Lay Counselor Delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): A Systematic Review

Lay Counselor Delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Lay Counselor Delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): A Systematic Review Laura Godfrey, Nevita George, Amy Lee This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6702006/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Mar, 2026 Read the published version in Journal of Child & Adolescent Trauma → Version 1 posted You are reading this latest preprint version Abstract Lay counselor delivery of trauma-focused cognitive behavioral therapy (TF-CBT) is a promising strategy to increase access to trauma-focused care and prevent trauma-related health disparities among youth in low-resource settings in the United States. This pre-registered systematic review sought to synthesize how TF-CBT has been tailored for lay counselor delivery, which can inform broader dissemination. Specifically, we examined (1) the modification process, (2) treatment modifications, and (3) implementation strategies (e.g., training and supervision) to support lay counselor delivery of TF-CBT. In June 2024, a literature search was conducted across PsycINFO, PubMed, MEDLINE, and PILOTS. Grey literature was identified through Google Scholar and ProQuest. A narrative synthesis summarized findings by research question. Ten trials (21 articles) met inclusion criteria and described modifications or implementation strategies for lay counselor-delivered TF-CBT. All trials implemented culturally tailored versions of TF-CBT in low- and middle-income countries. The modification process relied on input from local experts through community-researcher collaborations. TF-CBT modifications were contextual (e.g., modality) or surface-level (e.g., language) and no trials reported modifications to core components. Implementation strategies included enhancing training and supervision, addressing implementation barriers, and preserving counselor wellbeing. Findings suggest that TF-CBT can be successfully delivered by lay counselors through peripheral modifications, enhanced counselor supports, and strong community partnerships. This review provides a foundation for future research aimed at disseminating lay counselor-delivered TF-CBT in low-resource settings – a critical direction to close the mental health treatment gap and promote health equity in the United States and globally. TF-CBT lay counselors implementation modification systematic review Figures Figure 1 Introduction An estimated 60-80% of youth in the United States (US) have experienced a traumatic event (McLaughlin et al., 2013; Turner et al., 2010). Trauma exposure (i.e., an event involving actual or threatened death, serious injury, or sexual violence; American Psychiatric Association, 2013) is linked to a range of mental health consequences, including posttraumatic stress disorder (PTSD; McLaughlin et al., 2013), and is associated with impairments in cognitive, academic, social, and emotional functioning (De Bellis et al., 2009; Trickett et al., 2011). Effective evidence-based treatments for childhood trauma sequelae include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2017). However, most youth (up to 80%) in need of mental health services in the US do not receive care or interventions such as TF-CBT (Kataoka et al., 2002). This treatment gap affects health and wellbeing outcomes throughout the lifespan, which contribute to leading causes of death and disability and drive racial and socioeconomic health disparities (Felitti et al., 1998; López et al., 2017). Strategies to improve access to evidence-based treatments for childhood trauma-related mental health needs such as TF-CBT are urgently needed to improve public health and longitudinal outcomes for youth in the US. The shortage of mental health providers is one of the most potent barriers in access to evidence-based mental health services. National data suggest that the existing workforce in the US holds capacity to meet less than 30% of mental health needs (US Bureau of Health Workforce, 2024), and four-fifths of US counties are partial or whole Mental Health Professional Shortage areas (Cummings et al., 2013). These workforce shortages are most pronounced in low-resource, community-based settings (Cook et al., 2013; Dinwiddie et al., 2013; Mongelli et al., 2020). As a result, the mental health treatment gap disproportionately affects low-income and racially minoritized youth, who face higher rates of trauma exposure (Andrews et al., 2015; Hatch & Dohrenwend, 2007) yet have lower rates of access to services (Cummings et al., 2013; Merikangas et al., 2011). These data suggest that the pervasive mental health treatment gap and trauma-related health disparities cannot be fully remediated without solutions for the mental health workforce shortage in under-resourced settings. One strategy to address the mental health workforce shortage and expand access to mental health services is task-shifting . Task shifting involves training lay counselors (i.e., persons with little to no formal mental health training) such as teachers, community health workers, volunteers, or people with lived experience, to deliver interventions that are typically delivered by mental health professionals (Javadi et al., 2017; World Health Organization, 2007). A robust body of research, including four previous reviews, has demonstrated that mental health treatments delivered by lay counselors are effective in improving clinical outcomes (Barnett, Gonzalez, et al., 2018; Connolly et al., 2021; Singla et al., 2017; van Ginneken et al., 2013). For instance, a systematic review and meta-analysis of 1072 studies in low- and middle-income countries (LMICs) by Connolly and colleagues (2021) found a significant, medium-sized effect for lay counselor delivered interventions. In their review of 39 trials testing community health worker delivery of evidence-based mental health interventions, ten of which tested trauma-focused interventions, Barnett and colleagues (2018) found that most lay counselor-delivered treatments led to symptom reduction. Currently, most empirical support for lay counselor-delivered mental health treatments comes from implementation efforts in LMICs (Barnett, Gonzalez, et al., 2018; Connolly et al., 2021). Nonetheless, this strategy holds promise for closing mental health disparities that are driven by workforce shortages in the United States. Lay counselor-delivery may also be responsive to unique barriers faced by minoritized communities that exacerbate disparities in service utilization, including mistrust of medical systems (LaVeist et al., 2009) and stigma in seeking mental health services (Cook et al., 2017; Gary, 2005). Given the effectiveness and implementation advantages of task-shifting, lay counselor delivery of trauma-focused treatments is a promising strategy for closing treatment gaps and promoting health equity both internationally and domestically. Effective dissemination of task-shifting models requires an understanding of strategies that are needed to support their implementation. In a systematic review of the acceptability and feasibility of task-shifting, Padmanathan and De Silva (2013) underscored that sustainment of task-shifting requires attending to implementation determinants. As such, scholars have called for research that moves beyond demonstrating effectiveness towards identifying intervention modifications and implementation strategies for lay counselors (Barnett, Gonzalez, et al., 2018; Barnett, Lau, et al., 2018; Singla et al., 2017). Implementation science proposes that modification of evidence-based interventions is a necessary for successful translation of research to practice. Modification is the process of altering the design or delivery of an intervention to improve its fit in a given context (Wiltsey Stirman et al., 2019) and may include adaptations to the intervention itself, or implementation strategies that promote sustainability and scalability (e.g., training and supervision) (Powell et al., 2015; Proctor et al., 2013). To date, most literature describing modifications to evidence-based treatments has focused on cultural adaptation. For instance, a relevant systematic review by Lange and colleagues (2022) characterized adaptations to youth trauma-focused interventions and found that most adaptations were made to address cultural factors. Although the authors reported lay counselor treatment delivery as a modification in some studies, further details of how interventions were tailored for lay counselor delivery was outside of the scope of the review (Lange et al., 2022). Modifications improve feasibility, acceptability, and clinical effectiveness of interventions (Wiltsey Stirman et al., 2019), yet little is known about which modifications are used for task-shifting. For instance, two systematic reviews examining the effectiveness of lay counselor-delivered treatments found that training, supervision, and other supports were inconsistently reported (Barnett, Gonzalez, et al., 2018; Singla et al., 2017). No reviews have characterized how to support lay counselor-delivered treatments, which significantly limits scale-up of task-shifting. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based mental health treatment for youth who have experienced trauma (Cohen et al., 2017). TF-CBT is the most widely studied youth PTSD treatment and is deemed a well-established treatment with robust effectiveness in reducing symptoms of posttraumatic stress, depression, anxiety, and traumatic grief in children and adolescents ages 3-18 (Dorsey et al., 2017; Silverman et al., 2008; Thielemann et al., 2022). Although TF-CBT was initially developed to be delivered by trained mental health professionals, task-shifting presents an important opportunity to expand access to this highly effective treatment and prevent the longitudinal consequences of childhood trauma. Global mental health researchers have implemented lay counselor-delivered TF-CBT in LMICs, where workforce shortages and youth trauma-related mental health needs are particularly pronounced. For instance, trials of lay counselor-delivered TF-CBT have been included in prior reviews that demonstrate the effectiveness of TF-CBT (Thielemann et al., 2022), the effectiveness of task-shifting (Barnett, Gonzalez, et al., 2018), and adaptations to trauma-focused treatments (Lange et al., 2022). However, no prior systematic reviews have focused on lay counselor-delivered TF-CBT specifically or synthesized the modifications and strategies used to support implementation of this intervention. Taken together, lay counselor delivery of TF-CBT may be a promising avenue for interrupting the negative sequelae of youth trauma exposure, ameliorating the mental health treatment gap, and advancing public health. Existing reviews have demonstrated the effectiveness of lay counselor-delivered evidence-based treatments including TF-CBT, but none have attempted to synthesize strategies used to support implementation of task-shifting models. Understanding how, and what components, of TF-CBT are modified to yield successful delivery by lay counselors is critical to advance dissemination in low-resource settings. To fill this gap in the literature, this pre-registered systematic review [MASKED] sought to characterize how prior studies have modified and supported implementation of TF-CBT delivered by lay counselors. Specifically, we aimed to answer the following questions: 1) What is the process of identifying and operationalizing modifications to TF-CBT? 2) What intervention modifications are made? and 3) What implementation strategies (e.g., training and supervision) are used to support lay counselor delivery of TF-CBT? Materials and Methods Search Strategy In June 2024, we conducted a comprehensive literature search to identify studies describing modifications and implementation of lay counselor-delivered TF-CBT. The search was conducted across four search engines – PsycINFO, PubMed, MEDLINE, and PILOTS, and two additional search engines – Google Scholar and ProQuest, to identify gray literature. Reference lists of included articles were also manually screened to identify additional relevant studies. The search strategy included terms for 1) lay counselors, 2) modifications, and 3) TF-CBT (see Table 1 ). The search was not limited by publication date, study design, or location, and was re-run prior to analyses (August 2024). All procedures were conducted in