBT) protocol for the treatment of cocaine dependence. The study participants will be 150 experienced (i.e., at least 3 years of experience) licensed clinicians who work in 30 South African National Council on Alcoholism and Drug Dependence (SANCA) treatment centers in Johannesburg, Cape town (Gaunteng Province) and surrounding areas of South Africa (e.g., mental health nurse professionals, social workers, psychologists). Eighty percent have BA’s..consistent with Morgenstern study

Cultural Adaptation of CBTWorkgroup will review CBT for cultural

relevanceClinicians in RSA will have practice

sessions with clients not in study Training issues addressed by Jeanne

Obert

Design Continued All of the potential participating clinicians in SANCA centers speak English.

SANCA treatment facilities are located throughout the 9 provinces of South Africa: Gauteng | Kwazulu-Natal | Eastern Cape | Western Cape |Northern Cape | Northwest Province | Free State |Mpumalanga | Northern Province.

Most of the written materials are in English. Most of the patients (70%) speak English=ample population of English speaking patients for implementation of the CBT protocol.

The English speaking patients are evenly distributed among racial and ethnic groups. Manuals and trainings will all be provided in English. IRB may require translation into one of major dialects

If one mode (manual) is provided in multiple languages, the effects found may be confounded. 

Design continued The clinicians will be randomized into one of

three training conditions by clinic [i.e., all clinicians (minimum of 3 per clinic) in a specific clinic will be randomized into the same training condition].

The training conditions will be: 1) in-vivo training and supervision conducted on site at the clinic; 2) distance learning training conducted via teleconference (didactic and interactive presentations) and conference call (supervision); and 3) self-study manual training.

Design continuesAt the end of the 12 weeks (training completion) data will

be collected to compare with baseline. Follow up data will be collected at 6 months following

training completion to assess sustained training effects.

The 3 training conditions will be compared with regard to the relative changes in CBT-related knowledge, skills and attitudes via audio tapes. Clinician satisfaction data will be collected and post-training focus groups will be held.

Costs of each training model will be calculated over the course of the project to compare the relative costs of the 3 training models.

Dependent variables The Yale Adherence and Competence Scale: YACS (Corvino et

al., 2000) is a 55-item scale tapping general CBT will be adapted for use

Domains to be assessed for all clinicians during treatment sessions (baseline, wk-4, wk-8) will include:

Audiotape from the clinicians in each condition. These tapes are necessary to monitor clinician adherence/competence by the independent raters.

Therapist checklist. Domains to be assessed for all clinicians at completion of the 12

sessions will include: Post-protocol Audiotape from the clinicians in each condition. A

post-training audiotape is necessary to measure changes in clinical practice. The independent tape raters also will rate the post-training audiotape provided on the adherence/competence rating form.

Therapist checklist.

Clinic Sites

Study Limitations Adapt CBT core elements that were developed for use with

U.S. clinicians to a population of South African clinicians.

We address this concern by: (1) addressing the cultural issues with a group to consist of reasoned U.S. and South Africa Investigators and a cultural adaptation expert to ensure that our approach is culturally sensitive; (2) forming a U.S. research team with vast experience in developing culturally specific therapy manuals in international settings;

(3) having an “expert trainer” who has many years of training and supervising international groups; (4) choosing South African clinicians with at least 3 years of experience with substance abuse treatment and familiarity with core cognitive behavioral techniques; and (6) collaborating in a setting country where English is one of the official language used in the treatment settings by clinicians and patients.

Year One Plan

CBT experienced master trainers from RSA trained in CBT

IRB, US State Department, Pretoria Embassy

The content of the 12 CBT sessions and clinician instructions will be reviewed by Drs Rataemane, several RSA clinicians together with Drs Watson, Morgenstern, Rawson and Ms. Obert. Changes in the 12-session NIDA CBT manual will be made to make the materials relevant and appropriate to RSA clinicians and clients, while retaining the CBT style and content

Equipment (televisions, computers, fax machines) will be purchased

for study clinics and the research centers at MEDUNSA and Friends Research. Logistics for television transmission will be arranged with MEDUNSA staff.

Two independent raters from Friends Research Institute will travel to the Yale University Psychotherapy Development Center for training in the Yale Adherence and Competence Scale guidelines.

SUMMARY Lessons Learned and Project Update

(e.g., Domestic and International IRB Issues)