Parents Make the Difference, Liberia

My colleagues and I are partnering with the International Rescue Committee in Liberia to develop and evaluate a positive parenting intervention called “Parents Make the Difference”. This program is delivered over 10 weekly sessions to groups of caregivers of young children who come together to learn and practice new skills. There is also a home visiting component designed to reinforce learning and provide in-vivo practice. The initial study, a randomized trial with 270 caregivers in rural Lofa County, demonstrated that the program reduced the use of harsh punishment and improved caregiver-child interactions. Currently we are delivering an improved version of the program to 1,000 caregivers in Monrovia to study the impact of the program among this population and to test the cost-effectiveness of the home visiting protocol. 

Academic Collaborators: Eve Puffer (Duke), Rhea Chase (Duke)

Implementing Partner: International Rescue Committee

Paper: Puffer, E.S., Green, E.P., Chase, R., Sim, A., Zayzay, J. & Garcia-Rolland, E., & Boone, L. (2015). Parents Make the Difference: A randomized-controlled trial of a parenting intervention in Liberia. Global Mental Health, 2, e15.

Research Brief: Parents make the difference. International Rescue Committee.

Developing a measure of caregiver readiness to disclose HIV serostatus, Zimbabwe

An estimated 3.3 million children younger than 15 years are living with HIV, and most do not know it. Children who are not told that they have a serious health condition exhibit lower adherence to treatment and poorer health outcomes than those who are aware of their status, and research suggests that they have lower self-esteem, exhibit more behavior problems, and experience more psychological distress. Healthcare providers can be an important source of support for caregivers as they struggle with the decision to disclose and the process of disclosure; however, providers need training and tools to make sure that the support that they provide is genuinely effective in improving the ability of caregivers to disclose HIV status. Our long-term goal is to provide trained lay and professional counselors with an easy to use and valid tool to assess and monitor a caregiver’s readiness and self-efficacy to disclose serostatus (the caregiver’s or the child’s) to school-age children in order to promote the tailoring of existing disclosure support interventions, thereby facilitating a healthy disclosure process for caregiver and child alike. The specific objective of this study is to develop the assessment tool and test its reliability and validity in Zimbabwe.

Academic Collaborators: Eve Puffer (Duke), Kathy Sikkema (Duke), Katie Schenk (George Mason University), Lisa Langhaug (REPSSI), Simbarashe Rusakaniko (University of Zimbabwe)

Implementing Partners: BHASO

Funding: NICHD R21

Validating a culturally adapted screening tool for perinatal depression, Kenya

Routine screening for perinatal depression is not common in most primary health care settings. The U.S. Preventive Services Task Force only recently updated their recommendation on depression screening to specifically recommend screening during the pre- and postpartum periods. While practitioners in high-income countries can respond to this new recommendation by implementing one of several existing depression screening tools developed in Western contexts, such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9), these tools lack strong evidence of cross-cultural equivalence, validity for case finding, and precision in measuring response to treatment in developing countries. Thus, there is a critical need to develop and validate new screening tools for perinatal depression that can be used by lay health workers, primary health care personnel, and patients. Working in rural Kenya, we used free listing, card sorting, and item analysis methods to develop a locally-relevant screening tool that blended Western psychiatric concepts with local idioms of distress. We conducted a validation study with a random sample of 193 pregnant women and new mothers to test the diagnostic accuracy of this scale along with the EPDS and PHQ-9.

Academic Collaborators: Edith Kwobah (Moi Teaching and Referral Hospital), Menya D. (Moi University), Irene Chesire (Moi University)

Developing a digital market place for family planning, Kenya 

Based on global projections, meeting the unmet demand for contraceptives would prevent more than two-thirds of unintended pregnancies and more than two-thirds of maternal deaths. In 2008 alone, contraceptive use in low- and middle-income countries prevented more than 230,000 maternal deaths and could have prevented an additional 150,000 maternal deaths if women’s need for family planning had been met. Beyond preventing maternal deaths, voluntary family planning has also been shown to improve newborn health outcomes, advance women’s empowerment, and bring socioeconomic benefits through reductions in fertility and population growth. In short, family planning is an effective public health and economic development tool. Yet among the populations that would benefit the most from family planning, uptake remains too low. mPango (pango means “plan” in Kiswahili) is a new social venture that recognizes the potential of voluntary family planning and the great opportunity that exists in Kenya. This new digital marketplace is educating callers about family planning, offering free automated counseling, recommending suitable methods, and making referrals to local providers. Our long-term goal is to reduce the unmet need for contraception and expand the market for family planning services across the country.

Co-Founders: Ben Bellows (Population Council), Sidd Goyal (TinyURL)

Partners: Merck for Mothers


Women’s Income Generating Support Program (WINGS), Uganda

In this 3-year randomized controlled trial involving 1,800 people across 120 villages, we show that extremely poor, war-affected women in northern Uganda have high returns to a package of $150 cash, five days of business skills training, and ongoing supervision. Sixteen months after grants, participants doubled their microenterprise ownership and incomes, mainly from petty trading. Despite finding large increases in business, income, and savings among the treatment group, however, we do not find support for an indirect effect of poverty alleviation on symptoms of depression. We also find that involving men and changing framing to promote more inclusive programming can improve intimate partner relationships, but may not change gender attitudes or increase business success. Increasing women’s earnings has no effect on intimate partner violence.

