Evaluation of Two Mental Health Interventions Based on the Community for Violence-Displaced Afro-Descendants in Colombia.
Phase: NA
Conditions: Post-Traumatic Stress Disorder, Depression, Anxiety, Violence
Sponsor: Universidad del Valle, Colombia

Study Protocol: 
EVALUATION OF TWO COMMUNITY-BASED MENTAL HEALTH INTERVENTIONS FOR 
AFRO-COLOMBIANS VICTIMS OF VIOLENCE 
 
Evaluation of Two Community-based Mental Health Interventions for Violence-
Displaced Afro-Descendants in Colombia. (ACOPLE) 
ClinicalTrials.gov Identifier: NCT01856673 
 
Francisco J. Bonilla-Escobar, MD, MSc; Andrés Fandiño-Losada, MD, MSc, PhD; Diana M. 
Martínez-Buitrago, MD, MSc; Julián Santaella-Tenorio, MV, MSc; Daniel Tobón-García, MD, 
Edgar J. Muñoz-Morales, MD, MSc; María I. Gutiérrez-Martínez, PhD. 
Institute for Peace Promotion and Injury/Violence Prevention (CISALVA), Faculty of Health, 
Universidad del Valle, Cali, Colombia 
 
 
Judith K. Bass, PhD; Laura K. Murray, PhD; Paul Bolton MB BS. 
Department of International Health and Department of Mental Health, Bloomberg School of 
Public Health, Johns Hopkins University, Baltimore, MD, USA 
 
 
Shannon Dorsey, PhD. 
Department of Psychology, University of Washington. Seattle, WA, USA. 
 
 
Heartland Alliance International, Cali, Colombia and Chicago, IL, USA 
 
This study is made possible by the generous support of the American people through 
the United States Agency for International Development (USAID), contract number AID-
OAA-A-10-00046. The contents are the responsibility of the Cisalva Institute of 
Universidad del Valle and Heartland Alliance International and do not necessarily 
reflect the views of USAID or the United States Government. 
 
Cali, October 11th, 2011 
Universidad del Valle 

2 
 
TABLE OF CONTENTS 
 
List of Tables .......................................................................................................................... 4 
ABSTRACT. ........................................................................................................................... 5 
1. 
INTRODUCTION............................................................................................................. 7 
2. 
THOERETICAL FRAMEWORK ..................................................................................... 11 
2.1. Violence and its Mental Health Consequences .......................................................... 11 
2.2. Treatment Models for Victims of Violence .................................................................. 12 
3. 
OBJECTIVES ................................................................................................................ 16 
3.1. General Objective ...................................................................................................... 16 
3.2. Specific Objectives ..................................................................................................... 16 
4. 
METHODOLOGY .......................................................................................................... 17 
4.1. 
Phase 1: Qualitative Study of the Effects of Violence .............................................. 17 
4.2. 
Phase 2: Design and Validation of the Instrument Based on Qualitative Data of 
Victims of Violence and Torture ........................................................................................ 18 
4.3. 
Phase 3: Design and Pilot Test of Mental Health Intervention ................................. 20 
4.3.1. 
Selection and Adaptation of Interventions ........................................................ 20 
4.3.2. 
Pilot Test of Interventions and Fieldwork ......................................................... 21 
4.4. 
Phase 4. Randomized Controlled Trial. Implementation and Evaluation of the Mental 
Health Interventions .......................................................................................................... 22 
4.4.1. 
Trial Design ..................................................................................................... 22 
4.4.2. 
Participants ...................................................................................................... 22 
4.4.3. 
Selection Criteria ............................................................................................. 22 
 
4.4.3.1. Inclusion Criteria .............................................................................. 22 
 
4.4.3.2. Exclusion Criteria ............................................................................ 23 
4.4.4. 
Description of Interventions ............................................................................. 23 
 
4.4.4.1. Common Elements Treatment Approach (CETA) ............................ 23 
 
4.4.4.2. Narrative Community-Based Group Therapy, NCGT ....................... 24 
 
4.4.4.3. Wait-list Control ............................................................................... 26 
4.4.5. 
Enrollment Method and follow up assessment ................................................. 26 
4.4.6. 
Training of Participants in the research ............................................................ 27 
 
4.4.6.1. Lay Psychosocial Community Workers (LPCW) .............................. 27 
 
4.4.6.2. Psychologists .................................................................................. 27 
 
4.4.6.3. Interviewers ..................................................................................... 27 

3 
 
4.4.7. 
Monitoring and Supervision of the Intervention ................................................ 28 
 
4.4.7.1. Administrative Monitoring of the Process: ........................................ 28 
 
4.4.7.2. Monitoring of the Intervention Process ............................................ 28 
4.4.8. 
Definitions of Loss to Follow-up ....................................................................... 31 
4.4.9. 
Primary and secondary outcomes .................................................................... 32 
4.4.10. 
Instrument .................................................................................................... 32 
4.4.11. 
Sample Size ................................................................................................. 33 
4.4.12. 
Randomization ............................................................................................. 35 
4.4.13. 
Evaluation of the Psychosocial Interventions ................................................ 35 
 
4.4.13.1. Quantitative Impact of the Intervention ....................................... 36 
 
4.4.13.2. Qualitative Impact of the Intervention ......................................... 37 
4.4.14. 
Statistical Analysis Plan. .............................................................................. 37 
 
4.4.14.1. Multiple imputation ..................................................................... 38 
 
4.4.14.2. Selection of covariates for final mixed models ............................ 38 
 
4.4.14.3. ITT Final Mixed Models .............................................................. 39 
 
4.4.14.4. Subgroups analyses .................................................................. 39 
 
4.4.14.5. Sensitivity Analyses with Follow-up Predictors ........................... 40 
 
4.4.14.6. Sensitivity Analyses excluding regression outliers...................... 40 
 
4.4.14.7. Effect Sizes ................................................................................ 40 
4.5. 
Ethical considerations ............................................................................................. 41 
5. 
TIMETABLE .................................................................................................................. 43 
6. 
REFERENCES. ............................................................................................................ 46 
6.1. 
Appendix No 1. Survey ........................................................................................... 50 
6.2. 
Appendix No 2. Informed Consent ............................. Error! Bookmark not defined. 
6.3. 
Appendix No 3. Manual of Common Elements Treatment Approach     (CETA) ...... 59 
6.4. 
Appendix No 4. Manual of Narrative Community-Based Group Therapy (NCGT) ... 59 
6.5. 
Appendix No 5. Participant Referral Form for Adverse Events ................................ 59 
6.6. 
Appendix No 6. Security Protocol Manual ............................................................... 59 
 

4 
 
List of Tables 
 
Table 1. Estimate of the displaced population in Buenaventura, years 2007-2008 ..... 8 
Table 2. Distribution of study participants by intervention group and capacity of 
participants per Lay Psychosocial Community Workers (LPCW) in each city. .......... 35 
 

5 
 
ABSTRACT. 
 
Background: There are mental health consequences for individuals and communities that 
have been exposed to violence. The armed conflict in Colombia has caused death and 
massive displacement. In the Pacific region, displacement has been preponderant in 
Buenaventura and Quibdó. Evidence regarding effectiveness of mental health interventions is 
lacking in low-income settings, especially in areas with active conflict. 
Objective: To evaluate two community interventions in mental health designed to decrease 
symptoms of depression, anxiety, and post-traumatic stress symptoms in Afro-Colombian 
victims of violence in Buenaventura and Quibdó. 
Methods: A single-blind randomized controlled trial will be conducted in two municipalities of 
the Colombian Pacific in which participants will be randomly distributed to a cognitive-
behavioral intervention -Common Elements Treatment Approach (CETA) (Group A), a 
Narrative Community-Based Group Therapy (NCGT) Intervention (Group B) and a 
control/waiting list group. Assessments of mental health symptoms and dysfunction will be 
performed at baseline and two weeks after the treatment for Group A and B participants and 
after three to four months in the control group. Symptoms will be assessed with a validated 
survey which includes the Hopkins Symptom Checklist, the Harvard Trauma Questionnaire 
and relevant local symptoms; dysfunction will be assessed with a locally-validated gender-
specific scale. Missing values will be handled using multiple imputation methods. Means will 
be calculated for scales and sub-scales. The primary outcomes will be changes in 
depression, anxiety and post-traumatic stress symptoms; secondary outcomes will be 
changes in the Total Mental Health Symptom (TMHS) and dysfunction scales. Differences at 
baseline will be assessed with the specific test accordingly to the type of variable. Using 
mixed models, we will perform intention to treat analyzes and sensitivity analyzes removing 
those participants without follow up. Co-variables included in mixed-models will be those 
significant at the p<0.10 level identified using: 1) simple logistic regression clustering by 
counselor to identify baseline differences between intervention and control groups; 2) mixed 
models to determine interactions between potential co-variables and time on symptoms and 
dysfunction scores. Furthermore, models will be adjusted for age, gender, education and 
marital status. Sub-group analyzes by gender and civil status will be conducted. Extreme 
values in scales (> or < 4 standard deviations) will be identified as potential outliers and will 
be excluded in a sensitivity analysis to evaluate its impact on intervention outcomes. Effect 
sizes will be calculated using Cohen’s d statistic 

6 
 
Expected results: Evaluation of the effectiveness of two mental health interventions in order 
to describe alternatives for treatment in Afro-Colombian victims of violence in the Colombian 
Pacific Coast. 
 
Keywords: Depression; Anxiety; Stress Disorders, Post-Traumatic; Cognitive Therapy; 
Narrative Therapy; Violence; Torture; Mental Health; Community Mental Health Services. 

7 
 
1. INTRODUCTION 
The present study is framed within the Program called “Community-Based Treatment 
Services for Afro-Colombian Victims of Conflict and Torture (ACOPLE)”, developed by 
Heartland Alliance International (HAI), Association of Displaced African Descendants 
(AFRODES), and CISALVA Institute at the Universidad del Valle in Colombia, in conjunction 
with the Secretaries of Health of the municipalities of Quibdó and Buenaventura, with 
technical assistance from members of the Department of International Health and 
Department of Mental Health, Bloomberg School of Public Health of John Hopkins University 
(JHU),1 registered at ClinicalTrials.gov with code NCT01856673 
(http://clinicaltrials.gov/ct2/show/NCT01856673). 
 
The Afro-Colombian communities in the Pacific region of the country have been the target of 
ongoing attacks for the past several decades. As a consequence of this situation and poor 
socio-economic conditions, there is limited adequate care and accompaniment for the 
survivors of the conflict, especially if their intent is to recover societal bonds and functionality. 
This project is presented as an opportunity to identify an effective treatment to reduce the 
mental health symptoms generated by violence, while promoting mechanisms to generate a 
sustainable offer of mental health services in these regions. 
 
In order to propose solutions that are feasible and effective for the community in terms of 
mental health treatment, it is necessary to first understand the socio-cultural context of the 
affected population and the dynamics of violence that, for years, has affected this population. 
Understanding these contexts allows for the cultural and language-appropriate adoption of 
treatment alternatives that have been implemented in other settings. The incorporation of 
these locally-relevant aspects into interventions reduces the potential of adverse events in the 
community.  
 
The armed conflict that Colombia is undergoing has generated multiple confrontations that 
primarily affect rural communities causing the death of thousands and the displacement of 
large masses to major urban areas of nearby municipalities. On the Pacific coast, a region 
where many armed groups compete for resources in the area, the phenomenon of violence 
has intensified, which has generated an acute increase in Afro-Colombian internal 
displacement from the rural areas to the two most important towns in the region: 
Buenaventura in Valle del Cauca and Quibdó in Chocó.  

8 
 
 
The armed conflict in the pacific zone includes the presence of the Armed Forces of 
Colombia, paramilitary groups, the guerrilla groups (Revolutionary Armed Forces of Colombia 
(FARC) and National Liberation Army (ELN),) and emerging criminal groups dedicated to 
drug trafficking (BACRIM). These BACRIM have violated the human rights of people living in 
this area, carried out several massacres, generated massive displacements and conducted 
torture through the systematic elimination of community leaders. 
 