accordance with PRISMA guidelines ( Figure 1 ). Two independent coders (first and second authors) screened all titles, abstracts, and full texts of identified articles for relevance using Covidence, an online software for systematic reviews. Discrepancies were resolved through iterative coding team discussions and consultation with the senior author. Record inclusion was contingent on the following criteria: 1) available in English; 2) intervention is TF-CBT; 3) TF-CBT is delivered, or intended to be delivered, by lay counselors (i.e., non-mental health professionals); and 4) includes description of the modification process, intervention modifications, and/or implementation strategies for lay counselor delivery. Records were excluded if they reported 1) outcomes of lay counselor-delivered TF-CBT but did not describe modification components; 2) modifications to psychotherapy interventions for lay counselors broadly but nonspecific to TF-CBT; and 3) only cultural modifications of lay counselor-delivered TF-CBT and not modifications that are relevant to task-shifting. Given our focus on modifications, empirical outcomes were not necessary for inclusion. This allowed us to identify components of modification that may have been excluded from prior reviews focused on characterizing treatment effectiveness. Data Extraction A deductive coding approach was employed to analyze qualitative data given the efficacy in applying a pre-established theoretical framework within data analyses (Glaser & Strauss, 2017). Constructs for data extraction were informed by domains outlined by the Framework for Reporting Adaptations and Modifications—Expanded (FRAME; Wiltsey Stirman et al., 2019), a guide developed improve consistency in reporting of intervention modifications. A codebook with definitions of each variable was created. Two independent coders (first and second authors) independently extracted text excerpts from an initial set of three studies to assess inter-rater reliability and refine the codebook as needed. After achieving consensus (100% agreement), coders independently extracted variable-specific text excerpts from the remaining studies. Extracted data were cross-verified and conflicts were resolved by consensus with the involvement of the senior author. All qualitative data were managed and analyzed using Microsoft Excel. Bias/Quality Assessment Risk of bias and quality assessment were examined independently by two coders (first and second authors) for each full-text article included using the Quality Assessment for Diverse Studies (QuADS) tool (Harrison et al., 2021). QuADS was selected given its flexibility in assessing bias across methodology (quantitative, qualitative, mixed methods). QuADS contains 13 statements (e.g., “Theoretical or conceptual underpinning to the research”) rated on a scale of 0 (not addressed/low quality) to 3 (fully addressed/ high quality). Independent coders rated the included studies on each statement. Although not a requirement for inclusion in the review, all studies received a score of 2 or 3 on each statement from both coders. Qualitative Coding: Narrative Synthesis We applied a narrative synthesis approach to summarize findings given its strength in integrating and considering variations across qualitative and quantitative findings (Popay et al., 2006). Tabulation was used to understand trial characteristics (e.g., participants, lay counselors, version of TF-CBT, delivery setting). To answer the main research questions, two independent coders (first and second authors) conducted conceptual, content analyses to identify patterns of meaning and recurring themes within extracted text excerpts (Drisko & Maschi, 2015). Coders generated textual descriptions to synthesize findings, which were then sorted into their appropriate research question. Frequencies of reported modifications and strategies were tabulated to highlight prevalence, and textual descriptions provide contextual depth (Popay et al., 2006). Results Our search yielded 75 records and after removal of duplicates, 61 were assessed for eligibility. Of these, 21 records met criteria for inclusion ( Figure 1) . Most were published in peer-reviewed journals (n = 20), and one dissertation was included. The 21 records reflect a total of 10 larger trials. To avoid duplicate reporting, results are described by trial. Trials with multiple included articles are cited in-text by the record that contains the most detail pertaining to the parent trial. The full list of records per trial are presented in Tables 2 and 3 . Information on trial characteristics including location, participants, and lay counselors are presented in Table 2 and summarized below. Findings are then presented by research question, reflecting 1) the modification process, 2) intervention modifications, and 3) implementation strategies (e.g., training and supervision) to support TF-CBT delivery by lay counselors. Trial Characteristics All trials took place in LMICs (Zambia, The Democratic Republic of Congo, Tanzania, Kenya, China, and Haiti), and all implemented a culturally tailored version of TF-CBT. The sample size of trial participants (i.e., intervention recipients) ranged from 38 to 1280. Participant ages ranged from 4 years old to 20 years old. Two trials reported youth race/ethnicity (Li et al., 2023; Murray et al., 2015) and six reported their sex (Dorsey, Gray, et al., 2020; Murray, Dorsey, et al., 2013; Murray et al., 2015, p. 20; Murray, Familiar, et al., 2013; O’Donnell et al., 2014; Wang et al., 2016). Nine trials reported effectiveness outcomes of lay counselor-delivered TF-CBT, all of which found that it improved clinical outcomes (Dorsey, Lucid, et al., 2020; Li et al., 2023; Murray, Dorsey, et al., 2013; Murray et al., 2015; Murray, Familiar, et al., 2013; O’Callaghan et al., 2013, 2015; O’Donnell et al., 2014; Wang et al., 2016). Lay Counselor Characteristics The number of lay counselors who delivered TF-CBT ranged from one to 240. Seven trials described the roles of the lay counselors in the community. Lay counselors were staff or volunteers from local communities and organizations, teachers, social workers, and university students. Seven studies described how lay counselors were selected. Hiring was often facilitated through community partner organizations and qualifications were commonly described as general traits, such as interest or experience working with children, willingness and ability to deliver TF-CBT, and basic communication and social skills, rather than concrete criteria. Six trials reported the prior mental health training and education of lay counselors, which varied widely across and within studies given that these were not often required qualifications. Only one trial reported that some prior mental health training was required (Wang et al., 2016). Education level of counselors ranged from completion of 6 th grade to an undergraduate degree. Few studies reported additional demographic information of lay counselors. None reported counselor race or ethnicity, one reported age from a subset of counselors (Dorsey, Gray, et al., 2020) and two reported sex (Dorsey, Gray, et al., 2020; Murray, Dorsey, et al., 2013), both of which reported that most were female. 1) What is the process of identifying and operationalizing modifications to TF-CBT for delivery by lay counselors? The modification process refers to ways in which the need for alterations (to TF-CBT and/or implementation strategies) was determined and operationalized, including who was involved and when modification took place relative to TF-CBT implementation. This process was inconsistently reported, and the level of detail and components of the process reported varied widely. Many described modifications as a multiphasic, ongoing process. Most trials used a theoretical framework to guide this process, including the Apprenticeship Model of training and supervision (n = 5; Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; Murray, Dorsey, et al., 2013; Murray et al., 2015; Murray, Familiar, et al., 2013) and the Design, Implementation, Monitoring, and Evaluation (DIME) model (n = 2; Murray, Dorsey, et al., 2013; Wang et al., 2016). The Apprenticeship Model underscores the role of lay counselors as experts in their local setting and embeds intervention tailoring as a key activity throughout implementation (Murray et al., 2011). In this model, potential modifications to TF-CBT are identified by lay counselors during training and throughout supervision and are reviewed by trainers, supervisors, and TF-CBT experts to ensure adherence to fidelity. The DIME model comprises a series of steps to facilitate successful program implementation that are anchored in researcher-community partnerships, including a qualitative local needs assessment and development and adaptation of assessment tools that precede modification and testing of the intervention in later steps (AMHR, 2000). In addition to these frameworks, one trial selected a stepped-wedge cluster randomized control trial design to embed an iterative, data-driven adaptation process within the same trial (Dorsey, Gray, et al., 2020). In this trial, TF-CBT is delivered over seven sequences. Findings from the first sequence elucidate modifiable implementation determinants that are collaboratively translated into an implementation facilitation plan by researchers and lay counselors to support TF-CBT delivery in subsequent sequences. For some trials, the process of modification spanned multiple research initiatives within the same setting or researcher-community partnership (See Table 2) . For instance, three trials (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; O’Donnell et al., 2014) reflect a series of projects conducted with the same longstanding community partners, wherein initial intervention modifications were tested in a feasibility study (O’Donnell et al., 2014), followed by an RCT testing intervention effectiveness (Dorsey, Lucid, et al., 2020), and a larger RCT testing tailored implementation strategies that may support feasibility and sustainability of TF-CBT (Dorsey, Gray, et al., 2020). Similarly, (Murray, Dorsey, et al., 2013) tested modified TF-CBT in a feasibility study, which informed further evaluation of implementation in usual care (Murray, Familiar, et al., 2013) and in a subsequent RCT (Murray et al., 2015). Another study implemented a tailored version of TF-CBT that was tested in the local setting in a prior study (Li et al., 2023). A range of activities were used to identify and operationalize modifications pre-, during, and post-implementation. Pre-implementation, trials gathered preliminary recommendations and feedback on TF-CBT materials from local stakeholders (Dorsey, Lucid, et al., 2020; Li et al., 2023; O’Donnell et al., 2014; Wang et al., 2016), which some accomplished through focus groups (Dorsey, Gray, et al., 2020; Li et al., 2023; O’Donnell et al., 2014). During implementation, modifications were identified based on feedback from lay counselors who were delivering TF-CBT. Feedback was gathered during training and supervision (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; Murray, Dorsey, et al., 2013; Murray et al., 2015, p. 201; Murray, Familiar, et al., 2013; O’Callaghan et al., 2013; Wang et al., 2016), interviews (Murray, Dorsey, et al., 2013), and during a mixed methods evaluation of intervention acceptability, feasibility, appropriateness, and implementation determinants (Dorsey, Gray, et al., 2020). One trial also developed a comprehensive database of the identified modifications (Murray, Dorsey, et al., 2013). Some trials described activities to identify modifications post-implementation, including gathering feedback from participants who refused treatment (Murray, Familiar, et al., 2013), and feedback from counselors who continued delivering TF-CBT post-trial to identify modifications that they made to enhance sustainability in usual care (Dorsey, Gray, et al., 2020). Notably, all modification strategies involved engaging local personnel (e.g., lay counselors, staff from community organizations) as key informants given their role as experts of the local setting. 