Project Summary
Linked to a 20-year longitudinal study of war in Sierra Leone, the Youth Readiness Intervention (YRI) is a promising approach for addressing mental health problems among at-risk youth in low resource settings. The YRI uses a structured, manual curriculum divided into 12 modules, with sequential 90-minute group sessions designed to be delivered by non-specialists. It integrates six empirically-supported practice elements shown to have trans-diagnostic efficacy across symptom dimensions of mental health disorders, ranging from major depressive disorder and anxiety to conduct problems. The YRI has three phases which are delivered in a sequential fashion: stabilization, integration, and connection. The YRI is designed to be integrated into education or livelihood programs. It was initially delivered in educational settings, and later, integrated into youth employment programs tied to regional economic development in Sierra Leone, the Youth FORWARD (Youth Functioning and Organizational Success for West African Regional Development) project, in which the program was delivered by the German Corporation for International Development (GIZ), funded by the National Institute of Mental Health (U19MH109989). Through additional funding, we are evaluating the long-term effects four-years later to this Youth FORWARD project. In addition, to further strengthen the impact of the YRI, our research team has examined the potential of the YRI to reach a larger segment of the population by examining the extent to which indirect effects result in measurable incremental health benefits (symptoms and functioning) among nonparticipants. This project, funded by the NIH, titled Expanding the Reach of Evidence-Based Mental Health Treatment: Diffusion and Spillover of Mental Health Benefits Among Peer Networks and Caregivers of Youth Facing Compounded Adversity in Sierra Leone (R01MH117359), will investigate the mechanisms of natural diffusion of CBT techniques learned among peer groups and spillover phenomenon in reduction of burden to cohabitating caregivers in Sierra Leone.
In addition to the RPCA research in Sierra Leone on the YRI, the YRI has been adapted to multiple global cultural contexts including Somali refugees in Kenya, Venezuelan refugees in Colombia, and South Sudanese populations. The RPCA works with global partners to license our intervention with rigor to ensure the adaptability of our research in multiple contexts.
Background and Aims
The treatment gap resulting from poor access to mental health services in nations with a history of violence and loss due to civil unrest, widespread disease (e.g., AIDS, Ebola), and other forms of adversity is well known. More than one billion children and youth live in countries affected by war and communal violence. The consequences of exposure to violence, societal disruption, and personal loss include high rates of depression, anxiety, and post-traumatic stress reactions in youth throughout Sub-Saharan Africa, Asia, and the Middle East. Although feasible and effective evidence-based mental health interventions have closed health services gaps, their reach and societal benefits are often limited in low-resource settings. The Youth Readiness Intervention (YRI) is a cognitive behavioral therapy (CBT)-based intervention that has demonstrated feasibility and effectiveness for improving emotional dysregulation and daily functioning. The YRI has a transdiagnostic focus and the 12-session modules integrate 6 relatively simple CBT-based empirically supported practice elements that have shown transdiagnostic efficacy across disorders ranging from major depressive disorder, PTSD, and conduct disorders. YRI’s core treatment elements focus on targeting problems with emotion regulation, interpersonal deficits, and impairments in day-to-day functioning. Such integration of simple, transdiagnostic factors has demonstrated effectiveness in prior intervention research with youth. YRI has shown benefits in proving emotion regulation, prosocial attitudes and behaviors, and social support as well as reductions in functional impairment among at-risk youth.
Aims of Current YRI Studies:
- Collect quantitative data on 600 youth who received the 2019 YRI 4-years later and analyze long-term effects of Intervention using cross-sectional approaches and multilevel models to understand longitudinal outcomes related to mental health, emotional regulation, and economic self-sufficiency.
- Collect qualitative data to understand the mechanisms of change for 30 female youth, purposively sampled by treatment responders and nonresponders, participating in the YRI and to examine factors that serve as facilitators and barriers to treatment effects.
- Investigate mechanism of diffusion—the untargeted and unplanned spread of new practices among social network members—of YRI components and mental health benefits experienced by nonparticipant peers who learn YRI practices from YRI participants.
- Investigate indirect mental health benefits experienced by nonparticipants among cohabitating caregivers of YRI participants (spillover effects).
- Investigate incremental health costs and benefits among YRI participants' caregivers and peers through cost-effectiveness and return on investment analysis.
Key Findings of Projects to Date
- When the YRI was originally implemented in secondary schools in urban Freetown ten years ago, youth who received the YRI showed improvements in mental health, pro-social attitudes, daily functioning, and educational outcomes.
- Teachers reported that YRI participants were more likely to persist in school (28.8% vs. 4.7%) and had better attendance and classroom behavior.
- The cluster-randomized trial implemented in 2018/2019 demonstrated that youth (ages 18-30) participating in the YRI and the employment promotion program reported better socio-economic and mental health outcomes than counterparts in the EPP-only and in the control group.
- Improvements in emotion regulation and reductions in anxiety/depression were found, in addition to increases in self-employment hours.
- The ADAPT-ITT framework facilitated the adaptation of the YRI -- findings suggest that the ADAPT-ITT framework can be feasibly applied to guide the intervention adaptation process in LMICs.
Longitudinal, spillover, and return on investment data is currently under peer review.
Publications & Documents
Project Support
Projects have had support from the United States Institute of Peace, the UBS Optimus Foundation, the National Institute for Mental Health, the National Institute on Aging, Harvard Catalyst, the Julie Henry Junior Faculty Development Fund, the Australian Psychological Society, the Australian National Health and Medical Research Council, GDS, and Imaginable Futures.
Partnerships
Caritas Freetown
Innovations for Poverty Action
University of Georgia
University of Makeni
Brown University
Global Reach
The YRI is being tested and adapted in Sierra Leone, Kenya, Colombia, and South Sudan.
Contact: Kathryn Noon, Research Program Manager