Buenaventura is a vital municipality for the country's economy, and is now the poorest 
municipality of Valle del Cauca. The percentage of the population with unsatisfied basic 
needs is three times that found in Cali (the capital city of Valle del Cauca). Basic services are 
well below the departmental average and literacy rates, which are comparable to those found 
in Chocó (the Department were Quibdó is located) are low.2 The internal armed conflict taking 
place in the country has had serious consequences in Buenaventura, where violence has 
raged since 1998. Buenaventura is becoming a strategic corridor for drug output to various 
countries, is increasing illicit crop growth in rivers, and the river mouths have become storage 
sites for drugs, supplies and fuel.3 Some displacement figures are presented below. 
 
Table 1. Estimate of the displaced population in Buenaventura, years 2007-2008 
Displaced Population 
2007 
2008 
Arriving persons 
8,921 
3,580 
New homes 
1,778 
686 
Expelled persons 
12,322 
5,769 
Expelled homes 
2,780 
1,329 
Expelled women 
6,709 
3,127 
Expelled men 
5,613 
2,642 
Arriving women 
4,892 
1,995 
Arriving men 
4,029 
1.585 
Expelled minors 
5,902 
2,769 
Arriving minors 
4,438 
1,799 
Source: Presidential Agency for Social Action and International Cooperation.4 
 
Quibdó, capital municipality of Chocó, is the only center located between the mountains and 
the coast. Due to its characteristics, it is the midpoint of a natural link that exists between the 

9 
 
two Colombian coastlines, via the Atrato and San Juan rivers. The relationship of centrality 
converges in the San Pablo isthmus area, specifically between Quibdó and Istmina, and is 
explained by the fluvial communication between the two great Atrato and San Juan rivers. 
The phenomenon for displacement to urban areas and internal mobilization among districts 
has been intensified by violence generated by armed conflict forces This has created 
concentrated displacement centers as Tutunendo, La Troje, Negua, Villa del Rosario, Boca 
de Naurita and Quibdó have become the largest recipients of that population.5,6 
 
Furthermore, as the capital of the department, Quibdó currently has 4,014 displaced people 
constituting an adult population of 983 men, 1,189 women and 1,843 children under 18 years, 
which corresponds to 400 households.7 A large percentage comes from the Lower and 
Middle Atrato, Juradó, Urabá, Bagadó, Negua, and El Dieciocho. The areas of urban 
settlement are located in the neighborhoods of Villa España, Coliseo and Cascorba, which 
receive comprehensive care from the Municipality Social Solidarity Network. 
 
In 2002, over 4,000 people were killed for political reasons, more than 1,000 people were 
missing and at least 2,700 people were kidnapped in the Pacific region. Violence in the region 
is due to the resurgence of paramilitary groups and drug traffickers who are financed through 
the forced seizure of arable land, mineral resources and drugs that are taken from southern 
Colombia to the Pacific coast for shipment to other countries.7 It is estimated that 90% of 
forced disappearances and 55% of the acts of torture reported in the area are committed by 
paramilitary groups.7 
 
Between July 2003 and June 2008, 899 people reported having been tortured in the area, of 
which 86.3% were men. Of all the people tortured, 168 reported being psychologically 
abused.8 These figures however, are not all the torture cases that occur in the area, due to 
the vast majority of cases not being reported to any institution. The magnitude of the problem 
has not been fully determined and it is possible that a large number of people still continue to 
suffer from violence and torture in silence.6 
 
The 2009 report from the Colombian Government Social Action program, stated that 90% of 
the displaced population that has reached the urban headwaters of the municipalities of 
Buenaventura and Quibdó are Afro-Colombians (a total of 67,795 displaced persons in 
Buenaventura and 42,267 in Quibdó).9 

10 
 
 
Despite this, few mental health services are readily available for survivors of the conflict; the 
importance and need for these services only gained some recognition and attention from the 
State after the Victims Law (1448) was passed in 2011. Even so, public health programs 
targeting this population are still incipient and show definite strategic and methodological 
weaknesses. 
 
In 2009 the organization Heartland Alliance International (HAI) began developments to 
determine the mental health needs of Afro-Colombians in Colombia's Pacific coast, a process 
that also included the identification of institutions interested in the subject of providing 
appropriate treatment and solutions to the problems of victims due to violence in this region. 
In this initial phase, HAI identified that the availability of mental health help for the population 
living in Buenaventura and Quibdó is limited; a single specialist in Buenaventura and none in 
Quibdó, which shows a lack of trained personnel to meet the needs of individuals traumatized 
by violence.10 These services, along with the research study of two mental health 
interventions constitute ACOPLE. 

11 
 
2. THOERETICAL FRAMEWORK 
 
2.1. Violence and its Mental Health Consequences 
The long-term consequences of violence on health are well documented in the literature and 
evidence exists that it can affect physical functioning, psychological and social recovery of 
victims.11 
 
Violence is defined by the UN Convention Against Violence and the Criminal Code of the 
United States as “any act by which severe pain or suffering, whether physical or mental, is 
intentionally inflicted on a person for such purposes as obtaining from him or her or a third 
person information or a confession, punishing him or her for an act he or she or a third person 
has committed or is suspected of having committed, or intimidating or coercing him or her or 
a third person, or for any reason based on discrimination of any kind, when such pain or 
suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public 
official or other person acting in an official capacity”.11 
 
The consequences of violence on the mental health of individuals are often referred to as 
Post Traumatic Stress Disorder (PTSD), and most researchers and health care staff agreed 
that the symptoms described in the diagnostics criteria are often manifested in survivors of 
violence worldwide.12 
 
The most common mental problems associated with PTSD include, but are not limited to: 
flashbacks, escapism, agitation and feelings of guilt, that manifest in various ways such as 
memory problems and concentration, sleep problems and nightmares, hypertension and 
anxiety when confronted with reminders of the trauma, intrusive thoughts and memories of 
traumatic events, increased irritability and difficulties with interpersonal relationships, 
depression and social isolation, anxiety and other somatic problems.13 
 
The effects of violence cause severe discomfort in survivors, affecting their quality of life and 
ability to function in daily life. Symptoms such as chronic pain, problems with interpersonal 
relationships and depression prevent the individual from performing basic tasks at home, 
school, work, and at the community. The degree of dysfunction is related to several factors, 
including the severity and duration of the traumatic event, the existence of family and 
community support, and individual variations in terms of susceptibility to depression.14 

12 
 
Violence has the unique ability to isolate people, away from both their families and their social 
networks. The resulting suppression and PTSD limit social interaction of the victims and 
creates fear in the survivors as well as people who surround them.11 Thus, the effects of 
violence and trauma on individuals also have an impact on the family, community and society 
functioning. 
 
Although concern about the increase in manifestations of mental illness and the increase in 
the diagnosis of diseases of this type is widespread in the world, it still appears that many 
people who suffer violence and violation of human rights are unable to count on any health 
services or for healing or treatment of symptoms.11 
 
Given the interrelated dimensions of health from the physical, mental and social aspects, it is 
crucial that victims of violence are holistically met when an option in health care is provided;15 
since when one dimension is neglected the effects of violence become deeper.16 
 
The victims of displacement are among the most vulnerable populations worldwide and unlike 
refugees, have not crossed a border to protect them but remain relatively close to home. By 
2007, 1% of the 6.7 billion people of the world population was estimated as displaced due to 
armed conflict, violence, development projects and large-scale natural disasters.17 In 2011, 
Colombia, with more than 5.7 million Internally Displaced Persons, is found in the first place 
followed by Iraq and South Sudan; currently, Colombia has the second largest number of 
persons displaced by violence after Syria.18 
 
Specifically in Colombia, studies carried out in the country with victimized populations of 
violence in 2002, documented the existence of PTSD in children, youth and adults exposed to 
war and sociopolitical violence.19-22 Researchers found that multiple exposures to traumatic 
events of violence, in conjunction with social conditions of poverty, displacement, racial or 
ethnic discrimination, traumatic grief, and insecurity resulted in severe traumatic anguish and 
complexes, as in other countries in situations of conflict. Health factors were multidimensional 
and affected the functionality of the individual, family and community.19,21,22 
 
2.2. Treatment Models for Victims of Violence 
State of the art research on trauma treatment indicates that cognitive behavioral approaches 
are more successful in treating people.14,23 Some studies also emphasize the importance of 

13 
 
the relational aspects of treatment, such as developing a sense of security and confidence for 
a positive working relationship between the mental health provider and the patient. 
Multicultural considerations that influence the perception of the delivery of health services are 
also important to the success of the treatment.23 Thus, lay mental health workers (or lay 
psychosocial community workers (LPCW)) involved in interventions in this project, must focus 
on treatments that incorporate cognitive-behavioral strategies based on evidence, are 
flexible, and that are culturally sensitive.24 
 
The fundamental values of treating violence survivors include empowerment of the survivor 
and the development of a strong therapeutic alliance between the victim and the mental 
healthcare provider. This alliance should be flexible, based on mutual respect and culturally 
sensitive. A standardized format is typically contraindicated since it ignores the stressors of 
everyday life inherent in the social circumstances of the survivors of violence, such as being 
asylum seekers, refugees or internally displaced. An understanding of the psychological 
suffering caused by violence, neurobiological studies that explain aspects of functional 
deregulation, and the interaction between culture and symptom expression are also essential 
parts of the treatment of violence. A focus on treatment based on components is the best way 
to incorporate all of these concepts.23 
 
Starting from an assessment of population characteristics, the therapeutic intervention may 
include the following components: psycho-education techniques, relaxation and stress 
management, modulation of affect, and cognitive processing strategies.25 
 
The aim of the psycho-education component is to inform the survivor about the 
consequences of violence on health, as well to promote understanding of the symptoms they 
may be experiencing, changes in their behaviors and interpersonal interactions. For many 
survivors, the ability to understand the symptoms and changes is the beginning of the healing 
process that allows them to regain their functionality in society. These mechanisms allow for 
emotional release, emotional support, psychotherapeutic support, and support for self-help 
which, in turn, help in social adaptation and reduces relapses.  
 
Providing the means for survivors of violence to learn to manage their stress reactions with 
relaxation techniques is another step to regain mental health. Relaxation techniques aim to 
break vicious cycles and replace them with a reaction that is compatible with tension 

14 
 
reduction. These are behavioral techniques aimed at reducing problems such as anxiety, 
stress or pain. They become part of a systematic desensitization with the purpose of reducing 
anxiety, because the technique generates self-control over the person’s functionality, helping 
to increase the perception of competence, personal domain and the alteration of sleep.26 
 
The technique for stress management involves controlling and reducing the tension that 
occurs in stressful situations by making emotional and physical changes. The degree of 
stress and the desire to make changes determine how much change will take place. The 
mechanisms to create an individual program for stress management are to: find the positives 
in situations and not focus on the negatives, plan fun activities, and take regular breaks.26 
 
Cognitive strategies highlight the importance and the role that perceptions, thoughts and 
beliefs have on behavior. It is based on several theories, but with a common goal of providing 
the person with the necessary power to direct or control their own behavior.23,26 
 
The ability to contain reactive emotional responses to traumatic stimuli and not feel 
overwhelmed or burdened by the emotions, is an essential part in the process of healing from 
violence. The conflict between pre-traumatic conceptions of self and the world, such as the 
belief that "nothing bad will happen to me," and post-traumatic conceptions, such that trauma 
is evidence that the world is a dangerous place, reflected as the survivor perceives the world 
through the lens of an experience of violence and alters their concept of self and self-esteem. 
Therefore, restoring the psychological processes of modulating healthy affection and 
cognitive processes are also important aspects of healing.25,26 
 
Given the large number of victims of violence and that Afro-Colombian survivor populations 
are widely scattered in urban communities, as well as in the smaller towns along the Pacific 
coast of Colombia, 11,14 a community model of health services that could reach this population 
adequately, is presented as an option of access to treatment. 
 
