Moving from Effectiveness to Implementation Research for Task Shifting CBT
Alongside the promising results of effectiveness trials of CBT using task shifting models, clear implementation challenges emerge from these examples of task shifting CBT in this setting. Primary implementation challenges include poor role definition or clarity on scope of work for lay counselors, lack of standardized training, and inadequate supervision, support, and compensation. For long-term sustainability, a primary consideration is whether activities would be feasible if conducted in a clinic-based setting without any additional research resources. For instance, the amount of training and supervision described in each of the examples may likely not be sustainable in a real-world clinical setting. For instance, in the Papas et al. [4, 5] studies, counselors received 175-300 h of training and supervision prior to starting to see patients for the trial that included not only didactics, but also role plays, videotaped feedback, and supervised sessions with rated CBT skill use. Indeed, in that study, transitioning supervision and training to local supervisors was not attained, and the US-based lead investigator remained on-site throughout the course of the study to maintain her responsibilities of in-person supervision.
The model for supervision seemed to fully embody a task shifting approach in the Friendship Bench, as it was a tiered approach using daily peer supervision, weekly nurse-led supervision, and supervision with a clinical psychologist and psychiatrist once every two weeks and monthly, respectively . Although this is likely also more intensive than would be feasible in a non-research context, it is a good example of a task shifting model of supervision for this intervention. Additionally, in one study , numerous efforts were made to reduce barriers to attendance that may not be feasible in non-research contexts, such as text and phone call appointment reminders, reimbursement for transportation, and in some cases, transportation to the first CBT session. When a later stage of implementation is reached outside the context of a research study, ongoing evaluation is needed as to when clinic-based counselors, as opposed to lay counselors hired for research purposes, are feasibly and competently able to deliver the CBT intervention. Another important consideration when considering efforts to implement CBT in clinical settings outside of a research context will be how to standardize selection of paraprofes- sional counselors. Papas et al. [4, 5 ] aimed to hire for natural talents (empathy, emotional perceptiveness, good communication and analytical skills) assessed using case conceptualizations and behavioral role plays. It remains an empirical question whether this selection approach is effective and feasible in a real-world clinical setting. If task shifting CBT for behavioral medicine conditions proves to be feasible and effective in the ongoing work, it may be a particularly appealing approach to meet the needs for integrating behavioral health interventions into HIV care in sub-Saharan Africa .