2) What intervention modifications are made to TF-CBT for lay counselor delivery? All trials reported modifications to TF-CBT for lay counselor delivery, which are further characterized as context (i.e., how the intervention was delivered) or content (i.e., intervention components) (Wiltsey Stirman et al., 2019). Context modifications were more frequently reported (n = 9) than content modifications (n = 3). Additional detail on TF-CBT version, frequency, modality, and delivery setting are presented in Table 3 . Context Modifications Nine trials reported context modifications, including alterations to the setting, modality, frequency, and/or duration of treatment. Seven trials TF-CBT in non-specialty mental health settings, including schools, community organizations that provide other services to youth, and community spaces. In two trials, TF-CBT was implemented alongside usual services in the setting to facilitate sustainability, including 1-hour slots during the school day for lay counselors who were teachers (Dorsey, Gray, et al., 2020), and within programming in an organization that provides services to HIV-affected youth (Murray, Familiar, et al., 2013). Six trials implemented group-delivered TF-CBT. In one trial, this was informed by focus group interviews with counselors prior to trial start (Dorsey, Lucid, et al., 2020). Two studies used three-counselor “teams” to deliver TF-CBT (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020), where two counselors facilitated the child group, and one led the caregiver group. In terms of frequency, most trials (n = 8; 80%) implemented standard weekly sessions and two delivered three sessions per week. In one trial, the weekly frequency was modified during implementation. For some cases, multiple sessions were delivered per week to combat unexpected barriers (e.g., teacher strikes) (Wang et al., 2016). One trial reported that post-implementation, counselors who continued delivering TF-CBT in usual care changed the session frequency from weekly to two sessions per week to better accommodate their day-to-day roles (Dorsey, Gray, et al., 2020). Session length ranged from 30 to 120min, and the number of TF-CBT sessions ranged from 8 to 32, with most (80%) trials aiming for the standard 12-16 sessions. One trial implemented an abbreviated, 8-session version that was tested in a pilot study given the implementation and scale-up advantages of brief treatments (Dorsey, Gray, et al., 2020). Two trials described recommendations for contextual modifications based on their findings. Lay counselors in one trial recommended shortening session length (Murray, Dorsey, et al., 2013). During this trial, TF-CBT was intended to be delivered in 60min sessions but ranged from 30 – 120min. Participants in another trial recommended adding counselor follow-up after completion of TF-CBT (Dorsey, Lucid, et al., 2020), although it was not clear if this recommendation is specific to task-shifting or generalizable. Content Modifications Three trials reported content modifications, all of which were surface-level language modifications that did not change core components of TF-CBT. For instance, one trial replaced technical language with more understandable terms (e.g., referring to sessions as “class” rather than therapy) (Dorsey, Lucid, et al., 2020). This trial also offered recommendations for content modifications, including embedding procedures for safety planning and resources to link participants to services for other psychosocial needs within the intervention (Dorsey, Lucid, et al., 2020). In another trial, lay counselors crafted the introduction to TF-CBT that was presented to clients at the beginning of treatment (Murray, Familiar, et al., 2013). 3) What implementation strategies are used to support lay counselor delivery of TF-CBT? Training All trials reported that lay counselors received training in TF-CBT (see Table 4 for training details). In nine trials, lay counselors attended TF-CBT training sessions prior to implementation. The frequency and duration of training sessions varied, including two days, three days, 5-6 days, and 10 days of training. Most trials (n = 6) modified training by implementing ongoing training activities beyond completion of the initial sessions. These activities included a post-training period of practicing TF-CBT delivery with feedback, booster training sessions midway through implementation, and a post-training assessment. Similarly, one trial lengthened training for future initiatives based on feedback from lay counselors that the initial training (two, five-day sessions) was too condensed (Murray, Dorsey, et al., 2013). One trial reported that booster training sessions were also useful in training replacement counselors, which was common due to high counselor turnover (Dorsey, Lucid, et al., 2020). Another modification to the structure of training was involving local trainers as lead trainers rather than intervention experts (n = 3). Local trainers were lay counselors who had experience in delivering TF-CBT in prior studies (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020) or leadership from the local organization who were involved in TF-CBT tailoring (Wang et al., 2016). In these trials, local trainers completed their own training, including a five-day Train-the-Trainer led by an experienced TF-CBT trainer or workshops that covered didactic techniques and demonstration of their teaching skills. The content of lay counselor trainings retained standard components of TF-CBT training (e.g., psychoeducation on trauma and PTSD, didactic instruction on intervention strategies, role-play and practice groups, and manual review). Modifications to training activities included adding components or modifying language of training materials. Following the Apprenticeship model (n = 5 trials), intervention tailoring was included as a component of training. Lay counselors discussed and piloted ways to enhance fit of TF-CBT with the local setting, and modifications were reviewed by trainers to check adherence to fidelity. Similarly, another study described training as a “dialectical process,” wherein counselors provided feedback on material as it was taught (Wang et al., 2016). Three studies also added training on basic counseling skills (Li et al., 2023; O’Donnell et al., 2014; Wang et al., 2016), although details on these activities were not reported. In terms of language modifications, two studies replaced technical terms with plain language. In one trial, the lead trainer tailored existing materials prior to lay counselor training and presented modifications to TF-CBT and local experts to ensure that they were both adherent and understandable (e.g., changed “affective modulation” to “talking about feelings”). Another trial described intervention fidelity to counselors as “following the recipe,” and encouraged modifications that “spice it up” to fit the local context (Dorsey, Lucid, et al., 2020). Supervision In all trials, lay counselors received ongoing supervision throughout TF-CBT delivery. Supervision details are presented in Table 4. Of the eight trials that reported frequency, most (n = 7) implemented weekly supervision, and one implemented pre- and post-session meetings. Three trials used a combination of in-person and virtual modalities, and one implemented virtual-only supervision. Virtual supervision took place via skype/phone call, texting support (e.g., SMS/WhatsApp), or listening to an audio or video role play. One trial described a plan to modify the frequency and modality of supervision in the intervention sustainment phase, during which supervision would occur less frequently (once per month) and less often in-person (Dorsey, Gray, et al., 2020). This trial also developed implementation guidelines and conducted educational outreach visits with lay counselors beforehand to enhance success of the virtual modality. In six trials, supervision was led by local supervisors rather than external TF-CBT experts. Local supervisors were the local trainers described above (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; Wang et al., 2016), or lay counselors who demonstrated strong skill uptake and leadership during training or in a prior study (Murray, Dorsey, et al., 2013; Murray et al., 2015; Murray, Familiar, et al., 2013). In all these trials, local supervisors received their own training and supervision, including regular virtual meetings with TF-CBT experts, local leadership, and/or completing workshops in supervision skills and models of clinical supervision. Lay counselor supervision included review of intervention fidelity, discussion of cultural modifications, case presentation, session planning, and addressing logistical barriers. During their supervision, local supervisors presented cases from lay counselor supervision to TF-CBT experts to ensure intervention fidelity. One trial reported that as local supervisors gained experience, the focus of their supervision shifted towards monitoring participant safety and logistics (Dorsey, Gray, et al., 2020). Fidelity Most studies (n = 8) described procedures for fidelity monitoring to ensure counselor adherence to TF-CBT. Fidelity assessments included self-report checklists, detailed counselor-completed session notes, review of session audio/video recordings, observation of sessions by local supervisors or researchers, and/or local supervisor meetings with TF-CBT experts. Other Implementation Strategies Other implementation strategies were broadly defined as any activities beyond training and supervision that supported lay counselor delivery of TF-CBT. Some strategies focused on enhancing feasibility. For instance, two trials developed simplified step-by-step guidelines of session tasks to aid counselors in adhering to core components of fidelity (Dorsey, Lucid, et al., 2020; Li et al., 2023). Other strategies targeted implementation barriers that interfered with counselor’s ability to deliver TF-CBT. One trial described developing an “implementation coaching” plan (i.e., external facilitation in implementation science; Stetler et al., 2006), which involved local leaders and lay counselors meeting to generate workplans aimed at resolving anticipated implementation barriers (Dorsey, Gray, et al., 2020). Three trials reported that because lay counselors often had roles and jobs outside of TF-CBT delivery, their competing responsibilities posed challenges to implementation (Dorsey, Gray, et al., 2020; Murray et al., 2015; Murray, Familiar, et al., 2013). To address this, one trial described the need for monetary incentives for counselor time (Dorsey, Gray, et al., 2020) and two trials increased time dedicated to participating in TF-CBT delivery (Dorsey, Gray, et al., 2020; Murray, Familiar, et al., 2013). Collaborating with leadership in the local setting was an effective strategy to generate solutions for workload adjustments and promote implementation. Collaboration included inviting local leadership to the TF-CBT training to enhance their knowledge of the program and facilitate buy-in (Dorsey, Gray, et al., 2020), disseminating a training program tailored to the local organization that included TF-CBT materials and a summary of the evidence base (Wang et al., 2016), and obtaining support from the local school to facilitate recruitment and implementation (Li et al., 2023). Finally, another category of implementation strategies focused on lay counselor wellbeing. In one trial, lay counselors were given a list of resources and protocol to refer clients for non-mental health related needs (Dorsey, Lucid, et al., 2020). This was reported to be effective in helping counselors manage the impact of being exposed to hardships faced by the families that was outside of the scope of TF-CBT. Similarly, one trial outlined strategies that were specifically aimed at enhancing counselors’ confidence (e.g., encouragement, rewards) (Dorsey, Gray, et al., 2020). Another trial developed a detailed safety protocol to ensure provider self-efficacy in conducting risk assessments (Murray, Familiar, et al., 2013). Discussion This review provides the first synthesis of modifications and strategies to support TF-CBT for delivery by lay counselors. In total, 10 trials were located that reported components of the modification process, intervention modifications, or implementation strategies (e.g., training and supervision) to support lay counselor delivered-TF-CBT. All trials were conducted in LMICs and implemented culturally tailored TF-CBT in non-specialty mental health settings. The location, participant sample, and lay counselor characteristics varied. The process of tailoring TF-CBT commonly consisted of multiphasic collaborations between researchers and local experts, sometimes spanning multiple research initiatives. All modification activities involved engagement of community members in the identification