The World Health Organization (WHO) estimates that from the millions of people suffering 
from mental health disorders, as much as 76% and 85% from low and middle income 
countries, respectively, receive no treatment for their disorder.27 In developed countries, 
primary care has been called "the cornerstone of community psychiatry." This has promoted 

15 
 
the integration and development of skills, knowledge and attitudes of the professional 
community and society at large.28 
 
Due to the legacy of violence and mistrust, the most effective way to reach the Afro-
Colombian communities is through civil society organizations. Community-based treatments, 
consisting of a network of LPCW, allow easy access to victims and, through proposed 
treatments, generate dynamics that relieve post-traumatic stress symptoms (PTSS).11 
 
Interventions based on the community for the treatment of PTSS have been analyzed 
previously and the tools used allow for the identification treatment that will most effectively 
improve the quality of life of the individuals.23,38 However, the methodology should be 
adjusted to the culture and social characteristics of the victimized population so that the 
processes develop according to policy actions of do-no-harm. Therefore, it is necessary to 
coordinate studies under the perspective of a specific vision of the population and thus carry 
out adjustments of treatment tools, in the same way that one should evaluate possible 
treatments and determine its true efficacy in a sample population to be treated before being 
used in the entire population. 
 
Cognitive behavioral therapy has been proved effective in different settings for people 
experiencing different symptoms, especially post-traumatic stress symptoms.23 The Narrative 
Therapy model implemented by ACOPLE is grounded on the systematized proposal of 
Adalberto Barreto, a Brazilian Psychiatrist, Anthropologist and Theologist, that targets to 
stimulate the construction of solidarity networks of care between people, and strengthen 
individual and collective resources through socialization and narrative of experiences.29 

16 
 
3. OBJECTIVES 
 
3.1. General Objective 
To evaluate two community-based mental health interventions designed to decrease 
symptoms of depression, anxiety, and post-traumatic stress symptoms (PTSS) in Afro-
Colombian victims of violence in Buenaventura and Quibdó. 
 
3.2. Specific Objectives 
 
3.2.1. Design two mental health interventions based on LPCW, adapted to socio-cultural 
characteristics of Afro-Colombian residents in the municipalities of Buenaventura y 
Quibdó. 
 
3.2.2. Determine the effectiveness of the CETA intervention on mental health designed to 
diminish symptoms of depression, anxiety, and PTSS in Afro-Colombian victims of 
violence. 
 
3.2.3. Determine the effectiveness of the NCGT intervention on mental health designed to 
diminish symptoms of depression, anxiety, and PTSS in Afro-Colombian victims of 
violence. 

17 
 
4. METHODOLOGY 
 
The methodology of the program was developed under the design, implementation, 
monitoring, and evaluation (DIME) research model for programs developed and implemented 
since 2000 by the Applied Mental Health Research -AMHR Group at JHU. 
 
The implementation of this research requires different phases and methodologies that should 
consider the following phases. The first two phases have already been conducted: 
 
Phase 1: Qualitative study of the effects of violence.  
 
Phase 2: Design and validation of instruments based on qualitative data of victims of 
violence and torture. 
 
Phase 3: Design and pilot testing of interventions. 
 
Phase 4: Implementation and evaluation of interventions (Randomized Controlled 
Trial). 
 
4.1. 
Phase 1: Qualitative Study of the Effects of Violence 
CISALVA Institute staff conducted a pre-intervention qualitative research on the effects of 
violence on individuals and communities, which included a structured process to identify 
problems affecting the survivors of violence and their families; JHU staff accompanied the 
process. The methodology was put in place with a focus on the DIME methodology, which 
allows a constant monitoring and evaluation process to ensure maximum benefit of the 
interventions targeted in the study. 
 
Without a relevant process of monitoring and evaluating that is adapted to the local 
conditions, the standard indicators can be met without this meaning that the needs of the 
population have been met. In the area of mental health, the ability to monitor and evaluate 
interventions and programs presents important challenges as the measurements for baseline 
and post-established treatments must be performed with instruments sensitive enough to 
identify changes in the behavioral patterns of the population. 
 
This process focused especially on psychological problems that can be caused by violence 
and the difficulties in the normal operation of a person in society according to the perspective 
of the interviewee. 

18 
 
 
It was suggested that interviews be conducted by people who understand the community and 
belong to AFRODES, which led to the process of implementing the study within the two 
communities for victims of violence. For this study, 15 people were selected to receive skills 
training for a qualitative interview for the people in the community. 
 
The interviewers were trained in a variety of qualitative interview techniques (free listing, key 
respondent interviews, and focus groups) in order to investigate three principal themes: 
fundamental problems (in particular psychosocial problems) that affect survivors of violence 
and their families, including how these problems affect the community, their perceived effects, 
and their causes, and how people face or believe they have to face them. It explored the 
characteristics of survivors and the activities that people normally do in the society according 
to the culture, local customs (this last is used to implement adequate measurements of the 
local level operation). Additionally, the interviewers were trained in reliability of information 
and ethics employed in relation to the information provided by participants in the study. 
 
Two investigators from CISALVA and three from the Marjorie Kovler Center for Torture 
Treatment of Heartland Alliance carried out the training of interviewers and coordinated the 
fieldwork. The duration of the study was two weeks in each city. 
 
The interviewers conducted interviews in pairs. Both for the development of free listing as 
well as interviews with key respondents, one of the interviewers asked the questions to 
interviewees and the other handled note-taking. 
 
4.2. 
Phase 2: Design and Validation of the Instrument Based on Qualitative Data 
of Victims of Violence and Torture 
Using the information obtained in the qualitative study as a base and the identification of the 
problems that seem to be the most severe, frequent, and of highest importance for the 
population, existing quantitative measuring instruments were selected and adapted with the 
purpose of achieving a base-line of the problem faced by victims of violence. 
 
The design was based on a methodology centered on problems prioritized by the community, 
using interventions derived from the population and appropriately adapted to the expectations 
of the people, which facilitated their acceptance and understanding, gaining the ability to 

19 
 
more efficiently gather the expected results and later, during the intervention, a new 
measurement can be taken of new indicators of progress in the community. Thanks to this, it 
was possible to establish which of the interventions demonstrated successful diminishing of 
symptoms generated by violent processes. 
 
It was proposed that a modified version of the verification Hopkins Symptoms Checklist 
(HSCL) be used to evaluate depression and anxiety, and a modified version of the Harvard 
Trauma Questionnaire (HTQ) be used to evaluate PTSS.21,22 However, both instruments 
were modified to determine categories of psychological anguish lived by Afro-Colombian 
violence survivors. 
 
The survey instruments (HSCL and HTQ) were used to carry out a reference and 
measurement study of the psychological consequences of violence, including depression, 
anxiety and PTSS. The evaluations were conducted through direct interviews with at least 
120 participants who had either psychological history of sadness, suffering, violence, 
psychological trauma, or who had no previous symptoms. The result was a picture of the 
categorization of PTSS, its relative severity in the population of violence survivors, and a 
reliable instrument with which to measure treatment outcomes. 
 
The investigator team members will carry out the investigation with 15 mental health LPCW 
(the same individuals in charge of carrying out the qualitative surveys). The collection of data 
will take approximately two weeks. 
 
The chosen individuals were identified beforehand by AFRODES, under informed consent, as 
persons that had problems of sadness, suffering, and/or psychological trauma. The LPCW 
used language identified during the qualitative interviews to formulate the study questions. 
 
The resulting instrument was used in pilot field tests in the cities to evaluate the ease of its 
use, as well as its level of comprehension between the interviewees. The validity of the local 
instrument was evaluated through its utilization on recognized groups that have mental health 
problems originated during violent traumatic events and in recognized groups where this type 
of problem does not exist. Some participants were interviewed two times by the same or 
different interviewers to evaluate how reliable the instrument was with the passage of time, 
and how effective it was when used by different interviewers. 

20 
 
 
4.3. 
Phase 3: Design and Pilot Test of Mental Health Intervention 
In order to offer mental health interventions based on Afro-Colombian victims of violence, the 
methodology requires a design and validation process so that the objectives are completed 
and generate an approach in line with the community problems. To do so, the following 
aspects have been defined: 
 
4.3.1. Selection and Adaptation of Interventions 
Other than identifying primary problems that are going to be served, the qualitative study will 
also investigate the perceived causes of these problems, their impacts, as well as the ways in 
which the group confronts these problems and what they feel should or could be done to 
remedy them. This information will be used to identify and adapt two interventions that may 
have meaning for Afro-Colombian violence survivors (i.e., interventions that address matters 
that actually worry them and find solutions to the problems that afflict them) and to be 
acceptable for them (to be applied in a consistent and appropriate manner with what they 
now feel). 
 
It is more likely that these interventions include cognitive-behavioral techniques, including the 
behavioral activation and cognitive processing therapy. At least one of these interventions will 
be designed with a focus of “components.” This method consists in taking into account the 
actual knowledge about which components of treatment for violence seem to be most 
efficient and to group them into one intervention. The last studies and opinions of experts 
suggest that this methodology of treatment for violence has been successful in different 
contexts; however, it is necessary to adapt them to the scenarios of each culture.1 
Investigators from JHU, in conjunction with the team from CISALVA, will carry out an initial 
valuation of the literature and of the qualitative investigation results that will drive the design 
of two specific interventions and the culturally adapted investigation (Interventions A and B) 
according to the reality of the Afro-Colombian communities. 
 
 
1 Preliminary results of JHU Team studies in Northern Iraq suggest that a focus based on components employed 
there were highly effective. 

21 
 
The JHU and CISALVA personnel will train the supervisors and LPCW so that they can 
correctly accomplish the chosen interventions. The training sessions will be carried out during 
a two-week period and will be presented to the LPCW that will carry out the qualitative study. 
 
Afterward, the team of researchers will train two different groups of LPCW in how to deliver 
the intervention. The training program will provide a basic theoretical foundation about PTSD, 
mental health, and mental illnesses. It will also provide information about the hierarchies of 
need and treatment planning, the response to crisis, and the promotion of healthy behavior. 
The program will provide general directives and abilities of the mental health service features. 
 
4.3.2. Pilot Test of Interventions and Fieldwork 
Looking for people affected by violence in the Buenaventura and Quibdó communities 
requires testing the designed interventions (each intervention against the control group). 
Therefore, it is also necessary to test the fieldwork through a pilot experience. 
 
The fieldwork pilot will proceed as follows: The AFRODES team will carry out the contacting 
within the community and perform the informed consent survey. The CISALVA team will 
make sure that every assessment is completely filled out, entered, and that the information is 
valid. They will break up the users into groups. The team from HAI will start the interventions 
while JHU will supervise the attention of the cases and, when the close is finalized the 
trainers from AFRODES will begin to close the cases. The interviewers from AFRODES will 
conduct follow up assessments; CISALVA will digitize these assessments and analyze the 
database. 
 
In order for the intervention pilot tests to work within the communities of Buenaventura and 
Quibdó, three intervention groups will be designed: Group A will receive the individual 
intervention adapted by the investigators; Group B will receive the community therapy that is 
also conditioned based on the groups affected by violence; and the control/waiting list group, 
whose participants will not receive any intervention but will have an outcome assessment and 
will get psychological attention offered by HAI. The Groups A and B interventions will be 
conducted by the LPCW and will be permanently supervised by the project psychologists. 
 

22 
 
4.4. 
Phase 4. Randomized Controlled Trial. Implementation and Evaluation of the 
Mental Health Interventions 
4.4.1. Trial Design 
A single-blind controlled randomized trial with three parallel groups will be conducted: two 
intervention groups and one control/waiting list group in each city, powered for comparisons 
among each intervention against the control group. 
 
4.4.2. Participants 
The Participants will come from the municipalities of Quibdó and Buenaventura, located in 
districts identified as those sheltering large amounts of individuals displaced by the armed 
conflict in the country (Chocó and Valle del Cauca). Participants will be adults over the age of 
18 who are either Afro-Colombians or mestizos referred by key informants (from AFRODES 
or other community leaders) whom they recognize as having symptoms of depression, 
sadness or suffering, and having a history of trauma exposure. This will be followed by a 
snowball technic where the interviewed participants will be asked to suggest others that might 
have presented the same conditions. Further individuals will be identified, using a door-to-
door manner, visiting neighborhoods with high prevalence of victims.  
 
4.4.3. Selection Criteria 
4.4.3.1. 
Inclusion Criteria 
In order to select individuals that will likely be a part of the interventions, field visits will be 
taking place to identity adult (18 years of age or older) Afro-Colombian victims of violence and 
torture who have expressed sadness, suffering, psychological trauma caused by violence. 
 
Leaders from AFRODES and the CISALVA team will visit the communities accompanying the 
interviewers to assess the previously identified participants. The surveys will be conducted 
after participants have been explained to about the study and an informed consent form has 
been explained and signed with each participant. 
 