Academic Collaborators: Chris Blattman (Columbia University), Jeannie Annan (International Rescue Committee), Julian Jamison (World Bank), Christian Lehmann (University of Brasilia)

Implementing Partners: AVSI

Paper: Blattman, C., Green, E.P., Jamison, J., Lehmann, C. & Annan, J. (2016). The returns to microenterprise support among the ultra-poor: A field experiment in post-war Uganda. American Economic Journal: Applied Economics, 8(2), 35-64.

Paper: Green, E.P., Blattman, C., Jamison, J. & Annan, J. (2016). Does poverty alleviation decrease depression symptoms in post-conflict settings? A cluster-randomized trial of microenterprise assistance in Northern Uganda. Global Mental Health, 3, e7.

Paper: Green, E.P., Blattman, C., Jamison, J. & Annan, J. (2015). Women’s entrepreneurship and intimate partner violence: A cluster randomized trial of microenterprise assistance and partner participation in post-conflict Uganda. Social Science & Medicine, 133, 177-188.

Paper: Annan, J., Green, E. P. & Brier, M. (2013). Promoting recovery after war in northern Uganda: Reducing daily stressors by alleviating poverty. Journal of Child & Adolescent Trauma, 22(8), 849-868.

Policy Brief: Building Women’s Economic and Social Empowerment. Innovations for Poverty Action.

Data: See here for surveys, data, and replication materials

Resilience Education and Skill Development for Youth and Families (READY), Kenya

In 2009, Eve Puffer (Duke) began a program of research that led to the development of READY. My involvement has largely been to help with research design and analysis. Along the way I had the opportunity to study youth activity spaces. One paper was published in Global Public Health. Another is forthcoming.

Academic Collaborators: Eve Puffer (Duke), Kathy Sikkema (Duke), Sherryl Broverman (Duke), Rose Ogwang-Odhiambo (Egerton University)

Paper: Puffer, E.S., Green, E.P., Sikkema, K., Pian, J., Ogwang-Odhiambo & Broverman, S. (2016). A church-based intervention for families to promote mental health and prevent HIV among adolescents in rural Kenya: Results of a randomized pilot trial. Journal of Consulting and Clinical Psychology.

Paper: Green, E.P., Puffer, E.S., Warren, V. & Broverman, S. (2016). Participatory mapping in low-resource settings: Three novel methods used to engage Kenyan youth in community-based HIV prevention research. Global Public Health, DOI: 10.1080/17441692.2016.1170178.

TB Tech, Kenya

Individuals living with HIV are at increased risk of developing active tuberculosis (TB) and dying from the disease. Isoniazid preventative therapy (IPT) can prevent this, but only a small fraction of HIV positive individuals are on IPT. The intervention under investigation involved providing clinic-based medical care providers with patient-specific clinical reminders regarding TB that were generated from a patient’s electronic medical record and based on accepted clinical algorithms for TB screening and treatment. We conducted a pragmatic, parallel-group, cluster-randomized superiority trial involving 20 public medical facilities (clusters) in western Kenya. Clusters were sorted into four strata and randomly assigned via computer algorithm to the treatment or control arm with an allocation ratio of 1:1. A total of 3,782 IPT-eligible patients were included in the analysis. The reminders intervention increased the rate of INH prescriptions, but this effect was small and not statistically significant. Clinical decision support reminders for TB screening, prevention, and treatment might have a very small impact on INH prescription rates for HIV positive adult patients, but the finding is not robust. This was likely due to implementation failures that are possible to fix, but at considerable cost.

Academic Collaborators: Paul Biondich (Regenstrief), Caricia Catalani (InSTEDD), among other colleagues through the AMPATH partnership

Implementing Partners: AMPATH

Paper: Green, E.P., Catalani, C., Diero, L., Carter, J., Israelski, D., Gardner, A., Aggrey, K., Ndwiga, C. & Biondich, P. (2015). Do clinical decision-support reminders for medical providers improve the prevalence of IPT initiation among HIV positive adults?: Research protocol for a cluster-randomized trial in Western Kenya. Trials, 16, 141.

Paper: Catalani, C., Green, E.P., Aggrey, K., Owiti, P., Lameck, D., Yueng, A., Israelski, D. & Biondich, P. (2014). A Clinical Decision Support System for Integrating Tuberculosis and HIV Care in Kenya: A Human-Centered Design Approach. PLoS One, DOI: 10.1371/journal.pone.0103205.

Communities in Transition, Uganda

I conducted fieldwork for my dissertation in 2007 in northern Uganda. This was a time of massive social change following a protracted conflict and internal displacement of most of the population. Families were in the process of leaving large and crowded displacement camps and moving to smaller transit camps or relocating directly to the villages that they were forced to leave years before.

Academic Collaborators: Bret Kloos (University of South Carolina)

Implementing Partners: AVSI

Green, E.P. & Kloos, B. (2009). Facilitating youth participation in a context of forced migration: A Photovoice project in northern Uganda. Journal of Refugee Studies, 22(4).

Kloos, B., Townley, G., & Green, E.P. & Franco, M. M. (2011). Reconcilable differences? Human diversity, cultural relativity, and the psychological sense of community. American Journal of Community Psychology, 47(1-2), 69-85.