and operationalization of modifications. Modifications to TF-CBT included contextual (e.g., multiple sessions per week) and surface-level content modifications (e.g., language tailoring). Notably, no adaptations to core components of TF-CBT were reported. Training and supervision were modified to reduce involvement of external experts (e.g., reliance on local trainers) and to facilitate an ongoing learning process for lay counselors (e.g., post-training periods, booster sessions). Finally, additional implementation strategies targeted feasibility and logistical barriers (e.g., workload adjustments, fostering buy-in from community partners), and lay counselor wellbeing. Consistent with prior research testing the effectiveness lay counselor-delivered treatments (Barnett, Lau, et al., 2018; Connolly et al., 2021 ), TF-CBT was reported to be feasible and effective when delivered by lay counselors. When access to training and implementation supports are available, it appears that lay personnel can effectively deliver TF-CBT without prior specialized mental health training. Investigators have successfully adopted task shifting models to increase access to TF-CBT in LMIC’s. However, no studies were found that attempted to implement lay counselor-delivered TF-CBT in under-resourced settings in non-LMICs. Task-shifting remains an under-utilized approach to closing trauma-related health disparities in the US, where youth face high rates of trauma exposure and, in some communities, have limited access to treatment in a manner comparable to LMICs (Derr, 2016 ). Although prior reviews have demonstrated the effectiveness of task-shifted delivery of TF-CBT (Barnett, Lau, et al., 2018; Connolly et al., 2021 ), none have synthesized modifications that are needed to inform future research and implementation efforts. This review fills this gap as the first aimed at characterizing strategies to facilitate dissemination of lay counselor-delivered TF-CBT, with potential utility that may extend beyond LMICs. The process is the “how” of intervention tailoring and is critical in translating research to practice by providing a blueprint for future initiatives. This review answers calls in the field for enhanced transparency and reporting of the modification process (Wiltsey Stirman et al., 2019 ) by describing strategies that researchers have employed to identify and operationalize modifications for lay counselor-delivered TF-CBT. Although specific frameworks (e.g., DIME, Apprenticeship model), activities (e.g., focus groups, interviews), and timepoints (e.g., pre-, during, and post-implementation) of modifications varied, a ubiquitous component of the process was community engagement. Many studies anchored the process of tailoring TF-CBT in community-based participatory research (CBPR) approaches to ensure that adaptations and implementation centered the needs and voices of those being served. Because evidence-based interventions were developed and tested in controlled research environments that may differ from real-world settings, CBPR approaches can help ensure the effectiveness and sustainability of such interventions (Collins et al., 2018 ; Wallerstein & Duran, 2006 ). Consistent with CBPR, community members (e.g., lay counselors, local leadership) guided adaptations pre-, during, and post-implementation through focus groups, interviews, and feedback during training and implementation. By empowering community members as equal partners in research and experts of their context, researchers built trusting community-researcher partnerships that laid the foundation for implementation, refinement, and scale-up of TF-CBT. This review examined if components of TF-CBT warrant modification to enhance feasibility and sustainability of lay counselor delivery. This expands the literature on modifications to both TF-CBT and task-shifting, which have focused on cultural adaptations (Mabunda et al., 2022 ; Metzger et al., 2021 ), toward those specific to the sustainment of task-shifting models. All modifications to TF-CBT were either contextual, to enhance fit with the local setting, or surface-level content modifications. The absence of core content adaptations is an important finding given that identification of intervention adaptations was a goal in many studies. This suggests that TF-CBT is overall a highly acceptable, appropriate, and feasible intervention for lay counselor delivery. The active ingredients of TF-CBT may not need changing, but rather, peripheral components can be refined to enhance success of task-shifting. Contextual modifications were most common and included embedding TF-CBT in existing lay counselor schedules (e.g., during 1-hour school breaks), implementing an abbreviated 8-session version, delivering multiple sessions per week, and allowing flexibility in session duration (30-120min). TF-CBT typically includes approximately 12–16, 60-minute individual weekly sessions (Cohen et al., 2017 ) yet most studies did not fully adhere to this structure. Researchers recognized that the standard format of TF-CBT may be incompatible with the competing roles and responsibilities of counselors, and tailored delivery to fit the local context while adhering to the core intervention components. This underscores the importance of adopting a “flexibility within fidelity” approach to EBT implementation (Cohen et al., 2008 ; Kendall & Beidas, 2007 ), particularly in task-shifting models that introduce unique implementation barriers (e.g., counselor jobs outside of mental health delivery). Recommendations for content modifications included adding resources in TF-CBT to link clients to services for other ongoing stressors, which was implemented to ensure counselor wellbeing. Task-shifting is a particularly useful strategy for increasing access to mental health services in low-resource communities, where workforce shortages are concentrated. In addition to high trauma-related mental health needs, clients in these settings are likely to experience co-occurring psychosocial stressors (e.g., housing, financial, and food insecurity) that are relevant to their wellbeing and the ability to engage in mental health services. Ensuring TF-CBT considers the holistic needs of clients is important in not only meeting client needs, but also for preserving counselor wellbeing. Effective training and supervision are critical to successful implementation of evidence-based practice. Most adaptations to TF-CBT training reflected strategies to enhance counselor learning and ensure their preparedness and competency in delivering TF-CBT. TF-CBT training required for certification in the US comprises a 10-hour online asynchronous web-course, participation in a live two-day TF-CBT training led by a certified trainer, and a series of consultation sessions to support intervention delivery. In this review, most studies implemented initial training sessions and ongoing supervision. None implemented the web-course, which may be due to language barriers and/or limited technology access. Of the nine studies that implemented initial TF-CBT training sessions, eight increased the number of days (up to 10), and one study receive direct feedback from counselors that the initial training (two five-day sessions) was too condensed. Dividing the components of standard TF-CBT training to be delivered over a longer duration may be more digestible for lay counselors, thereby enhancing their learning and self-efficacy. Similarly, training was often described as an ongoing process with recurring training activities throughout implementation (e.g., post-training practice, booster sessions mid-implementation). Many studies followed the Apprenticeship Model of training, which provides specific guidelines on ongoing training and supervision activities for lay counselors (Murray et al., 2011 ). These insights highlight the importance of ongoing training for lay counselors, with implications for advancing the quality of training in evidence-based treatments broadly. While initial training sessions are necessary, “one-off” trainings do not result in sustained behavioral change, even among mental health specialists (Beidas & Kendall, 2010 ; Herschell et al., 2010 ; Murray et al., 2011 ). Implementing recurring training activities, such as those outlined in TF-CBT (e.g., ongoing consultation) and the Apprenticeship Model (e.g., practice groups) may enhance uptake and sustainability of evidence-based treatments. Lastly, studies enhanced the content of training by teaching basic counseling skills prior to intervention-specific components; however, details of these components were not provided. This modification warrants further attention given its importance in bridging the inherent the gaps in knowledge between lay counselors, who do not have prior formal training in mental health services. Modifications to training and supervision also targeted capacity building by equipping local personnel to serve as trainers and supervisors and using technology to reduce the resource burden of supervision. Despite the centrality of training and supervision to effective implementation of evidence-based interventions, the resource-intensiveness of ongoing provider supports pose challenges for sustainability, even in mental health care settings (Marques et al., 2016 ). Identifying strategies to build local capacity for training and supervision is necessary for intervention uptake. This may be particularly important in task-shifting because mental health delivery is not central to counselors’ day-to-day roles. Findings suggest that not only can lay counselors be effectively trained to deliver TF-CBT, but with adequate support, they can also become effective trainers and supervisors themselves, thereby reducing the need for external involvement. This review elucidated multi-level implementation determinants, including barriers unique to task-shifting models that will require additional solutions. For instance, the competing responsibilities of lay counselors was as a barrier that could not fully be remediated through modifications to training, supervision, and TF-CBT. Organizational-level factors are salient determinants of implementation (Damschroder et al., 2009 ). Consistent with existing recommendations (Powell et al., 2015 ), engaging gatekeepers of the local setting (i.e., those with decision-making authority) in research emerged as an important strategy to resolve organizational barriers. By collaborating with local leadership, researchers fostered community buy-in which enabled workload adjustments and increased counselor time allocated to TF-CBT delivery. Counselor wellbeing also emerged as an important consideration. The intensity of trauma therapy can have negative impacts on counselor wellbeing, and these impacts may be more severe for therapists with personal trauma histories (Pearlman & Mac Ian, 1995 ). Because lay counselors are often members of the communities they serve, they may be more susceptible to the negative impacts of trauma-focused work. Developing context-specific supports (e.g., safety protocol, resource list for psychosocial stressors) and ensuring open communication with lay counselors (e.g., during supervision) is important to facilitate their own coping and processing of trauma-focused work. Limitations This review provides the first synthesis of modifications to TF-CBT for lay counselor delivery. We note several limitations of this work. First, only studies published in English were included in this review. Second, because we aimed to synthesize modifications, we are unable to draw conclusions about the efficacy of specific strategies. Future research should examine the relative importance of modifications and implementation strategies to better understand which are essential for lay counselor-delivery. The detail of adaptations varied widely across studies and were not systematically reported, which further limited this review. It is possible that some modification activities were omitted from papers due to various reasons (e.g., were not the main aim of the paper, length limitations of journals), and as a result would be missing from the present review. Similarly, this review was focused on characterizing adaptations that were relevant to task-shifting models and cultural adaptations were not included. All studies included in the review implemented culturally modified versions of TF-CBT and in some cases, it was difficult to discern whether the process and modifications reported were aimed at enhancing cultural relevance