The selection of people that will be included in the study will be based on the severity of the 
symptoms and the level of dysfunction identified using the instruments of the investigation, as 

23 
 
well as the history of exposure to traumatic violent experiences. The inclusion criteria will be: 
a) being over 18 years of age, b) being Afro-Colombian or mestizo, c) reporting having 
experienced at least one violent traumatic experience, d) having a TMHS score ≥49, and e) 
having any reduced functionality in routine activities. Participants’ scores will represent a 
baseline assessment on which to compare with further follow up assessments. 
 
The administrative supervision of the project will be done by the stakeholders: HAI, 
AFRODES, and CISALVA. Along the research process, the JHU staff will be advisors. The 
supervision of the fieldwork will be led by three professionals from CISALVA, two 
professionals from HAI, and the CETA supervision will be led by JHU. 
 
4.4.3.2. 
Exclusion Criteria 
People of ethnicities other than Afro-Colombian or mestizos and children under 18 are not 
included in the study, therefore they do not fall under the survey inclusion requirements.  
 
Adult Afro-descendants, who show symptoms of severe mental illness like schizophrenia, 
psychosis, endorsing suicidal thoughts, and those who are a potential harm for others, will be 
excluded from the study. Excluded individuals due to these criteria will be referred to a 
psychologist from the study staff to determine the need for specialized psychiatric care; 
psychologists and social workers will ensure the participant is offered and given appropriate 
care. Lastly, anyone related to the LPCW will be also excluded. 
 
4.4.4. Description of Interventions 
Two interventions will be conducted in a randomized controlled study in Buenaventura and 
Quibdó. In both cities, there will be a group receiving Intervention A, another receiving 
Intervention B, and a control/waiting list group to compare each intervention’s effectiveness. 
The wait-list/control group will receive psychological attention once the follow up assessment 
is conducted. 
 
4.4.4.1. 
Common Elements Treatment Approach (CETA) 
The CETA intervention, which is a transdiagnostic psychotherapy model based on a CBT 
(Components Based Therapy), was developed by two of the study authors for use in low-

24 
 
resource countries. CETA components include: (1) Encouraging Participation, (2) Psycho-
education, (3) Cognitive coping, (4) Gradual exposure: trauma memories, (5) Cognitive 
reprocessing, (6) Safety skills, (7) Relaxation, (8) Behavioral activation and (9) Live gradual 
exposure. 
 
Twenty LPCW (10 from each city) will be trained and supervised via the apprenticeship model 
of training.30 They will participate in a 10-day training by CETA experts, followed by weekly 
practice groups and then personalized supervision meetings with a mental health 
professional and a local supervisor (one per city) after each session. This will be key, not only 
to ensure a correct delivery of the model, but also as means to ensure alignment with the 
Norms and Codes of Practice of Psychology in Colombia.31 
 
4.4.4.2. 
Narrative Community-Based Group Therapy, NCGT 
Narrative Therapy is founded on a social construction that puts forth the theory that the 
stories we tell ourselves and others represent our view of the world and of our relationships; 
these stories are the most powerful tool we have to modify our lives.29 
 
The NCGT consists of a series of steps that will be accomplished throughout 12 sessions of 
approximately 1 hour and 30 minutes. The first session aims to present the therapy approach 
and presentation and the last one to close, conclude and evaluate; the 10 sessions in the 
intermedium aim to conduct the NCGT itself. Therapy sessions will be held in community 
meeting locations (schools, churches, and community centers). The sessions consist of 
several steps: 1) Welcome and group dynamics dealt with presentation, ground rules and 
psycho-education; 2) Sharing and selecting a problematic topic; 3) Adding context to the 
topic, linkages to suffering; 4) Sharing local knowledge; 5) Closure and relaxation. 
 
In this therapy, the word “narrative” refers to what the person tells him or herself, as well as 
others, about their lives (dominant history), and the manner in which they have construed 
symbol and meaning. It also refers to experiential knowledge and how this “local” knowledge 
has surfaced, how it has been expressed and put together in interactions with others. 
 
The intervention will be directed by LPCW who will be in charge of 5 participants each. The 
NCGT group will be composed of 25 participants and 5 LPCW, with the supervision and 

25 
 
support of a psychologist and a social worker.  
 
Some of the Techniques of Narrative Therapy: 
Naming the Problem: Given a story that is “saturated” or “densely filled” with the problem, a 
therapist invites the person to put a specific name to the problem. It can be a word or short 
phrase and allows the person to feel that they are in control of the situation. 
 
Externalizing Language: This consists of the therapist passing onto the client, in an implicit 
manner, a language that permits the person to feel that the problem and the effects of the 
problem over their life, are external instead of the belief that they form a part of the self: “the 
problem is the problem” and it has nothing to do with the person’s personality or 
psychological state. Its objective is to help the person to distance themselves from their 
problems and to consider them as circumstantial problems and interpersonal processes.  
 
Deconstruction – Unexpected Outcomes: Through questions, the therapist invites the person 
to detail the circumstances and nature of the unexpected outcomes such that they realize 
how they are out of place with the “saturated” story of the problem, permitting a 
deconstruction of the dominant story while at the same time allowing for an alternative 
account that is rich with new meaning. 
 
Use of Therapeutic Documents: The therapist will use records from each group meeting. 
These documents record achievements, discoveries by the person which relate their progress 
and alternative accounts. 
 
Use of External Witnesses: The person can choose who to invite to the session and with 
whom they will share their stories, especially family members, close friends or people in the 
community with whom they share the same problems. External witnesses can share their 
own memories with the client in order to reinforce the story with the "resonances" that 
produced them. 
 
Memory: People can gain support through memories of important people they have lost 
(through death) or with those with whom they have lost contact such as relatives, friends, 
neighbors or acquaintances that are highly significant in their lives. 
 

26 
 
Narrative Therapy is appropriate in community work with those communities that are victims 
of armed conflict, not only through the concepts already mentioned, but also because it is a 
therapy based on relationships that requires that people take a stand against the world, that 
they discover and rediscover themselves, i.e., that they recover their identity. It requires the 
therapist to be a facilitator of creativity and imagination as they work with metaphors and 
analogies. This creates an understanding of the complexity of human beings and recognition 
of the individual experience.  
 
4.4.4.3. 
Wait-list Control 
These participants act as the control group. As intervention participants, they will have a 
baseline (at the same time as intervention participants) and follow up assessments (about 12 
weeks after baseline). 
 
The control participants are unlikely to receive any mental health treatment outside the study 
as access to these kind of services is extremely limited in both cities.32 Controls will be 
contacted by study staff on a monthly basis to screen for acute serious mental problems 
(suicide ideation, anxiety or depression). When necessary, they will be assessed by a 
psychologist and if it is needed, they will be excluded from the study and provided with the 
appropriate care. A psychological evaluation will be offered and provided to each of the 
controls after their completion of the follow-up and, when necessary, psychological care will 
be provided in ACOPLE centers. 
 
4.4.5. Enrollment Method and follow up assessment 
Allocation of finally accepted participants for either arm of the trial will be done in a 
randomized fashion by researchers from CISALVA who will not have access to participants. 
Random assignment will be performed by giving consecutive ID numbers to baseline surveys 
as they are conducted and these will then be allocated randomly to any of the arms of the trial 
(CETA, NCGT, wait-list control). The interviewers who will conduct the baseline and follow-up 
assessments will be masked to the participants’ arm allocation. Follow-up assessments for 
controls will be conducted, approximately, at 3-4 months after baseline assessment according 
to their time of enrollment.  
 

27 
 
4.4.6. Training of Participants in the research 
4.4.6.1. 
Lay Psychosocial Community Workers (LPCW) 
HAI will carry out the first series of trainings, estimated to be four to six weeks long, about 
concepts and basic abilities for all the LPCW selected to participate in the project. 
 
The initial plan for the LPCW is based on instructional curriculums used in Iraq and 
developed for mental health workers with two years of postsecondary education but modified 
for use in Colombia (see Appendix) 
 
4.4.6.2. 
Psychologists 
Psychologists will be trained by the JHU team and will conduct the training component of the 
intervention (CETA), according to the schedule and training manual (see Appendix) 
 
Training for NCGT will be conducted by the CISALVA staff and HAI according to the planned 
program (see Appendix). 
 
4.4.6.3. 
Interviewers 
CISALVA will carry out trainings on assessment instruments. Staff from CISALVA will 
participate in the training of the interviewers with the support from center coordinators, the 
field supervisors, and AFRODES leaders. 
 
The training will last three hours and will have the following content: 
 
Explaining the organic structure of the Project.  
 
Explaining the security protocol in fieldwork and how to carry out the activity and 
collection of information (see Appendix). 
 
Explaining the project and the importance of the survey. 
 
Survey components of the training, informed consent, and its necessity. 
 
Validation of learning. 
 
 
 

28 
 
4.4.7. Monitoring and Supervision of the Intervention  
4.4.7.1. 
Administrative Monitoring of the Process:  
1. Assistance in the training of Psychologists and LPCW. 
2. Monthly progress reports to HAI. 
3. Yearly reports to the ethics committee of the Universidad del Valle. 
4. Monthly financial reports for the accepted budget under the norms of HAI and the 
Universidad del Valle. 
 
4.4.7.2. 
Monitoring of the Intervention Process 
CETA Intervention for Group A will have close supervision for all individuals in the study. 
In each weekly treatment session, the LPCW will keep a tracking form that will include the 
level of severity of the main symptoms and clinical history for each participant. The LPCW will 
meet with their local supervisors weekly to discuss each case. Local supervisors will assess 
the suitability of the tasks performed by the LPCW and provide feedback and support for 
future sessions according to the case and the LCPW’s doubts. Supervisors should answer 
questions that the LPCW may have regarding identified problems after performing the 
interventions, as well as the special health needs that they identify in the population (i.e., a 
person who intends to commit suicide; the supervisor should redirect the person to specific 
health facilities that can help solve their mental health problems). These adverse events will 
be reported to the Institutional Review Board of Human Ethics in a format designed for that 
purpose. 
 
The CETA coordinators and the LPCW will be supervised weekly by phone calls from JHU 
psychologists, where the intervention as a whole will be evaluated and monitored. Feedback 
will be provided. At the same time, the supervisors should inform the CISALVA staff about the 
details and questions that the LPCW team may have regarding the interventions for better 
support.  
 
The supervisors also have an obligation to deliver all registers and relevant information of the 
study to the lead researchers from CISALVA. In this way, the researchers can confirm 
whether the intervention is being carried out correctly and they will be able to identify and 
correct the difficulties that are presented as the study is carried out. Tracking of session 
attendance by participants was stored in a google drive account which could only be 

29 
 
accessed by the research team and was secured with a password. To track attendance, 
participants’ codes will be used instead of their names or any other information that could 
lead to uncovering their identity. 
 
In this group, the supporting documents of the research for CETA will be: 
 
Baseline assessment.  
 
Signed informed consent. 
 
Database baseline assessments.  
 
Database of random assignment to the intervention Group (A, B, or control). 
 
Clinical history of each participant. 
 
Weekly supervision records. 
 
Document tracking session attendance. 
 
Follow up assessment. 
 
Database of follow up assessments. 
 
NCGT Intervention for group B: A close monitoring for all individuals in the study will be 
conducted. In each weekly session, the LPCW will fill out the tracking record that will include 
the level of severity of principal symptoms of the person, as well as their clinical history. The 
LPCW will meet with their local supervisors once per week and will share this information with 
them. Local supervisors will assess the suitability of the tasks performed by the LPCW and 
will make suggestions for the further session, based on the current problems of the individual 
and how he or she responded to previous sessions. 
 
Supervisors should answer questions that the LPCW may have regarding identified problems 
after performing the interventions, as well as the special health needs that they identify in the 
population (i.e., a person who intends to commit suicide; the supervisor should redirect the 
person to specific health facilities that can help solve their mental health problems). These 
adverse events will be reported to the Institutional Review Board of Human Ethics in a format 
designed for that purpose. 
 
