Table 3 Summary of implementation phase adaptations

Primary training of VHTs and government health workers

• Training curriculum was modified for a 7-day curriculum with content derived from WHO mhGAP-IG materials for community health workers, the IPT-G manual previously used in Uganda [13], recommendations from the stakeholder consultative meeting, and objectives of the IPT-G for NS study.

• Core components of intervention were considered to be: identification of depressive symptoms and their effects on each group member’s life, articulation of the link between interpersonal problems and symptoms of depression, exploration of triggers of depression, classification of triggers into one IPT problem area (grief, role disputes, role transition, or interpersonal deficits), and collaborative establishment of practical treatment goals with caregivers.

• For supervision training, previously trained Ugandan IPT therapists conducted an orientation of health workers to IPT-G processes in a half-day session held in parallel to VHT training.

Recruitment within government health systems

• VHTs were able to identify 86 caregivers to participate in the pre-group exercise and 73 fulfilled criteria (PHQ score ≥ 9) for inclusion in the therapy groups. However, participants with low PHQ scores were allowed to participate after they requested to participate to learn IPT skills for managing stress associated with caregiving for children with NS. Two additional caregivers self-presented after the intervention had started and were included as well.

Delivery of IPT-G in government health systems

Initiation phase

• Sessions 1 and 2: common presenting problems were life changes associated with caring for children with NS, experiencing domestic violence, living with HIV/AIDS, and poverty. Caregivers disclosed suicide ideation, and additional training and supervision were provided in making referrals to health facilities and follow-up of caregivers with suicidal behavior.

Middle phase

• Sessions 3 and 4: caregivers displayed increasing openness to share problems and explore solutions.

• Session 5: as caregivers were expected to provide more concrete weekly and long-term goals, they expressed difficulty in articulating these targets. VHTs reported difficulties completing group session forms for this phase of treatment. To address the documentation challenge, peer supervision by VHTs who were more literate was used to support documentation for less educated VHTs and for other VHTs with difficulties understanding documentation.

• Session 6: VHTs noted that the caregivers not showing symptomatic improvement were those experiencing ongoing domestic violence. In response, supervision sessions were dedicated to exploring and supporting caregivers experiencing domestic violence.

• Session 7: VHTs displayed increasing competence in basic IPT concepts and group facilitation techniques. VHTs reported difficulty engaging caregivers who were reporting symptom resolution, e.g., these caregivers did not see the merit in returning for further sessions. IPT-G therapists made group session visits to observe challenges and tailor content of refresher trainings.

• Sessions 8, 9, and 10: caregivers testified about the positive effects of the IPT-G on their lives.

Termination phase

• Sessions 11 and 12: the majority of caregivers expressed positive future plans. Some of the groups decided to continue as self-help support and income generating groups (Bol Cup). VHTs continue to voluntarily engage with caregivers in the community and encourage their self-care.

Supervision and booster/refresher training

• VHT implementation challenges were used to inform supervision sessions and a booster/refresher training was conducted after session 7, with a focus on preparing for subsequent phases and understanding the need and implementation of the termination phase of IPT-G. Supervision focused on adherence to IPT-G structure and addressing challenges faced by VHTs during IPT-G delivery.

Process and outcome evaluation

• In post-intervention debriefings, both caregivers and VHTs reported benefits of the intervention.

• Caregivers formed and maintained self-help groups to sustain change.

• Recommendations for MOH from stakeholders include dissemination of the VHTs model for IPT-G delivery and health workers to serve as facilitators; VHTs requested financial compensation to maintain services.

• The IPT-G session notes and implementation process evaluation were used to develop a training guide for IPT-G in nodding syndrome affected areas.

• Results from the study were used to inform a pilot of the WHO mhGAP intervention IPT component by the government.

• Validation study of a bigger population is planned to inform scale-up