of the intervention or fit with the lay counselor treatment model. We attempted to resolve this through double-coding and consensus meetings during data extraction, but it is possible that relevant modifications were not included in this review if they were described by authors as cultural adaptations. These limitations underscore the importance of systematic reporting of key details of modifications (e.g., the purpose of each modification). Consistent with calls in the field, we recommend that researchers anchor reporting of modifications in established frameworks that have been developed to enhance consistency, such as FRAME (Wiltsey Stirman et al., 2019 ). Conclusion Given the known health consequences of childhood trauma, strategies to close the mental health treatment gap and increase access to evidence-based interventions such as TF-CBT are urgently needed. The current review sought to synthesize how TF-CBT has been modified for delivery by lay counselors. Trials reported activities from the modification process, modifications made to TF-CBT, and implementation strategies (e.g., training and supervision) to support lay counselor delivery. Findings provide critical insights on how researchers and clinicians, both internationally and within the US, may apply task-shifting to increase access to TF-CBT in usual care settings. Declarations No funding was received for conducting this study. The authors have no relevant financial or non-financial interests to disclose. This study is a systematic review and did not involve human participants, therefore ethical approval and informed consent were not needed. The data from this review are not publicly available but may be made available upon request. This systematic review was pre-registered on PROSPERO (CRD#). Authors 1 and 3 developed the idea for the study. Author 1 developed the research questions, pre-registration, protocol, and data analytic plan, and oversaw study activities. Authors 1 and 2 performed the literature search and data analysis. Author 1 wrote the main manuscript, and all authors reviewed the manuscript. Author Contribution L.G. and A.H.L. developed the idea for the study. L.G. developed the research questions, pre-registration, protocol, and data analytic plan, and oversaw study activities. L.G. and N.G. performed the literature search and data analysis. L.G. wrote the main manuscript and all authors reviewed the manuscript. References Andrews, A. R., Jobe-Shields, L., López, C. M., Metzger, I. W., de Arellano, M. A. R., Saunders, B., & Kilpatrick, D. (2015). Polyvictimization, Income, and Ethnic Differences in Trauma-Related Mental Health During Adolescence. Social Psychiatry and Psychiatric Epidemiology , 50 (8), 1223–1234. https://doi.org/10.1007/s00127-015-1077-3 Barnett, M. L., Gonzalez, A., Miranda, J., Chavira, D. A., & Lau, A. S. (2018). Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review. Administration and Policy in Mental Health , 45 (2), 195–211. https://doi.org/10.1007/s10488-017-0815-0 Barnett, M. L., Lau, A. S., & Miranda, J. (2018). Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care. Annual Review of Clinical Psychology , 14 (Volume 14, 2018), 185–208. https://doi.org/10.1146/annurev-clinpsy-050817-084825 Beidas, R. S., & Kendall, P. C. (2010). Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective. Clinical Psychology : A Publication of the Division of Clinical Psychology of the American Psychological Association , 17 (1), 1–30. https://doi.org/10.1111/j.1468-2850.2009.01187.x Cohen, D. J., Crabtree, B. F., Etz, R. S., Balasubramanian, B. A., Donahue, K. E., Leviton, L. C., Clark, E. C., Isaacson, N. F., Stange, K. C., & Green, L. W. (2008). Fidelity Versus Flexibility: Translating Evidence-Based Research into Practice. American Journal of Preventive Medicine , 35 (5, Supplement), S381–S389. https://doi.org/10.1016/j.amepre.2008.08.005 Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating Trauma and Traumatic Grief in Children and Adolescents . Guilford Publications. Collins, S. E., Clifasefi, S. L., Stanton, J., Straits, K. J. E., Espinosa, P. R., Andrasik, M. P., Miller, K. A., Orfaly, V. E., Gil-Kashiwabara, E., Nicasio, A. V., Hawes, S. M., Nelson, L. A., Duran, B. M., & Wallerstein, N. (2018). Community-based Participatory Research (CBPR): Towards Equitable Involvement of Community in Psychology Research. The American Psychologist , 73 (7), 884–898. https://doi.org/10.1037/amp0000167 Connolly, S. M., Vanchu-Orosco, M., Warner, J., Seidi, P. A., Edwards, J., Boath, E., & Irgens, A. (2021). Mental health interventions by lay counsellors: A systematic review and meta-analysis. Bulletin of the World Health Organization , 99 (8), 572–582. https://doi.org/10.2471/BLT.20.269050 Cook, B. L., Doksum, T., Chen, C.-N., Carle, A., & Alegría, M. (2013). The role of provider supply and organization in reducing racial/ethnic disparities in mental health care in the U.S. Social Science & Medicine (1982) , 84 , 102–109. https://doi.org/10.1016/j.socscimed.2013.02.006 Cook, B. L., Trinh, N.-H., Li, Z., Hou, S. S.-Y., & Progovac, A. M. (2017). Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004–2012. Psychiatric Services , 68 (1), 9–16. https://doi.org/10.1176/appi.ps.201500453 Cummings, J. R., Wen, H., & Druss, B. G. (2013). Improving Access to Mental Health Services for Youth in the United States. JAMA , 309 (6), 553. https://doi.org/10.1001/jama.2013.437 Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science , 4 (1), 50. https://doi.org/10.1186/1748-5908-4-50 De Bellis, M. D., Hooper, S. R., Spratt, E. G., & Woolley, D. P. (2009). Neuropsychological findings in childhood neglect and their relationships to pediatric PTSD. Journal of the International Neuropsychological Society: JINS , 15 (6), 868–878. https://doi.org/10.1017/S1355617709990464 Derr, A. S. (2016). Mental Health Service Use Among Immigrants in the United States: A Systematic Review. Psychiatric Services (Washington, D.C.) , 67 (3), 265–274. https://doi.org/10.1176/appi.ps.201500004 Dinwiddie, G. Y., Gaskin, D. J., Chan, K. S., Norrington, J., & McCleary, R. (2013). Residential segregation, geographic proximity and type of services used: Evidence for racial/ethnic disparities in mental health. Social Science & Medicine (1982) , 80 , 67–75. https://doi.org/10.1016/j.socscimed.2012.11.024 Dorsey, S., Gray, C. L., Wasonga, A. I., Amanya, C., Weiner, B. J., Belden, C. M., Martin, P., Meza, R. D., Weinhold, A. K., Soi, C., Murray, L. K., Lucid, L., Turner, E. L., Mildon, R., & Whetten, K. (2020). Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): Protocol for a stepped wedge cluster randomized trial. BMC Psychiatry , 20 (1), 10. https://doi.org/10.1186/s12888-019-2364-4 Dorsey, S., Lucid, L., Martin, P., King, K. M., O’Donnell, K., Murray, L. K., Wasonga, A. I., Itemba, D. K., Cohen, J. A., Manongi, R., & Whetten, K. (2020). Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial. JAMA Psychiatry , 77 (5), 464–473. https://doi.org/10.1001/jamapsychiatry.2019.4475 Dorsey, S., McLaughlin, K. A., Kerns, S. E. U., Harrison, J. P., Lambert, H. K., Briggs, E. C., Revillion Cox, J., & Amaya-Jackson, L. (2017). Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events. Journal of Clinical Child & Adolescent Psychology , 46 (3), 303–330. https://doi.org/10.1080/15374416.2016.1220309 Drisko, J., & Maschi, T. (2015). Content Analysis . Oxford University Press. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine , 14 (4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8 Gary, F. A. (2005). Stigma: Barrier to mental health care among ethnic minorities. Issues in Mental Health Nursing , 26 (10), 979–999. https://doi.org/10.1080/01612840500280638 Glaser, B., & Strauss, A. (2017). Discovery of Grounded Theory: Strategies for Qualitative Research . Routledge. https://doi.org/10.4324/9780203793206 Harrison, R., Jones, B., Gardner, P., & Lawton, R. (2021). Quality assessment with diverse studies (QuADS): An appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies. BMC Health Services Research , 21 (1), 144. https://doi.org/10.1186/s12913-021-06122-y Hatch, S. L., & Dohrenwend, B. P. (2007). Distribution of Traumatic and Other Stressful Life Events by Race/Ethnicity, Gender, SES and Age: A Review of the Research. American Journal of Community Psychology , 40 (3–4), 313–332. https://doi.org/10.1007/s10464-007-9134-z Herschell, A. D., Kolko, D. J., Baumann, B. L., & Davis, A. C. (2010). The Role of Therapist Training in the Implementation of Psychosocial Treatments: A Review and Critique with Recommendations. Clinical Psychology Review , 30 (4), 448–466. https://doi.org/10.1016/j.cpr.2010.02.005 Javadi, D., Feldhaus, I., Mancuso, A., & Ghaffar, A. (2017). Applying systems thinking to task shifting for mental health using lay providers: A review of the evidence. Global Mental Health , 4 , e14. https://doi.org/10.1017/gmh.2017.15 Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. American Journal of Psychiatry , 159 (9), 1548–1555. https://doi.org/10.1176/appi.ajp.159.9.1548 Kendall, P. C., & Beidas, R. S. (2007). Smoothing the trail for dissemination of evidence-based practices for youth: Flexibility within fidelity. Professional Psychology: Research and Practice , 38 (1), 13–20. https://doi.org/10.1037/0735-7028.38.1.13 Lange, B. C. L., Nelson, A., Lang, J. M., & Stirman, S. W. (2022). Adaptations of evidence-based trauma-focused interventions for children and adolescents: A systematic review. Implementation Science Communications , 3 , 108. https://doi.org/10.1186/s43058-022-00348-5 LaVeist, T. A., Isaac, L. A., & Williams, K. P. (2009). Mistrust of Health Care Organizations Is Associated with Underutilization of Health Services. Health Services Research , 44 (6), 2093–2105. https://doi.org/10.1111/j.1475-6773.2009.01017.x Li, J., Li, J., Zhang, W., Wang, G., & Qu, Z. (2023). Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: A randomized controlled trial. The Lancet Regional Health. Western Pacific , 33 , 100699. https://doi.org/10.1016/j.lanwpc.2023.100699 López, C. M., Andrews III, A. R., Chisolm, A. M., de Arellano, M. A., Saunders, B., & Kilpatrick, Dean. G. (2017). Racial/ethnic differences in trauma exposure and mental health disorders in adolescents. Cultural Diversity and Ethnic Minority Psychology , 23 (3), 382–387. https://doi.org/10.1037/cdp0000126 Mabunda, D., Oliveira, D., Sidat, M., Cavalcanti, M. T., Cumbe, V., Mandlate, F., Wainberg, M., Cournos, F., & de Jesus Mari, J. (2022). Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: Scoping review and expert consultation. International Journal of Mental Health Systems , 16 (1), 14. https://doi.org/10.1186/s13033-022-00526-x Marques, L., Dixon, L., Valentine, S. E., Borba, C. P. C., Simon, N. M., & Wiltsey Stirman, S. (2016). Providers’ Perspectives of Factors Influencing Implementation of Evidence-Based Treatments in a Community Mental Health Setting: A Qualitative Investigation of the Training-Practice Gap. Psychological Services , 13 (3), 322–331. https://doi.org/10.1037/ser0000087 McLaughlin, K. A., Koenen, K. C., Hill, E. D., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry , 52 (8), 815-830.e14. https://doi.org/10.1016/j.jaac.2013.05.011 Merikangas, K. R., He, J., Burstein, M. E., Swendsen, J., Avenevoli, S., Case, B., Georgiades, K., Heaton, L., Swanson, S., & Olfson, M. (2011). Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry , 50 (1), 32–45. https://doi.org/10.1016/j.jaac.2010.10.006 Metzger, I. W., Anderson, R. E., Are, F., & Ritchwood, T. (2021). Healing Interpersonal and Racial Trauma: Integrating Racial Socialization Into Trauma-Focused Cognitive Behavioral Therapy for African American Youth. Child Maltreatment , 26 (1), 17–27. https://doi.org/10.1177/1077559520921457 Mongelli, F., Georgakopoulos, P., & Pato, M. T. (2020). Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States. Focus , 18 (1), 16–24. https://doi.org/10.1176/appi.focus.20190028 Murray, L. K., Dorsey, S., Bolton, P., Jordans, M. J., Rahman, A., Bass, J., & Verdeli, H. (2011). Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers. International Journal of Mental Health Systems , 5 (1), 30. https://doi.org/10.1186/1752-4458-5-30 Murray, L. K., Dorsey, S., Skavenski, S., Kasoma, M., Imasiku, M., Bolton, P., Bass, J., & Cohen, J. A. (2013). Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: The use of TF-CBT in Zambia. International Journal of Mental Health Systems , 7 (1), 24. https://doi.org/10.1186/1752-4458-7-24 Murray, L. K., Familiar, I., Skavenski, S., Jere, E., Cohen, J., Imasiku, M., Mayeya, J., Bass, J. K., & Bolton, P. (2013). An evaluation of trauma focused cognitive behavioral therapy for children in Zambia. Child Abuse & Neglect , 37 (12), 1175–1185. https://doi.org/10.1016/j.chiabu.2013.04.017 Murray, L. K., Skavenski, S., Kane, J. C., Mayeya, J., Dorsey, S., Cohen, J. A., Michalopoulos, L. T. M., Imasiku, M., & Bolton, P. A. (2015). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial. JAMA Pediatrics , 169 (8), 761–769. https://doi.org/10.1001/jamapediatrics.2015.0580 O’Callaghan, P., McMullen, J., Shannon, C., & Rafferty, H. (2015). Comparing a trauma focused and non trauma focused intervention with war affected Congolese youth: A preliminary randomised trial. Intervention Journal of Mental Health and Psychosocial Support in Conflict Affected Areas , 13 (1), 28. O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., & Black, A. (2013). A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. Journal of the American Academy of Child and Adolescent Psychiatry , 52 (4), 359–369. https://doi.org/10.1016/j.jaac.2013.01.013 O’Donnell, K., Dorsey, S., Gong, W., Ostermann, J., Whetten, R., Cohen, J. A., Itemba, D., Manongi, R., & Whetten, K. (2014). Treating maladaptive grief and posttraumatic stress symptoms in orphaned children in Tanzania: Group-based trauma-focused cognitive-behavioral therapy. Journal of Traumatic Stress , 27 (6), 664–671. https://doi.org/10.1002/jts.21970 Padmanathan, P., & De Silva, M. J. (2013). The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: A systematic review. Social Science & Medicine (1982) , 97 , 82–86. https://doi.org/10.1016/j.socscimed.2013.08.004 Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice , 26 (6), 558–565. https://doi.org/10.1037/0735-7028.26.6.558 Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., & Britten, N. (n.d.). Guidance on the Conduct of Narrative Synthesis in Systematic Reviews . Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science , 10 (1), 21. https://doi.org/10.1186/s13012-015-0209-1 Proctor, E. K., Powell, B. J., & McMillen, J. C. (2013). Implementation strategies: Recommendations for specifying and reporting. Implementation Science , 8 (1), 139. https://doi.org/10.1186/1748-5908-8-139 Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 , 37 (1), 156–183. https://doi.org/10.1080/15374410701818293 Singla, D. R., Kohrt, B. A., Murray, L. K., Anand, A., Chorpita, B. F., & Patel, V. (2017). Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries. Annual Review of Clinical Psychology , 13 , 149–181. https://doi.org/10.1146/annurev-clinpsy-032816-045217 Thielemann, J. F. B., Kasparik, B., König, J., Unterhitzenberger, J., & Rosner, R. (2022). A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents. Child Abuse & Neglect , 134 , 105899. https://doi.org/10.1016/j.chiabu.2022.105899 Trickett, P. K., Noll, J. G., & Putnam, F. W. (2011). The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. Development and Psychopathology , 23 (2), 453–476. https://doi.org/10.1017/S0954579411000174 Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine , 38 (3), 323–330. https://doi.org/10.1016/j.amepre.2009.11.012 Bureau of Health Workforce. (2024). Health professional shortage areas statistics: First quarter of fiscal year 2025, designated HPSA quarterly summary [Report]. Health Resources and Services Administration, U.S. Department of Health & Human Services. https://www.hrsa.gov van Ginneken, N., Tharyan, P., Lewin, S., Rao, G. N., Meera, S. M., Pian, J., Chandrashekar, S., & Patel, V. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. The Cochrane Database of Systematic Reviews , 11 , CD009149. https://doi.org/10.1002/14651858.CD009149.pub2 Wallerstein, N. B., & Duran, B. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice , 7 (3), 312–323. https://doi.org/10.1177/1524839906289376 Wang, D. C., Aten, J. D., Boan, D., Jean-Charles, W., Griff, K. P., Valcin, V. C., Davis, E. B., Hook, J. N., Davis, D. E., Van Tongeren, D. R., Abouezzeddine, T., Sklar, Q., & Wang, A. (2016). Culturally adapted spiritually oriented trauma-focused cognitive–behavioral therapy for child survivors of restavek. Spirituality in Clinical Practice , 3 (4), 224–236. https://doi.org/10.1037/scp0000101 Wiltsey Stirman, S., Baumann, A. A., & Miller, C. J. (2019). The FRAME: An expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Science , 14 (1), 58. https://doi.org/10.1186/s13012-019-0898-y World Health Organization, PEPFAR, & UNAIDS. (2007). Task shifting: Rational redistribution of tasks among health workforce teams : global recommendations and guidelines . 88. Tables Table 1 Search Terms 1. (“lay worker” OR “lay health worker” OR LHW OR “lay mental health worker” OR “lay counselor” OR “lay health counselor” OR “lay counsellor” OR “community health worker” OR CHW OR “task shift*” OR “peer deliver*” OR “peer support” OR “nonprofessional” OR “community volunteer”) AND 2. (Adapt* OR tailor* OR implement* OR “implementation strateg*” OR “implementation facilitation” OR optimiz* OR modif* OR train* OR supervis* ) AND 3. (“trauma focused cognitive behavioral therapy” OR “trauma focused CBT” OR “TF CBT” OR “trauma focused cognitive behavioural therapy”) Table 2. Characteristics of studies included in systematic review Trial Characteristics Trial Participants Lay Counselor Characteristics Trial Design Country N; Condition Age, Sex N; Role Selection & Qualifications 1. Dorsey et al. (2019) Dorsey, Gray, et al., (2020) Dorsey et al., (2023) Johnson et al., (2024) Martin (2022) Meza et al. (2020) Triplett et al. (2021) Triplett, Mbwayo et al. (2023) Triplett, Johnson, et al. (2023) Stepped wedge cluster RCT a Kenya 1280; TF-CBT in health or education sector Ages 11-14; 50% girls/boys N = 240 teachers and community health volunteers. Nominated by local leadership; Good with children, may have counseling experience (not required), have time to deliver the program, no plans for leaving the area. 2. Dorsey et al., (2022) Dorsey, Lucid et al. (2020) Woods-Jaeger et al., (2017) RCT a Tanzania & Kenya 640; TF-CBT (320), usual care (320) Ages 7-13; 50% girls/boys N = 12; NR Hired by local organization. Expected to have experience/interest working with children/families, did not need mental health training, all had undergraduate degrees. 3. Murray, Dorsey et al. (2013) Murray et al., (2014) Feasibility study b Zambia 40 Ages 4-18; 100% girls (N = 21 treatment completers) N = 19 university students, staff from university, organizations, and hospitals. Experience and education varied; 3 had some clinical training. 4. Li et al. (2023) RCT China 234; TF-CBT (118), TAU (116) Ages 9-12 N = 15 college students Recruited from university; None had experience in mental health treatment. 5. Murray, Familiar et al. (2013) Feasibility study b Zambia 94 Ages 5-18 (N = 58 completers) N = 18; NR Counselors with minimal formal training. 6. Murray et al. (2015) RCT b Zambia 257; TF-CBT (131), TAU (126) Ages 5-18 N = 20; NR Backgrounds varied; All had high school education and basic communication/social skills. 7. O'Callaghan et al. (2013) RCT Democratic Republic of Congo 52; TF-CBT (24), waitlist (28) Ages 12-17; 100% girls NR; Social workers Staff from the local organization who provide psychosocial support to youth. 8. O'Callaghan et al. (2015) RCT Democratic Republic of Congo 50; TF-CBT (26, non-trauma focused (24) Ages 8-17; 29 boys, 21 girls One teacher with assistance from two social workers Teacher from prior trial and social workers from organization/funder. 9. O'Donnell et al. (2014) Feasibility study a Tanzania 64 Ages 7-13 N = 4; NR Hired by local organizations; Desired capabilities were experience working with children and/or counseling, bilingual in English, willingness to be trained and work with the US investigators; 3 had some university education, 3 had prior work with children, none had mental health experience. 10. Wang et al. (2016) RCT Haiti N = 58; TF-CBT (38), control (20) Ages 6-20; 68% girls (TF-CBT group) N = 24; community members from local churches, organizations, or university students. Must be part of a local organization that supports participation. Counselors from churches: leader endorsement, 6 th grade education, some prior training, and ³3 years working with local youth. Organization volunteers: bachelor’s degree and ³1 year working with local youth. Students: ³2 years of undergraduate work and some training. Note. NR = not reported, RCT = randomized controlled trial, TF-CBT = trauma-focused cognitive behavioral therapy, TAU = treatment as usual. Superscripts are used to indicate trials that were conducted by the same researcher-community partnerships over multiple research initiatives. Table 3. Intervention characteristics across trials of lay counselor delivered TF-CBT Modifications Trial TF-CBT Delivery Setting Format Frequency & Duration Context Content 1. Dorsey et al. (2019) Dorsey, Gray, et al., (2020) Dorsey et al., (2023) Johnson et al., (2024) Martin (2022) Meza et al. (2020) Triplett et al. (2021) Triplett, Mbwayo et al. (2023) Triplett, Johnson, et al. (2023) Culturally tailored (Pamoja Tunaweza) “Village clusters”: Schools and their surrounding community Group and individual 8 weekly 60min sessions. Setting, modality, number of sessions NR 2. Dorsey et al., (2022) Dorsey, Lucid et al. (2020) Woods-Jaeger et al., (2017) Culturally tailored (Pamoja Tunaweza) NR Group and individual 30-120min sessions over 12 consecutive weeks. Modality, duration Language 3. Murray, Dorsey et al. (2013) Murray et al., (2014) Culturally tailored NR Individual Weekly sessions (range 12 – 32 sessions). NR Language 4. Li et al. (2023) Culturally tailored (Power up Children’s Psychological Immunity) Four public schools and two private schools Group and individual 50min sessions over 9 consecutive weeks (10-12 sessions) Setting, modality NR 5. Murray, Familiar et al. (2013) Culturally tailored Seven local centers (hospices, centers for street youth, childcare for HIV-affected youth, health clinic) Individual Weekly 30-120min sessions over an average of 11 weeks (range 8–23). Setting, duration Language 6. Murray et al. (2015) Culturally tailored Five local sites (home-based care, center for street youth, health clinic, school/residential) Individual Weekly 60-90min sessions (10-16 sessions) Setting NR 7. O'Callaghan et al. (2013) Culturally tailored Hall in the local secondary school Group and individual 120min/day, 3 days/week for 5 weeks (15 sessions). Setting, modality, frequency NR 8. O'Callaghan et al. (2015) Culturally tailored Under a tent set up in a field attached to a local school Group Three 90min sessions per week. Setting, modality, frequency NR 9. O'Donnell et al. (2014) Culturally tailored TF-CBT for Traumatic Grief Community buildings Group and individual 12 weekly 60min sessions. Setting, modality NR 10. Wang et al. (2016) Culturally tailored spiritually-oriented TF-CBT NR Individual 12 weekly sessions. Some required up to 6 months and > 1 session/week. Frequency NR Note. NR = not reported, TF-CBT = trauma-focused cognitive behavioral therapy. Table 4. Training and supervision characteristics across trials of lay counselor-delivered TF-CBT Trial Training Supervision Fidelity 1. Dorsey et al. (2019) Dorsey, Gray, et al., (2020) Dorsey et al., (2023) Johnson et al., (2024) Martin (2022) Meza et al. (2020) Triplett et al. (2021) Triplett, Mbwayo et al. (2023) Triplett, Johnson, et al. (2023) 5-6 day in-person training led by local trainer followed by 2-3 weeks practice delivering TF-CBT (Apprenticeship model). Local trainers complete Train-the-Trainer led by TF-CBT expert followed by 2 months practice. Weekly in-person or virtual (e.g., phone call, text) meetings with local supervisors. Local supervisors attend weekly virtual consultation with TF-CBT experts (1-1.5hr). Self-report fidelity checklist, supervisor observation of sessions. 2. Dorsey et al., (2022) Dorsey, Lucid et al. (2020) Woods-Jaeger et al., (2017) 10-day in-person training led by local trainers followed by practice delivering TF-CBT and booster training sessions (Apprenticeship model). Local trainers complete 5-day in-person Train-the-Trainer led by experienced TF-CBT trainer. Weekly in-person or virtual (skype/telephone) meetings with local supervisors. Local supervisors attend weekly consultation calls with TF-CBT experts. Counselor reports, session audio recordings, and discussion. 