At the same time, the supervisors should inform CISALVA staff about the details and 
questions that the LPCW may have regarding the interventions. The supervisors also have an 
obligation to deliver all registers and relevant information about the study to the principal 
investigators. In this way, the investigators can confirm whether the intervention is being 

30 
 
carried out correctly and they will be able to identify and correct the difficulties that are 
presented as the study is carried out. Tracking of session attendance by participants was 
stored in a google drive account which could only be accessed by the research team and was 
secured with a password. To track attendance, participants’ codes will be used instead of 
their names or any other information that could lead to uncovering their identity.  
 
In this group, the supporting documents of the research for NCGT will be: 
 
Baseline assessment.  
 
Signed informed consent. 
 
Database baseline assessments. 
 
Database of random assignment to the intervention Group (A, B, or control). 
 
Records of each NCGT session. 
 
Weekly supervision records. 
 
Document tracking session attendance was stored on Google-Drive. 
 
Follow up assessment. 
 
Database of follow up assessments. 
 
Wait-list Control Group: CISALVA researchers will have monthly check in calls with each 
participant in this group. During the call, participants will be screened for acute serious mental 
problems (suicide ideation, anxiety or depression). When necessary, they will be assessed by 
a psychologist and if it is the case they will be excluded from the study and provided with the 
appropriate care. A psychological evaluation will be offered and provided to each of the 
controls after their completion of the follow-up and, when necessary, psychological care will 
be provided in ACOPLE. Participants who decide to drop out from the study (maybe due to 
adverse events) will be reported accordingly to the Institutional Review Board of Human 
Ethics for this purpose. 
 
In this group, the supporting documents of the research for the Wait-list Control Group will be: 
 
Baseline assessment. 
 
Signed informed consent. 
 
Database of baseline assessments. 
 
Database of random assignment to the intervention Group (A, B, or control). 
 
Follow up assessment. 

31 
 
 
Database of follow up assessments. 
 
4.4.8. Definitions of Loss to Follow-up 
After randomization is conducted, participants will be allocated to a group (A, B, or Control). 
During the monitoring, the participants can drop out of the investigation voluntarily, be 
removed from the study because of particular indications, monitoring failure, or through a 
deviation from protocol. Definitions are as follows: 
 
Voluntary Withdrawal: Participants from the study who decide not to continue being 
enrolled in the trial, either for unavailability or whatever other reason. For example, if 
the person moves to another municipality, suspends the CETA therapy before the 
management session of the traumatic experience, or suspends the NCGT before the 
sixth session. Attempts to contact the participant will be done every three (3) weeks, 
until the end of the study in order to obtain the follow up assessment before declaring 
loss to follow-up. Only in cases where participants express their desire to abandon the 
trial, will these participants not be further contacted.  
 
Withdrawal by Indication (Adverse Event): Includes participants who meet the 
criteria for withdrawing from the study due to specifically determined circumstances 
within the protocol like the onset of exclusionary criteria through changes in their 
clinical state of mental health: psychosis, endorsing suicidal thoughts, and homicidal 
ideation. In such cases, the participant will be referred to a staff psychologist who will 
define the need of further specialized care and will offer it to participant if required. 
These cases will be reported to the Institutional Committee of Human Ethics. These 
participants will not be followed up with nor will they be included in analysis. In the 
case of a withdrawn participant showing significantly improved indication, as defined 
by the staff psychologist, this person could return to the trial. Regarding the follow up 
assessment, the information will be collected from the participant’s clinical record, if it 
is available. 
 
Monitoring Failure: Includes participants in the study who do not attend the indicated 
therapy sessions and those for whom it is not possible to obtain monitoring data. 
Contact attempts will be done every three (3) weeks, until the end of the study, in 
order to a follow up assessment before declaring the loss to follow up. Definitions for 
each group are as follow: 

32 
 
o CETA: A participant who has surpassed the trauma experience session 
(approximately the sixth session) and who discontinues attending therapy 
sessions and/or whom the study staff fails to re-contact. 
o NCGT: A participant who has surpassed the sixth session and discontinues 
attending therapy sessions and/or whom the study staff fails to re-contact. 
o Wait-list Control Group: It is not possible to establish communication with the 
person to complete the follow up assessment. 
 
Protocol Deviation: Includes patients who, due to different circumstances, do not 
follow the assigned protocol. These participants would change groups and they will be 
included in the analyses.  
 
4.4.9. Primary and secondary outcomes 
The primary outcomes will be changes in depression, anxiety and post-traumatic stress 
symptoms.  
 
The secondary outcomes will be changes in the Total Mental Health Symptom (TMHS) and 
dysfunction scales. 
 
4.4.10. Instrument 
A brief instrument validation study was conducted with a sample of Afro-Colombians for the 
two study communities to evaluate the psychometric properties of the culturally adapted 
mental health and functional impairment assessments.  In addition to measuring mental 
health problems and functionality, the study questionnaire included socio-demographic and 
socio-economic items, and questions related to traumatic experiences, access to healthcare 
services and support networks.33  
 
Mental health symptoms will be measured with the Total Mental Health Symptoms (TMHS) 
scale of 64 items including locally relevant symptoms and sub-scales of depression (n=15 
symptoms), anxiety (n=10 symptoms) and PTSD (n=16 symptoms). Depression and anxiety 
symptoms will be assessed using the Hopkins Symptom Checklist (HSCL-25) and symptoms 
of trauma using the Harvard Trauma Questionnaire.34,35 The measures were into Spanish 
using the language and terminology from the previous qualitative study.33 The symptom 

33 
 
scales does not measure if a participant has a specific psychiatric diagnosis but rather to 
characterize severity of the study participant’s psychological symptoms.36,37 The dysfunction 
measure will be done using a gender-specific questionnaire with 12-item for females and 10-
item for males.  
 
For each symptom, respondents will be asked to report the frequency with which they had 
experienced that symptom in the prior month, with response options: 0 for “never”, 1 for “a 
few times”, 2 for “sometimes”, and 3 for “all the time”. For the dysfunction scale, participants 
will be asked to state the level of “difficulty” experienced during the previous month in the 
execution of a named task and included these response options: “no difficulty” scored as 0; “a 
little difficulty” as 1; “regular” as 2; “a lot” as 3; “cannot execute the task” as 4; “does not 
apply” as 9. The “does not apply” option was included given that some participants may not 
perform tasks for reasons other than dysfunction caused by mental health symptoms (i.e., if a 
question about caring for children was asked to someone who does not have children). 
 
Outcome assessment will be done per individual by the calculation of symptom means for 
each scale, with symptom scales ranging from 0-3 and dysfunction scales from 0-4.  
 
The survey is comprised of 7 sections (see Appendix):  
A. Personal and socio demographic information.  
B. Socioeconomic information.  
C. Gender-specific dysfunction assessment.  
D. Mental health symptoms assessment. 
E. Exposure to traumatic experiences information. 
F. Ability to address problems and connections.  
G. Access to general health care services and mental health services. 
 
4.4.11. Sample Size 
The sample size will be calculated taking into account the comparison of two mean scores of 
the averaged symptoms of each study group with respect to control. Baseline scores will be 
obtained from the Phase 3 study. Taking into account a difference in averaged changing 
scores between the control group and the intervention group, with an alpha error of 5%, a 
power of 80% and the standard deviation obtained.  

34 
 
 
Using a comparison of two means formula: 
 
 
Where: 
 
n = subjects needed in each of the samples 
 
Zα = Z value corresponding to the desired risk 
 
Zβ = Z value corresponding to the desired risk 
 
S2 = Variance of the quantitative variable the control group has or for reference 
 
d = Minimum value of the difference to be detected (quantitative data) 
 
Sample size adjusted to losses: 
After estimating the possible loss of patients for different reasons (loss of monitoring, 
abandonment, withdrawal) the sample size will be increased according to such losses.  
The adjusted sample size according to loss can be calculated as: n (1 / 1–R) 
 
n = number of subjects not lost  
 
R = estimated proportion of loss  
 
Taking the average of the worst and the best scenarios (differences in changes between 
groups of 0.20 and 0.30 points, respectively) and considering that there will be four cycles, 
the number of subjects will be rounded up to 72. So, to compare interventions A, B with the 
Wait-list control group, the sample size for each group will be 72 people in the CETA therapy, 
72 people receiving NCGT, and 72 people in the Control/Waiting list Group, for a total of 216 
people in the Buenaventura investigation and a further 216 in Quibdó. 
 
In order to make it efficient, the individuals that conduct the weekly interventions, CETA 
therapy or NCGT, where the average duration is between 5 and 12 weeks, it was necessary 
to program a series of cycles for the collection of the sample in each municipality (see Table 
2):  
 
n = 2 (Zα + Zβ)² * S² 
            (x1 – x2 ) ² 

35 
 
Table 2. Distribution of study participants by intervention group and capacity of participants 
per Lay Psychosocial Community Workers (LPCW) in each city. 
Capacity of 
clients per 
LPCW 
CETA  
NCGT 
Wait-list 
Control 
Group 
Total 
clients 
Time 
required 
Up to 5 people 
per counselor 
24 
24 
24 
72 
3-5 months 
Up to 5 people 
per counselor 
24 
24 
24 
72 
3-5 months 
Up to 5 people 
per counselor 
24 
24 
24 
72 
3-5 months 
Up to 5 people 
per counselor 
24 
24 
24 
72 
3-5 months 
TOTAL 
96 
96 
96 
288 
 
 
The total number of required people for the study in both municipalities is approximately 576. 
 
4.4.12. Randomization 
Consecutive ID numbers will be assigned to baseline surveys as they are conducted and 
these will then be allocated to intervention A, B, and to a wait-list control group using a 
blocked randomization procedure. The allocation sequence will be developed by a statistician 
from the CISALVA Institute whose participation in the project is limited to the randomization of 
people into the groups. The results from the interventions will be anonymous as the analysis 
will be done by an investigator from CISALVA without knowledge of the intervention codes of 
each participant. 
 
4.4.13. Evaluation of the Psychosocial Interventions 
The methodology to be carried out for the comparison of the community interventions will 
include quantitative and qualitative analyses. The quantitative one will be done through a 
controlled trial that is random, single-blind, longitudinal and prospective.  
 
 

36 
 
4.4.13.1. Quantitative Impact of the Intervention 
There is little evidence on the effectiveness of psychosocial interventions in the target 
population. Assessments of pre- and post-intervention changes in non-controlled studies are 
not sufficient to demonstrate the effectiveness as other factors may also have an effect on 
peoples’ outcomes. This control group usually improves symptoms over time, even without 
any kind of intervention; the latter change can be due to the mere passage of time or a 
regression to the average among those that were identified as having severe problems at the 
baseline. Keeping this natural tendency in mind, each of the interventions will be effective if 
only those that receive the intervention are evaluated. To demonstrate the real effect, a 
control group should be assessed wherever possible and any change in this group must be 
subtracted from the changes found among those receiving the intervention. The resulting 
difference is the only real measurement of intervention impact. 
 
For the purpose of this trial, it is proposed that the methods used in other settings be 
adopted: two interventions will be evaluated in two separate tests carried out simultaneously 
in the study cities (one in Buenaventura and the other in Quibdó). Within each test the people 
that are eligible for the study (based on the screening evaluation and the quantitative 
instrument) will be divided into two groups: those who receive the intervention (whether 
through CETA or NCGT), and those who will be allocated to the wait-list control group.  
 
To assess effectiveness of the interventions, a follow up assessment will be conducted two 
(2) weeks after the end of each intervention and after 3-4 months after baseline assessment 
for those in the wait-list group. If an intervention group had significantly better changes (from 
baseline to follow up assessments) than the control group, the intervention will be considered 
effective.  
 
Baseline characteristics of participants from intervention and control groups will be compared 
using Chi-square tests or Fisher’s exact test for categorical variables and t tests or Wilcoxon 
test for continuous variables. The main indicators of effect will derive from a comparison of 
the mean changes scale scores from baseline to follow-up assessment between intervention 
and control groups. End-point analysis, where baseline scores are carried forward as follow-
up assessment scores, will be used in cases where the team fails to re-contact some 
participants; a widely used method in mental health clinical trial,38 thereby assuming no 

37 
 
change over the course of study period for these individuals. An Intention-to-treat sample will 
be used to mitigate potential selection bias by participants or interviewers. 
 
Additionally, a descriptive analysis of the demographic variables and those related to mental 
health will be carried out for each arm. The quantitative variables will be described according 
to statistics of central tendencies and dispersion, and the qualitative variables according to 
frequency. The analyses of different groups will be conducted in accordance to tests of 
significant statistics using the sampling distributions of the variables. 
 
The quantitative and qualitative analyses of the effectiveness of the interventions will take 
place approximately three months after the base line. This time is approximate because it will 
depend on the inclusion rate of subjects in the study. The effectiveness of the intervention is 
estimated to significantly reduce the general symptoms generated by violence on the mental 
health of the individuals after three months, as has been observed in other previous studies. 
 
4.4.13.2. Qualitative Impact of the Intervention 
A qualitative evaluation will be performed of the interventions from material recorded in the 
transcripts of the CETA and NCGT therapies. This qualitative analysis will allow a description 
of unexpected effects, both negative and positive, of the interventions, as well as the 
perceptions of study participants, as feedback to better the formulation and delivery of 
interventions. Results from these analyses will also permit to validate in a qualitative way the 
study so that strategic partners from ACOPLE can advocate on its behalf to scale-up the 
methodologies, if effective. 
 
4.4.14. Statistical Analysis Plan. 
For the analyses, the outcome will be defined as the average score among items of a specific 
scale (i.e., depression, anxiety). The analysis approach will use longitudinal mixed effects 
regression models assessing interaction of study arm (any intervention [i.e., CETA or NCGT] 
vs. the control group) with time. Thus, the interaction is a measure of the difference in 
changing scores over time (follow-up minus baseline) between intervention and control. 
Mixed effects regressions will be estimated separately for each city (Buenaventura and 
Quibdó). The approach for handling missing data is to apply multiple imputation techniques 
for all missing values. Lost to follow up will be handled using two methods: 1) multiply 

38 
 
imputing scores for those lost to follow up and 2) a sensitivity analysis of creating an inverse 
probability weight of follow up and including this weight as a covariate in the final analysis. 
 
4.4.14.1. Multiple imputation 
Missing data will be imputed using multiple imputation procedures. All variables will be 
imputed, with exception of (somewhat) static demographic variables at follow-up (i.e., age, 
gender, education). All cluster variables above the individual level (i.e., counselor, cycle, etc.) 
will be predictors of imputations with imputing equations using legal ranges. Multiple 
imputation procedures will be performed separately for each city (Buenaventura and Quibdó) 
and for each trial (CETA vs. control and NCGT vs. control) databases. 
 
All missing values of a particular scale will be imputed. For missing data both at baseline (T0) 
and follow-up (T1), an iterative process will be used for imputing both T0 and T1 using other 
T0 and T1 variables as predictors, and then replacing imputed values at T0 with only T0 
predictors, for avoiding temporal incoherence among imputed variables. The full multiply 
imputed database will be used for the Intention to Treat Analysis (ITT), according to the 
subject’s arm allocation after the randomization. 
 
4.4.14.2. Selection of covariates for final mixed models 
Potential confounders will be identified, in imputed datasets, by means of two strategies: 
1) Baseline differences between groups (CETA vs. control; NCGT vs. control). 
2) Potential confounders of changes on scales outcomes over time. 
 
The first strategy will use baseline characteristics and scale scores to explore what’s different 
across groups – (CETA vs. control; NCGT vs. control) – by means of appropriated statistical 
tests (i.e., T-tests, Chi-squared, Fisher’s exact, etc.). Anything significantly different at a 0.10 
level between treatment (CETA or NCGT) and control, will be included as a covariate in final 
mixed models. When a baseline outcome score is significantly different between groups, we 
will not include as a covariate when looking at that same outcome in final models. 
 
In the second strategy, covariates associated with changes in scale outcomes over time will 
be identified using mixed (xtmixed) models with an interaction between the potential 
confounder and time, as fixed effects. If the variable of interest is associated with change in 

39 
 
the scale outcome at the 0.10 level, then it will be included the final ITT model. Also, all socio-
demographic variables (i.e., gender, age, marital status, education/employment status) will be 
included as covariates in the ITT models. Clustering variables (LPCW or cycle) will be 
included as random effects. 
 
Finally, all possible confounding variables (both dichotomous and continuous) will be 
centered, in order to report the averaged sample effect of the treatment, CETA or NCGT, 
among the sample of subjects of each trial, in each city (Buenaventura or Quibdó). 
 
4.4.14.3. ITT Final Mixed Models 
Full imputed datasets will be organized as a longitudinal array with time assessments 
clustered within study subjects, who are clustered within LPCW (for the CETA trial) or within 
recruitment cycle (for the NCGT trial). Analysis will be performed with the information of both 
cities but also split by city (Buenaventura and Quibdó); in the lasts models the city will not be 
included as a clustering variable. Treatment effects are defined as the difference of 
differences between intervention and control between time intervals. Thus, treatment effects 
will be expressed as the interaction term between time and treatment, controlling by all 
identified covariates in the mixed effects regressions (xtmixed). We will include number of 
weeks at follow-up as a covariate if it was associated at the p < 0.10 level for each scale 
outcome. Clustering variables will be included as random effects. The mixed models will use 
the identity link function. Imputation procedures are imputing baseline missing values and 
follow-up missing values, so each person who is missing follow-up will have their follow-up 
scores imputed. 
 
4.4.14.4. Subgroups analyses 
For each study trial (CETA vs. control and NCGT vs. control), in each city, the following 
subgroups analyses will be done: 
 
Females subsample. 
 
Males subsample. 
 
Non-married/non-coupled subjects’ subsample. 
 
Married/coupled subjects’ subsample. 
 

40 
 
4.4.14.5. Sensitivity Analyses with Follow-up Predictors 
Results of ITT analyses will be tested by sensitivity analyses adjusting for the conditional 
probability of nonresponse at follow-up. Thus, the baseline covariates and baseline 
symptom/function scores will be used for predicting the follow-up by means of simple logistic 
regressions clustered by lay community worker, in the CETA trial, or by recruitment cycle, in 
the NCGT trial. Variables associated with follow up at an alpha level of 0.10 will be used. If no 
variables in the data set were predictive of loss to follow up, then we will assume that data 
missing due to loss-to-follow up is missing completely at random (MCAR). Using the 
prediction from results of logistic regressions, the inverse of the probability of follow-up will be 
calculated. The inverse gives us the conditional probability of non-response at follow-up: the 
“iweight” variable. 
 
The distribution of iweight will be explored using histograms. If outliers appeared, they will be 
winsorized bringing only the outliers in the higher end of the tail (p=0.01). We will use the 
inverse weight as a covariate in the mixed (xtmixed) regression models of follow-up sensitivity 
analyses. 
 
4.4.14.6. Sensitivity Analyses excluding regression outliers 
Per each scale outcome, regression outliers will be identified using the residuals from ITT 
mixed models. Outliers will be identified by looking at numbers above/below an absolute 
value of 4 standard deviations against the expected number according to the mixed model. 
Sensitivity analyses will be done excluding those outliers, in order to test the robustness of 
ITT regressions results. 
 
4.4.14.7. Effect Sizes 
It will be done using the Cohen’s D approach to effect size calculation. The numerator will be 
the difference of difference between intervention and control between time intervals, per each 
outcome (i.e., specific mental health symptoms and dysfunction). Denominator will be the 
pooled standard deviation of each outcome at baseline, across levels (i.e., clusters) of the 
model in the non-imputed dataset. 
 
 

41 
 
4.5. 
Ethical considerations 
The inclusion of individuals in the study poses minimum risk for both participants and 
interviewers. The information that will be solicited from the individuals is related to their 
attitudes and thoughts towards the situations and problems that affect their lives and to how 
they believe these problems can be solved.  
 
The community-based intervention has produced benefits in the majority of the populations 
where it has been implemented; however, there is a risk that interventions can produce 
unexpected negative results like those that occur with local or national interventions by 
government attention programs. In the case this were to happen, provisions have been put 
forth that will allow the interventions to be stopped to avoid any type of damage to the 
population. 
 
In order for a person to be included in the study, the person must give their consent by 
signing an informed consent agreement (see Appendix) which clarifies all the pertinent 
information about the study and how the information given by the participants will be used. 
People’s participation in the study is completely voluntary and every participant can withdraw 
from the study at any point. The collected information will not be used under any 
circumstance for other purposes not related to the objectives of this study. 
 
Additionally, in case any participant suffers intimidation or is at risk due to threats by actors 
outside the study, the center and study will provide appropriate support in getting competent 
authorities to manage the risky situation. Moreover, when a risky situation presents, any 
fieldwork activity will be suspended to secure the lives and integrity of any person. 
 
Personal data from individuals, other than name, identification and contact information, will 
not be collected. In the case there is need to use participants’ information for purposes 
outside the aims of this study, it would be necessary to request special permission from the 
ethics committee at Universidad del Valle. 
 
The safety of the study staff (researchers, field staff and interviewers) is of equal priority. For 
this reason, it has been decided that interviewers should come from the same community so 
they can understand the dynamics of the area serve and do some sort of risk assessment in 
any given situation. At the least sign of risk to the integrity or life of the interviewers or study 

42 
 
staff, the work will be suspended and activities will not resume until there is assurance that 
there is no further risk for the group. In the same manner, interviewers will work in groups of 
at least 5 people and will wear outfits and nametags that identify them as study personnel for 
security reasons. The objectives and methodology of the study will be presented to 
community leaders and people from the communities in order to increase awareness of our 
project to increase safety by the time fieldwork starts.  
 
The researchers of the study, due to the fact that they are people from outside the 
community, will direct the fieldwork from installations in the Seminar Building of San 
Buenaventura, which lies outside the fieldwork zone, and in the city of Quibdó they will stay in 
a hotel that is located across from a police station. This will ensure that the researchers are at 
minimum risk while the study is carried out. In case threats are received or in any other 
moment where there may be evidence that the group is at risk, any activity will be suspended 
and only restarted when the situation is addressed and safety concerns are adequate.  
 
This research proposal was developed in accordance with the legal guidelines of resolution 
8430 of 1993 of the Republic of Colombia. Finally, the study was approved by the Institutional 
Review Board of Human Ethics, CIREH (from the Spanish acronym), of Universidad del 
Valle, Colombia with code 014-011. 

43 
 
5. TIMETABLE 
  
2011 
2012 
2013 
Activity 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Project presentation to the 
IRB 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Lay Psychosocial 
Community Workers 
(LPCW) identification 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Training of researchers in 
qualitative methods 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Qualitative study 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Analysis of the Qualitative 
study (QS) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Modification to the survey 
based on QS 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Training of interviewers 
about the interventions 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Pilot test of the survey 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Analysis of pilot test of the 
survey 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Selection and definition of 
psychosocial interventions 
(PI) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

44 
 
  
2011 
2012 
2013 
Activity 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Staff training on PI of the 
trial 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Staff training on Informed 
consent and the survey 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Pilot test of the trial 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Adjustments to 
interventions after the 
pilot test 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Selection, baseline 
assessment, and 
randomization of 1st cycle 
of clients 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
1st cycle of intervention 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Follow up assessment 
(1rs cycle) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Selection, baseline 
assessment, and 
randomization of 2nd 
cycle 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
2nd cycle of intervention 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

45 
 
  
2011 
2012 
2013 
Activity 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Follow up assessment 
(2nd cycle) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Selection, baseline 
assessment, and 
randomization of 3rd cycle   
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
3rd cycle of intervention 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Follow up assessment 
(3rd cycle) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Selection, baseline 
assessment, and 
randomization of 4th cycle 
of clients 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
4th cycle of intervention 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Follow up assessment 
(4th cycle) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Data Analysis 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Writing report with results 
and discussion 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Delivery of Final Report to 
IRB and HAI 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

46 
 
6. REFERENCES. 
 
1. 
Murray L, Dorsey S, Bolton P, et al. Building capacity in mental health 
interventions in low resource countries: an apprenticeship model for training 
local providers. Int J Ment Health Syst. 2011;5(1):30. 
2. 
United Nations High Commissioner for Refugees (UNHCR). [International Year 
for Afrodescendant People]. 2011:4. 
http://www.acnur.org/t3/fileadmin/scripts/doc.php?file=t3/fileadmin/Documentos
/RefugiadosAmericas/Colombia/Situacion_Colombia_-
_Afrodescendientes_2011. Accessed Sep 2011. 
3. 
International Council of Swedish Industry (NIR), Asociación Nacional de 
Empresarios en Colombia (ANDI), Fundación Ideas para la Paz (FIP). 
[Complex Environments: Buenaventura]. 2011:70. 
http://cdn.ideaspaz.org/media/website/document/52eac7346a293.pdf. 
Accessed Sep 2011. 
4. 
Presidential Agency for Social Action and International Cooperation (Acción 
Social). [Dynamics of Forced Displacement (June 2010)]. In: National 
Observatory of Forced Displacement, ed. Bogota D.C.: Presidency of the 
Republic of Colombia; 2010:15. 
5. 
Superior School of Public Administration / Escuela Superior de Administración 
Pública (ESAP). [Territorial diagnosis]. Quibdó: ESAP, Sistema de 
Documentación e Información Municipal; 2001. 
6. 
Cisalva Institute. Profile: Municipality of Quibdo. 2006:10. 
http://prevencionviolencia.univalle.edu.co/observatorios/choco/quibdo/archivos
/perfil_quibdo.pdf. Accessed Sep 2011. 
7. 
Amnesty International. Amnesty International’s briefing to the UN Committee 
against Torture on the Republic of Colombia. London: Amnesty International; 
2003. 
8. 
Colombian Coalition against Torture. Alternative Report to the 4th Periodic 
Report of the Colombian State to the Committee Against Torture. Bogota D.C.: 
Colombian Coalition against Torture; 2009. 