3. Murray, Dorsey et al. (2013) Murray et al., (2014) Two five-day live trainings led by lead author followed by practice groups (Apprenticeship model). Group supervision (2hr/week) with local supervisors. Local supervisors attend weekly (2hr) consultation calls with TF-CBT experts. Counselor-completed case notes of components delivered, logistics, details on implementation strategy. 4. Li et al. (2023) 3-day group training led by three manual developers from local institution followed by test of knowledge/ skills, 1.5 days of booster training in the midterm, and detailed intervention manual. Weekly virtual supervision from three manual developers. Video-recorded therapy sessions and review of counselor reports from sessions. 5. Murray, Familiar et al. (2013) In-person training followed by practice groups (Apprenticeship model). Weekly (2-4hr/week) meetings with local supervisors. Local supervisors attend weekly consultation calls with trainers (2hr/week). Self-report fidelity checklist 6. Murray et al. (2015) 10-day on-site training led by TF-CBT experts (Apprenticeship model). Weekly group meetings with local supervisors. Local supervisors attend weekly consultation with TF-CBT experts. Counselor-completed detailed session notes reviewed by supervisors and TF-CBT experts during supervisor supervision. 7. O'Callaghan et al. (2013) Facilitators received the manualized intervention to study before each session and raise questions or suggest modifications. Pre- and post-session meetings with the lead authors. Lead researcher monitored each session. 8. O'Callaghan et al. (2015) Six training sessions on how to deliver the intervention; received intervention manuals. Counselors received prior “in-the-field” supervision while delivering the intervention. NR 9. O'Donnell et al. (2014) 10-day in-person training led by TF-CBT trainer followed by 1-month practice with expert oversight. Weekly calls with US investigators and four in-person meetings. Self-report fidelity checklists reviewed by US investigators. 10. Wang et al. (2016) Two-day workshop (Day 1 basic helping skills, Day 2 TF-CBT and modifications) led by local staff who were involved in cultural adaptation and completed their own training. Meetings with local supervisors who completed workshops on supervision models and attend their own ongoing supervision with the organization director. NR Note. NR = not reported, TF-CBT = trauma-focused cognitive behavioral therapy. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2026 Read the published version in Journal of Child & Adolescent Trauma → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6702006","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":460900043,"identity":"3a70e0d7-9e5a-423b-a943-4144d60425ce","order_by":0,"name":"Laura Godfrey","email":"data:image/png;base64,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","orcid":"","institution":"Hofstra University","correspondingAuthor":true,"prefix":"","firstName":"Laura","middleName":"","lastName":"Godfrey","suffix":""},{"id":460900046,"identity":"49b7b8fe-9668-4741-b296-49bba4a7eba2","order_by":1,"name":"Nevita George","email":"","orcid":"","institution":"Hofstra University","correspondingAuthor":false,"prefix":"","firstName":"Nevita","middleName":"","lastName":"George","suffix":""},{"id":460900048,"identity":"76865da7-ee1e-4626-b10b-abd538e30a88","order_by":2,"name":"Amy Lee","email":"","orcid":"","institution":"Hofstra University","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2025-05-19 21:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6702006/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6702006/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s40653-026-00852-z","type":"published","date":"2026-03-26T16:11:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83553491,"identity":"c8b444a0-05e2-4125-a48b-057278fea45d","added_by":"auto","created_at":"2025-05-28 11:04:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27582,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA flow diagram\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6702006/v1/24d09dd56f342d78529ac475.png"},{"id":105756090,"identity":"21a09442-4484-4481-99e5-d573b1a27f41","added_by":"auto","created_at":"2026-03-30 16:35:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1024616,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6702006/v1/8d9d971d-1551-4070-8de6-18f4e5aa96df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lay Counselor Delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): A Systematic Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAn estimated 60-80% of youth in the United States (US) have experienced a traumatic event (McLaughlin et al., 2013; Turner et al., 2010). Trauma exposure (i.e., an event involving actual or threatened death, serious injury, or sexual violence; American Psychiatric Association, 2013) is linked to a range of mental health consequences, including posttraumatic stress disorder (PTSD; McLaughlin et al., 2013), and is associated with impairments in cognitive, academic, social, and emotional functioning (De Bellis et al., 2009; Trickett et al., 2011). Effective evidence-based treatments for childhood trauma sequelae include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2017). However, most youth (up to 80%) in need of mental health services in the US do not receive care or interventions such as TF-CBT (Kataoka et al., 2002). This treatment gap affects health and wellbeing outcomes throughout the lifespan, which contribute to leading causes of death and disability and drive racial and socioeconomic health disparities (Felitti et al., 1998; L\u0026oacute;pez et al., 2017). Strategies to improve access to evidence-based treatments for childhood trauma-related mental health needs such as TF-CBT are urgently needed to improve public health and longitudinal outcomes for youth in the US.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe shortage of mental health providers is one of the most potent barriers in access to evidence-based mental health services. National data suggest that the existing workforce in the US holds capacity to meet less than 30% of mental health needs (US Bureau of Health Workforce, 2024), and four-fifths of US counties are partial or whole Mental Health Professional Shortage areas (Cummings et al., 2013). These workforce shortages are most pronounced in low-resource, community-based settings (Cook et al., 2013; Dinwiddie et al., 2013; Mongelli et al., 2020). As a result, the mental health treatment gap disproportionately affects low-income and racially minoritized youth, who face higher rates of trauma exposure (Andrews et al., 2015; Hatch \u0026amp; Dohrenwend, 2007) yet have lower rates of access to services (Cummings et al., 2013; Merikangas et al., 2011). These data suggest that the pervasive mental health treatment gap and trauma-related health disparities cannot be fully remediated without solutions for the mental health workforce shortage in under-resourced settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;One strategy to address the mental health workforce shortage and expand access to mental health services is \u003cem\u003etask-shifting\u003c/em\u003e. Task shifting involves training lay counselors (i.e., persons with little to no formal mental health training) such as teachers, community health workers, volunteers, or people with lived experience, to deliver interventions that are typically delivered by mental health professionals (Javadi et al., 2017; World Health Organization, 2007). A robust body of research, including four previous reviews, has demonstrated that mental health treatments delivered by lay counselors are effective in improving clinical outcomes (Barnett, Gonzalez, et al., 2018; Connolly et al., 2021; Singla et al., 2017; van Ginneken et al., 2013). For instance, a systematic review and meta-analysis of 1072 studies in low- and middle-income countries (LMICs) by Connolly and colleagues (2021) found a significant, medium-sized effect for lay counselor delivered interventions. In their review of 39 trials testing community health worker delivery of evidence-based mental health interventions, ten of which tested trauma-focused interventions, Barnett and colleagues (2018) found that most lay counselor-delivered treatments led to symptom reduction. Currently, most empirical support for lay counselor-delivered mental health treatments comes from implementation efforts in LMICs (Barnett, Gonzalez, et al., 2018; Connolly et al., 2021). Nonetheless, this strategy holds promise for closing mental health disparities that are driven by workforce shortages in the United States. Lay counselor-delivery may also be responsive to unique barriers faced by minoritized communities that exacerbate disparities in service utilization, including mistrust of medical systems (LaVeist et al., 2009) and stigma in seeking mental health services (Cook et al., 2017; Gary, 2005). Given the effectiveness and implementation advantages of task-shifting, lay counselor delivery of trauma-focused treatments is a promising strategy for closing treatment gaps and promoting health equity both internationally and domestically.\u003c/p\u003e\n\u003cp\u003eEffective dissemination of task-shifting models requires an understanding of strategies that are needed to support their implementation. In a systematic review of the acceptability and feasibility of task-shifting, Padmanathan and De Silva (2013) underscored that sustainment of task-shifting requires attending to implementation determinants. As such, scholars have called for research that moves beyond demonstrating effectiveness towards identifying intervention modifications and implementation strategies for lay counselors (Barnett, Gonzalez, et al., 2018; Barnett, Lau, et al., 2018; Singla et al., 2017). Implementation science proposes that modification of evidence-based interventions is a necessary for successful translation of research to practice. Modification is the process of altering the design or delivery of an intervention to improve its fit in a given context (Wiltsey Stirman et al., 2019) and may include adaptations to the intervention itself, or implementation strategies that promote sustainability and scalability (e.g., training and supervision) (Powell et al., 2015; Proctor et al., 2013). To date, most literature describing modifications to evidence-based treatments has focused on cultural adaptation. For instance, a relevant systematic review by Lange and colleagues (2022) characterized adaptations to youth trauma-focused interventions and found that most adaptations were made to address cultural factors. Although the authors reported lay counselor treatment delivery as a modification in some studies, further details of how interventions were tailored for lay counselor delivery was outside of the scope of the review (Lange et al., 2022). Modifications improve feasibility, acceptability, and clinical effectiveness of interventions (Wiltsey Stirman et al., 2019), yet little is known about which modifications are used for task-shifting. For instance, two systematic reviews examining the effectiveness of lay counselor-delivered treatments found that training, supervision, and other supports were inconsistently reported (Barnett, Gonzalez, et al., 2018; Singla et al., 2017). No reviews have characterized how to support lay counselor-delivered treatments, which significantly limits scale-up of task-shifting.