47 
 
9. 
Presidential Agency for Social Action and International Cooperation (Acción 
Social). [Register of Displaced Population]. Bogota D.C.: Acción Social; 2009. 
10. 
Heartland Alliance for Human Needs and Human Rights, Instituto Cisalva, 
Johns Hopkins University, Asociación de Afrocolombianos Desplazados - 
AFRODES. Analysis of mental health services in Buenaventura and Quibdo. 
Chicago: Heartland Alliance for Human Needs and Human Rights; 2009. 
11. 
Gerrity E, Keane T, Tuma F. The Mental Health Consequences of Torture. 
New York: Springer Science & Business Media; 2001. 
12. 
Danelius H. Convention against Torture and Other Cruel, Inhuman or 
Degrading Treatment or Punishment. New York: UN; 2008. 
13. 
American Psychiatric Association. Diagnostic and Statistical Manual of Mental 
Disorders, Fourth Edition: DSM-IV-TR®: American Psychiatric Association; 
2000. 
14. 
Sjolund BH, Kastrup M, Montgomery E, Persson AL. Rehabilitating torture 
survivors. J Rehabil Med. 2009;41(9):689-696. 
15. 
Keller A, Lhewa D, Rosenfeld B, et al. Traumatic experiences and 
psychological distress in an urban refugee population seeking treatment 
services. J Nerv Ment Dis. 2006;194(3):188-194. 
16. 
Keller AS. Caring and advocating for victims of torture. Lancet. Dec 2002;360 
Suppl:s55-56. 
17. 
United Nations Office for the Coordination of Humanitarian Affairs (OCHA). 
Internal Displacement - Overview.  http://www.unocha.org/what-we-
do/advocacy/thematic-campaigns/internal-displacement/overview. Accessed 
Sep 2011. 
18. 
United Nations High Commissioner for Refugees (UNHCR). On the Run in 
Their Own Land. Internally Displaced People 2011; 
http://www.unhcr.org/pages/49c3646c146.html. Accessed Sep 2011. 
19. 
Perez-Olmos I, Fernandez-Pineres PE, Rodado-Fuentes S. [The prevalence of 
war-related post-traumatic stress disorder in children from Cundinamarca, 
Colombia]. Rev Salud Publica (Bogota). 2005;7(3):268-280. 

48 
 
20. 
Pineda DA, Guerrero OL, Pinilla ML, Estupinan M. [Usefulness of a screening 
questionnaire for post traumatic stress in a Colombian population]. Rev Neurol. 
2002;34(10):911-916. 
21. 
Richards A, Ospina-Duque J, Barrera-Valencia M, et al. Posttraumatic stress 
disorder, anxiety and depression symptoms, and psychosocial treatment 
needs in Colombians internally displaced by armed conflict: A mixed-method 
evaluation. Psychol Trauma. 2011;3(4):384-393. 
22. 
Sistiva-Castro DL, Sabatier C. Violence sociopolitique, ESPT et Coping 
religieux: Une étude comparative en Colombie. / Socio-political violence, 
posttraumatic stress, and religion as a coping strategy. A comparative study in 
Colombia. Revue Francophone du Stress et du Trauma. 2005;5(2):97-107. 
23. 
Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder 
(PTSD). Cochrane Database Syst Rev. 2007;18(3):CD003388. 
24. 
Bass J, Bolton P, Murray L. Do not forget culture when studying mental health. 
Lancet. 2007;370(9591):918-919. 
25. 
Kinzie J. Psychotherapy for massively traumatized refugees: the therapist 
variable. Am J Psychother. 2001;55(4):475-490. 
26. 
Johns Hopkins University Bloomberg School of Public Health, Cisalva Institute, 
Heartland Alliance International. Protocol of Cognitive-Behavioral Therapy 
Based on Components. Community Care Program for Victims of Violence. 
Cali: Universidad del Valle; 2011. 
27. 
Funk M, Drew N, Freeman M, Faydi E, World Health Organization (WHO). 
Mental health and development: Targeting people with mental health 
conditions as a vulnerable group. Italy: WHO; 2010: 
http://whqlibdoc.who.int/publications/2010/9789241563949_eng.pdf?ua=1. 
Accessed Feb 2011. 
28. 
World Health Organization (WHO). Psychiatry and primary health care. Report 
on a working group. Geneva: WHO;1973. 
29. 
Barreto AdP. Terapia comunitária passo a passo. Brazil: Gráfica LCR; 2005. 
30. 
Murray L, Dorsey S. Intervention: Colombian version. Therapist manual. Cali: 
Heartland Allaince International; 2011. 

49 
 
31. 
Congress of Colombia. Act 1090 2006 (Wednesday September 6) whereby the 
exercise of the profession of psychology is regulated, dictates the Code of 
Ethics and Bioethics and other provisions. 46.383 ed. Bogota D.C.: Congress 
of Colombia; 2006. 
32. 
Heartland Alliance International. Treating survivors in Colombia. Chicago: 
Heartland Alliance International; 2011. 
33. 
Santaella J, Bonilla-Escobar FJ. Validating an instrument for victims of 
violence in Colombia. [Unpublished data]. 2011. 
34. 
Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins 
Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 
1974;19(1):1-15. 
35. 
Mollica R, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard 
Trauma Questionnaire. Validating a cross-cultural instrument for measuring 
torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J 
Nerv Ment Dis. 1992;180(2):111-116. 
36. 
Chorpita BF, Daleiden EL. Mapping evidence-based treatments for children 
and adolescents: application of the distillation and matching model to 615 
treatments from 322 randomized trials. J Consult Clin Psychol. 
2009;77(3):566-579. 
37. 
Barlow DH, Farchione TJ, Fairholme CP, et al. Unified protocol for 
transdiagnostic treatment of emotional disorders: Therapist guide: Oxford 
University Press; 2010. 
38. 
Bolton P, Bass J, Neugebauer R, et al. Group interpersonal psychotherapy for 
depression in rural Uganda: a randomized controlled trial. JAMA. 
2003;289(23):3117-3124. 
 

50 
 
LIST OF APPENDICES 
 
6.1. 
Appendix No 1. Survey 
A. Survey of the study 
 
Interviewer Number ________    
Respondent Number: _________ 
Date:  DD/MM/YY:                         
    
   
Start Time____________  End Time ____________ 
Name of the person who recommended the interviewee: ____________________________ 
SECTION A: DEMOGRAPHICS 
A1. Gender: 
______  Male         ______ Female 
A2. What is your age: 
_______  years 
A3. What is your Marital status? 
 
_____ Single 
_____ Married   
_____ Divorced 
_____ Separated   
_____ Widowed  
A4. Education 
_____ Primary School 
_____ High School 
_____ University 
A5. Have you been displaced? 
 
A5a. If the answer is yes, are you registered at 
Accion Social or other similar organization? 
___ Yes    ___NO  
 
___ Yes   ___ NO 
A6. Do you have any disabilities? 
 
A6a. If the answer is yes, what kind of 
disability? 
___ Yes    ___NO  
 
_____________________________ 
A7, What is your current work situation? 
___ Full time job 
___ Part time job   
___ Self employed  
___ Not working 
 
SECTION B: SOCIO ECONOMIC 
B1. How many people help with the home 
expenses in your family? 
  
_____  Number 

51 
 
B2. How many people economically depend on 
you? 
 
_____  Number 
B3. Characteristic of the house you live in 
 
___ Own 
___ Rented 
___ Loaned 
___ Invaded 
B4. Type of home 
 
___ House 
___ Apartment  
___ Vicinity 
___ Campsite 
___ Shelter 
B5 What are your house walls predominantly 
build of? 
 
 
___ Plastic 
___ Wood 
___ Cardboard 
___ Other  
              ___________ Specify 
B6. What is your house floor predominantly 
build of? 
___ Mosaic 
___ Polished Concrete 
___ Concrete 
___ Dirt 
___ Wood  
___ Other: 
             ___________ Specify 
B7. How many people sleep per room? 
_____  Number 
B8. What kind of social security do you have?  
___ Contributory 
___ Subsidized 
___ None  
___ Other   ___________ Specify 
 
SECTION C: FUNCIONALITY  
For each task say: In the last 4 weeks, how much difficulty have you had doing 
FUNCTIONS IN WOMEN 
Amount of difficulty doing the task-activity 
Tasks/Activities  
None 
Little 
Moderate 
amount 
A 
lot 
Often 
cannot do 
Not 
applicable 
CM01. to work (Q) 
0 
1 
2 
3 
4 
9 
CM02. To clean oneself (Q) 
0 
1 
2 
3 
4 
9 
CM03. Organize my life (Q) 
0 
1 
2 
3 
4 
9 

52 
 
CM04. To take care of oneself 
health/go to the doctor (Q) 
0 
1 
2 
3 
4 
9 
CM05, To take care of the children 
(Q) 
0 
1 
2 
3 
4 
9 
CM06. To do domestic work (Q) 
0 
1 
2 
3 
4 
9 
CM07. To give love to family 
members (Q) 
0 
1 
2 
3 
4 
9 
CM08. To keep the home unified (Q) 
0 
1 
2 
3 
4 
9 
CM9. To belong to support groups (Q) 
0 
1 
2 
3 
4 
9 
CM10. To show oneself as an 
example to the community (Q) 
0 
1 
2 
3 
4 
9 
CM11. To respect others when having 
meeting with the community (Q) 
0 
1 
2 
3 
4 
9 
CM12. To socialize with neighbors (Q)
0 
1 
2 
3 
4 
9 
 
For each task say: In the last 4 weeks, how much difficulty have you had doing 
FUNCTIONS IN MEN 
Amount of difficulty doing the task/activity 
Tasks/activities  
None 
Little 
Moderate 
amount 
A 
lot 
Often 
cannot do 
Not 
applicable 
CH01. To play sports/to exercise (Q) 
0 
1 
2 
3 
4 
9 
CH02. To clean oneself (Q) 
0 
1 
2 
3 
4 
9 
CH03. To clean the common areas 
near the house (Q) 
0 
1 
2 
3 
4 
9 
CH04. To work (Q) 
0 
1 
2 
3 
4 
9 
CH05. To dialogue with own children 
(Q) 
0 
1 
2 
3 
4 
9 
CH06. To keep the family together (Q) 
0 
1 
2 
3 
4 
9 
CH07. To take care of the children (Q) 
0 
1 
2 
3 
4 
9 
CH08. To participate in activities of the 
community (Q) 
0 
1 
2 
3 
4 
9 
CH09. To beware of the necessities of 
the community and help to find 
solutions for the problems of the 
community 
0 
1 
2 
3 
4 
9 
CH10. To collaborate with the 
neighbors to find solutions to the 
conflicts of the community 
0 
1 
2 
3 
4 
9 

53 
 
SECTION D: MENTAL HEALTH SYMPTOMS 
The following questions are about some problems that you may or may not have experienced. Please 
answer YES or NO according to what you think: 
Problems 
No 
Yes
D01. Do you think you dealing with a problem of being sad most of the time? 
0 
1 
D02. Do you think you dealing with a problem of being suffering or frightening most of 
the time? 
0 
1 
D03. Do you think you dealing with a problem of psychological trauma most of the 
time? 
0 
1 
 
The following questions are about some symptoms you may or may not have experienced. For each 
please tell how often you have felt in the past four weeks: a lot, moderate, a little bit, not at all. 
 
For each symptom say: For the problem _____ in the last 4 weeks, how often have you experienced it. 
Problems 
Not 
at all 
A little 
bit 
Moderat
e 
amount. 
A lot 
D04. Feeling low in energy, slowed down (Hopkins Symptom 
Checklist – Depression [HSCL-D], Qualitative Symptoms [Q]) 
0 
1 
2 
3 
D05. Blaming yourself for things (HSCL-D) 
0 
1 
2 
3 
D06. Crying easily (HSCL-D, Q) 
0 
1 
2 
3 
D07. Loss of sexual interest or pleasure (HSCL-D) 
0 
1 
2 
3 
D08. Poor appetite (HSCL-D, Q) 
0 
1 
2 
3 
D09. Difficulty falling asleep, staying asleep (HSCL-D, Harvard 
Trauma Questionnaire [HTQ], Q) 
0 
1 
2 
3 
D10. Feeling hopeless about the future (HSCL-D, HTQ, Q)  
0 
1 
2 
3 
D11. Feeling sad (HSCL-D, Q) 
0 
1 
2 
3 
D12. Feeling lonely (HSCL-D, Q) 
0 
1 
2 
3 
D13. Thoughts of ending your life (HSCL-D, Q) 
0 
1 
2 
3 
D14. Feeling of being trapped or caught  (HSCL-D, Q) 
0 
1 
2 
3 
D15. Worrying too much about things (HSCL-D, Q) 
0 
1 
2 
3 
D16. Feeling no interest in things (HSCL-D, Q) 
0 
1 
2 
3 
D17. Feeling everything is an effort (HSCL-D) 
0 
1 
2 
3 
D18. Feelings of worthlessness (HSCL-D, Q) 
0 
1 
2 
3 
D19. Suddenly scared for no reason (Hopkins Symptom 
Checklist – Anxiety [HSCL-A], Q) 
0 
1 
2 
3 
D20. Feeling fearful (HSCL-A, General Symptoms [GS], Q) 
0 
1 
2 
3 

54 
 
D21. Faintness, dizziness or weakness (HSCL-A, GS, Q) 
0 
1 
2 
3 
D22. Nervousness or shakiness inside (HSCL-A, GS, Q) 
0 
1 
2 
3 
D23. Heart pounding or racing (HSCL-A, GS, Q) 
0 
1 
2 
3 
D24. Trembling (HSCL-A, GS, Q) 
0 
1 
2 
3 
D25. Feeling tense or keyed up (HSCL-A, Q) 
0 
1 
2 
3 
D26. Headaches (HSCL-A, GS, Q) 
0 
1 
2 
3 
D27. Spells of terror or panic (HSCL-A, Q) 
0 
1 
2 
3 
D28. Feeling restless, can’t sit still (HSCL-A) 
0 
1 
2 
3 
D29. Repeated disturbing memories, thoughts or images of an 
event  (HTQ, Q) 
0 
1 
2 
3 
D30. Repeated disturbing dreams of an event (HTQ) 
0 
1 
2 
3 
D31. Suddenly acting or feeling as if event were happening 
again/reliving it (HTQ) 
0 
1 
2 
3 
D32. Feeling very upset when something reminds you of event 
(HTQ, Q) 
0 
1 
2 
3 
D33. Having physical reactions (heart pounding, breathing, 
sweating) when something reminds you of event (HTQ, GS, Q) 
0 
1 
2 
3 
D34. Avoiding thinking about or talking about event or avoiding 
having feelings related to it (HTQ, Q) 
0 
1 
2 
3 
D35. Avoiding activities or situations because they remind you 
of event (HTQ, Q) 
0 
1 
2 
3 
D36. Trouble remembering important parts of event (HTQ, Q) 
0 
1 
2 
3 
D37. Loss of interest in activities you used to enjoy (HTQ) 
0 
1 
2 
3 
D38. Feeling distant or cut off from other people (HTQ, Q) 
0 
1 
2 
3 
D39. Feeling emotionally numb or being unable to have loving 
feeling s for those close to you (HTQ, Q) 
0 
1 
2 
3 
D40. Feeling irritable or having angry outbursts (HTQ, Q) 
0 
1 
2 
3 
D41, Having difficulty concentrating (HTQ, Q) 
0 
1 
2 
3 
D42. Being ‘super-alert’ or watchful or on guard (HTQ, Q) 
0 
1 
2 
3 
D43. Feeling jumpy or easily started (HTQ, Q) 
0 
1 
2 
3 
D44. Accelerated breathing (dyspnea) or asphyxiated (GS) 
0 
1 
2 
3 
D45. Chest pain (GS) 
0 
1 
2 
3 
D46. Weird feeling about oneself or of unreality (GS) 
0 
1 
2 
3 
D47. Numb and tickles (GS) 
0 
1 
2 
3 
D48. Blush and chills (GS) 
0 
1 
2 
3 
D49. People talking incoherence (Q) 
0 
1 
2 
3 

55 
 
D50. People laugh, scream or sing in a euphoric way (Q) 
0 
1 
2 
3 
D51. People talk euphorically with other people (Q) 
0 
1 
2 
3 
D52. Fear to get out of the house or to talk to other people (Q) 
0 
1 
2 
3 
D53. Anxiety attack (Q) 
0 
1 
2 
3 
D54. Loss of color in the face and brightness in the eyes (Q) 
0 
1 
2 
3 
D55. Loss of happiness (Q) 
0 
1 
2 
3 
D56. People do not trust other people anymore (Q) 
0 
1 
2 
3 
D57. I feel I am being followed (Q) 
0 
1 
2 
3 
D58. Pain in the soul (Q) 
0 
1 
2 
3 
D59. Loss of self-steam (Q) 
0 
1 
2 
3 
D60. Anxiety, cannot control oneself (Q) 
0 
1 
2 
3 
D61. Use drugs or alcohol to find relief for symptoms (Q) 
0 
1 
2 
3 
D62. I feel intolerant at other people (Q) 
0 
1 
2 
3 
D63. Loss of memory, people cannot remember anything (Q) 
0 
1 
2 
3 
D64. I feel impotent, as I cannot do anything to solve my 
problems (Q) 
0 
1 
2 
3 
D65. I feel unstable (Q) 
0 
1 
2 
3 
D66. I have feeling to take revenge (Q) 
0 
1 
2 
3 
D67. I feel angry about certain things in my life (Q) 
0 
1 
2 
3 
D68. I have violent daydreams and fantasies against people 
that bother me (Q) 
0 
1 
2 
3 
 
SECTION T: Traumatic Experiences 
Please respond if you have suffered or seen that it happened to someone else any of the following 
situations: 
Situations 
T01. Have a member of your family or a neighbor been disappeared or killed by 
armed groups in control of a region? 
0 No     1 Yes 
T02. Threats, humiliation or someone has been hurt to make it run away or cause 
damage 
0 No     1 Yes 
T03. Have you been kicked or beaten with a bat, a stick or other objects? 
0 No     1 Yes 
T04. Have you been forced to watch how a person is tortured or killed? 
0 No     1 Yes 
T05. Attacked from armed groups? 
0 No     1 Yes 
T06. Have you been rape or sexually abused? 
0 No     1 Yes 
T07. Have you witness the assassination of a person? 
0 No     1 Yes 

56 
 
T08. Displacement, loss of home and or property caused by pressure by an arm 
group? 
0 No     1 Yes 
T09. Other traumatic events 
              Specify___________  
0 No     1 Yes 
 
SECTION E. COPING, SERVICE USAGE AND SOCIAL CONNECTIONS 
In the next questions I will ask you how often you do different things to help yourself when you feel 
bad. These are different things that some people do. You may do some also or you may not do them. 
For each one, please tell whether you do it often, sometimes, rarely or not at all to help yourself feel better. 
 
Not at 
all 
Rarely 
Sometime
s 
Often
E01. Go to church  (Q) 
0 
1 
2 
3 
E02. Find psychological help from a professional (Q) 
0 
1 
2 
3 
E03. To think in a positive way (Q) 
0 
1 
2 
3 
E04. Visit the justice house (Q) 
0 
1 
2 
3 
E05. Seek neighbors for help  (Q) 
0 
1 
2 
3 
E06. To find strength and to strive (Q) 
0 
1 
2 
3 
E07. Look for friends to talk about the problems (Q) 
0 
1 
2 
3 
E08. To get spiritual help (Q) 
0 
1 
2 
3 
E9. To get help from social organizations (Q) 
0 
1 
2 
3 
E10. Participate in recreational activities with the 
community (Q) 
0 
1 
2 
3 
E11. To accept reality as it is (Q) 
0 
1 
2 
3 
E12. Be patient (Q) 
0 
1 
2 
3 
E13. Watch TV or do other things to take my mind off my 
problems (Q) 
0 
1 
2 
3 
 
Now, I am going to ask you about questions about your relationships with other people. Please tell me 
No or Yes in agreement of what you think: 
Ye
s 
No 
Relationships 
1 
0 
E14. I am happy with the friendships I have. 
1 
0 
D15. I feel I belong in my community. 
1 
0 
E16. I know people who will listen and understand me when I need to talk.  
1 
0 
E17. I have people that I am comfortable talking with about my family’s problems.  
1 
0 
E18. In a crisis, I would have the support I need from family or friends. 
 

57 
 
The next three questions ask about how often you socially connect with other people. By “socially 
connect,” we mean social interactions you have with other people. Examples of social interactions are 
playing sports, doing religious activities, taking courses, having discussions or eating meals together. 
 
 
> 8 
times  
5-7 
times 
2-4 
times 
0-1 
times 
E19. In the last 2 weeks, how often did you socially 
connect with your friend? 
0 
1 
2 
 
E20. In the last 2 weeks, how often did you socially 
connect with other families from the community?  
0 
1 
2 
3 
 
I am going to ask you about relationships with people in the community who are not in your family.  
 
Never 
Rarely
Sometimes
Often 
E21. In the last month, how often have people visited you 
in your home? 
0 
1 
2 
3 
E22. In the last month, how often have you visited people 
in their home? 
0 
1 
2 
3 
E23. If you suddenly needed a small amount of money, for example like enough to pay for 
your household for one week, how many people could you turn to who would be willing to 
provide this money? 
Number 
E24. If you suddenly faced a long-term emergency, such as a family death or harvest 
failure, how many people could you turn to who would be willing to assist you? 
Number
 
Now we want to learn more generally about the different types of services you may have used in the 
past 6 months.  For each type of service, I will ask whether you have used it in the past 6 months 
 
Services 
No 
Yes
E25. Have you gone to the health clinic for your own health problems? 
0 
1 
E26. Have you received psychosocial services 
0 
1 
E26a. If yes, what did you receive and from whom? 
______________________________________________ 
E27. Have you received any non-money assistance (i.e., animal, farm materials)? 
0 
1 
E27a. If yes, what did you receive? 
___________________________________________________________ 
E28. Are you currently participating in any loan or grant activities?   
0 
1 
 

58 
 
We would also like to ask you several questions about your general level of satisfaction with different 
components of your life. What is your level of dissatisfaction-satisfaction concerning? 
 
  
Non
e 
A Little 
bit 
Regular 
Very 
good 
Excellent 
E29. Your health  
0 
1 
2 
3 
4 
E30. Your financial situation  
0 
1 
2 
3 
4 
E31. Your housing 
0 
1 
2 
3 
4 
E32. Your life in general 
0 
1 
2 
3 
4 
 
 
 

59 
 
Documents provided upon request. 
 
6.2. 
Appendix No 2. Informed consent 
 
6.3. 
Appendix No 3. Manual of Common Elements Treatment Approach (CETA) 
 
6.4. 
Appendix No 4. Manual of Narrative Community-Based Group Therapy 
(NCGT) 
 
6.5. 
Appendix No 5. Participant Referral Form for Adverse Events 
 
6.6. 
Appendix No 6. Security Protocol Manual