\u003c/p\u003e\n\u003cp\u003eTrauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based mental health treatment for youth who have experienced trauma (Cohen et al., 2017). TF-CBT is the most widely studied youth PTSD treatment and is deemed a \u003cem\u003ewell-established\u003c/em\u003e treatment with robust effectiveness in reducing symptoms of posttraumatic stress, depression, anxiety, and traumatic grief in children and adolescents ages 3-18 (Dorsey et al., 2017; Silverman et al., 2008; Thielemann et al., 2022). Although TF-CBT was initially developed to be delivered by trained mental health professionals, task-shifting presents an important opportunity to expand access to this highly effective treatment and prevent the longitudinal consequences of childhood trauma. Global mental health researchers have implemented lay counselor-delivered TF-CBT in LMICs, where workforce shortages and youth trauma-related mental health needs are particularly pronounced. For instance, trials of lay counselor-delivered TF-CBT have been included in prior reviews that demonstrate the effectiveness of TF-CBT (Thielemann et al., 2022), the effectiveness of task-shifting (Barnett, Gonzalez, et al., 2018), and adaptations to trauma-focused treatments (Lange et al., 2022). However, no prior systematic reviews have focused on lay counselor-delivered TF-CBT specifically or synthesized the modifications and strategies used to support implementation of this intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaken together, lay counselor delivery of TF-CBT may be a promising avenue for interrupting the negative sequelae of youth trauma exposure, ameliorating the mental health treatment gap, and advancing public health. Existing reviews have demonstrated the effectiveness of lay counselor-delivered evidence-based treatments including TF-CBT, but none have attempted to synthesize strategies used to support implementation of task-shifting models. Understanding how, and what components, of TF-CBT are modified to yield successful delivery by lay counselors is critical to advance dissemination in low-resource settings. To fill this gap in the literature, this pre-registered systematic review [MASKED] sought to characterize how prior studies have modified and supported implementation of TF-CBT delivered by lay counselors. Specifically, we aimed to answer the following questions: 1) What is the process of identifying and operationalizing modifications to TF-CBT? 2) What intervention modifications are made? and 3) What implementation strategies (e.g., training and supervision) are used to support lay counselor delivery of TF-CBT?\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSearch Strategy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn June 2024, we conducted a comprehensive literature search to identify studies describing modifications and implementation of lay counselor-delivered TF-CBT. The search was conducted across four search engines \u0026ndash; PsycINFO, PubMed, MEDLINE, and PILOTS, and two additional search engines \u0026ndash; Google Scholar and ProQuest, to identify gray literature. Reference lists of included articles were also manually screened to identify additional relevant studies. The search strategy included terms for 1) lay counselors, 2) modifications, and 3) TF-CBT (see \u003cstrong\u003eTable 1\u003c/strong\u003e). The search was not limited by publication date, study design, or location, and was re-run prior to analyses (August 2024). All procedures were conducted in accordance with PRISMA guidelines (\u003cstrong\u003eFigure 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo independent coders (first and second authors) screened all titles, abstracts, and full texts of identified articles for relevance using Covidence, an online software for systematic reviews. Discrepancies were resolved through iterative coding team discussions and consultation with the senior author. Record inclusion was contingent on the following criteria: 1) available in English; 2) intervention is TF-CBT; 3) TF-CBT is delivered, or intended to be delivered, by lay counselors (i.e., non-mental health professionals); and 4) includes description of the modification process, intervention modifications, and/or implementation strategies for lay counselor delivery. Records were excluded if they reported 1) outcomes of lay counselor-delivered TF-CBT but did not describe modification components; 2) modifications to psychotherapy interventions for lay counselors broadly but nonspecific to TF-CBT; and 3) only cultural modifications of lay counselor-delivered TF-CBT and not modifications that are relevant to task-shifting. Given our focus on modifications, empirical outcomes were not necessary for inclusion. This allowed us to identify components of modification that may have been excluded from prior reviews focused on characterizing treatment effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Extraction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA deductive coding approach was employed to analyze qualitative data given the efficacy in applying a pre-established theoretical framework within data analyses (Glaser \u0026amp; Strauss, 2017). Constructs for data extraction were informed by domains outlined by the Framework for Reporting Adaptations and Modifications\u0026mdash;Expanded (FRAME;\u0026nbsp;Wiltsey Stirman et al., 2019), a guide developed improve consistency in reporting of intervention modifications. A codebook with definitions of each variable was created. Two independent coders (first and second authors) independently extracted text excerpts from an initial set of three studies to assess inter-rater reliability and refine the codebook as needed. After achieving consensus (100% agreement), coders independently extracted variable-specific text excerpts from the remaining studies. Extracted data were cross-verified and conflicts were resolved by consensus with the involvement of the senior author. All qualitative data were managed and analyzed using Microsoft Excel.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBias/Quality Assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRisk of bias and quality assessment were examined independently by two coders (first and second authors) for each full-text article included using the Quality Assessment for Diverse Studies (QuADS) tool (Harrison et al., 2021). QuADS was selected given its flexibility in assessing bias across methodology (quantitative, qualitative, mixed methods). QuADS contains 13 statements (e.g., \u0026ldquo;Theoretical or conceptual underpinning to the research\u0026rdquo;) rated on a scale of 0 (not addressed/low quality) to 3 (fully addressed/ high quality). Independent coders rated the included studies on each statement. Although not a requirement for inclusion in the review, all studies received a score of 2 or 3 on each statement from both coders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualitative Coding: Narrative Synthesis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe applied a narrative synthesis approach to summarize findings given its strength in integrating and considering variations across qualitative and quantitative findings (Popay et al., 2006). Tabulation was used to understand trial characteristics (e.g., participants, lay counselors, version of TF-CBT, delivery setting). To answer the main research questions, two independent coders (first and second authors) conducted conceptual, content analyses to identify patterns of meaning and recurring themes within extracted text excerpts (Drisko \u0026amp; Maschi, 2015). Coders generated textual descriptions to synthesize findings, which were then sorted into their appropriate research question. Frequencies of reported modifications and strategies were tabulated to highlight prevalence, and textual descriptions provide contextual depth (Popay et al., 2006).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur search yielded 75 records and after removal of duplicates, 61 were assessed for eligibility. Of these, 21 records met criteria for inclusion (\u003cstrong\u003eFigure 1)\u003c/strong\u003e. Most were published in peer-reviewed journals (n = 20), and one dissertation was included. The 21 records reflect a total of 10 larger trials. To avoid duplicate reporting, results are described by trial. Trials with multiple included articles are cited in-text by the record that contains the most detail pertaining to the parent trial. The full list of records per trial are presented in \u003cstrong\u003eTables 2 and 3\u003c/strong\u003e. Information on trial characteristics including location, participants, and lay counselors are presented in \u003cstrong\u003eTable 2\u003c/strong\u003e and summarized below. Findings are then presented by research question, reflecting 1) the modification process, 2) intervention modifications, and 3) implementation strategies (e.g., training and supervision) to support TF-CBT delivery by lay counselors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll trials took place in LMICs (Zambia, The Democratic Republic of Congo, Tanzania, Kenya, China, and Haiti), and all implemented a culturally tailored version of TF-CBT. The sample size of trial participants (i.e., intervention recipients) ranged from 38 to 1280. Participant ages ranged from 4 years old to 20 years old. Two trials reported youth race/ethnicity (Li et al., 2023; Murray et al., 2015) and six reported their sex (Dorsey, Gray, et al., 2020; Murray, Dorsey, et al., 2013; Murray et al., 2015, p. 20; Murray, Familiar, et al., 2013; O\u0026rsquo;Donnell et al., 2014; Wang et al., 2016). Nine trials reported effectiveness outcomes of lay counselor-delivered TF-CBT, all of which found that it improved clinical outcomes (Dorsey, Lucid, et al., 2020; Li et al., 2023; Murray, Dorsey, et al., 2013; Murray et al., 2015; Murray, Familiar, et al., 2013; O\u0026rsquo;Callaghan et al., 2013, 2015; O\u0026rsquo;Donnell et al., 2014; Wang et al., 2016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLay Counselor Characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe number of lay counselors who delivered TF-CBT ranged from one to 240. Seven trials described the roles of the lay counselors in the community. Lay counselors were staff or volunteers from local communities and organizations, teachers, social workers, and university students. Seven studies described how lay counselors were selected. Hiring was often facilitated through community partner organizations and qualifications were commonly described as general traits, such as interest or experience working with children, willingness and ability to deliver TF-CBT, and basic communication and social skills, rather than concrete criteria. Six trials reported the prior mental health training and education of lay counselors, which varied widely across and within studies given that these were not often required qualifications. Only one trial reported that some prior mental health training was required (Wang et al., 2016). Education level of counselors ranged from completion of 6\u003csup\u003eth\u003c/sup\u003e grade to an undergraduate degree. Few studies reported additional demographic information of lay counselors. None reported counselor race or ethnicity, one reported age from a subset of counselors (Dorsey, Gray, et al., 2020) and two reported sex (Dorsey, Gray, et al., 2020; Murray, Dorsey, et al., 2013), both of which reported that most were female.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1) What is the process of identifying and operationalizing modifications to TF-CBT for delivery by lay counselors?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe modification process refers to ways in which the need for alterations (to TF-CBT and/or implementation strategies) was determined and operationalized, including who was involved and when modification took place relative to TF-CBT implementation. This process was inconsistently reported, and the level of detail and components of the process reported varied widely. Many described modifications as a multiphasic, ongoing process. Most trials used a theoretical framework to guide this process, including the Apprenticeship Model of training and supervision (n = 5; Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; Murray, Dorsey, et al., 2013; Murray et al., 2015; Murray, Familiar, et al., 2013) and the Design, Implementation, Monitoring, and Evaluation (DIME) model (n = 2; Murray, Dorsey, et al., 2013; Wang et al., 2016). The Apprenticeship Model underscores the role of lay counselors as experts in their local setting and embeds intervention tailoring as a key activity throughout implementation (Murray et al., 2011). In this model, potential modifications to TF-CBT are identified by lay counselors during training and throughout supervision and are reviewed by trainers, supervisors, and TF-CBT experts to ensure adherence to fidelity. The DIME model comprises a series of steps to facilitate successful program implementation that are anchored in researcher-community partnerships, including a qualitative local needs assessment and development and adaptation of assessment tools that precede modification and testing of the intervention in later steps (AMHR, 2000). In addition to these frameworks, one trial selected a stepped-wedge cluster randomized control trial design to embed an iterative, data-driven adaptation process within the same trial (Dorsey, Gray, et al., 2020). In this trial, TF-CBT is delivered over seven sequences. Findings from the first sequence elucidate modifiable implementation determinants that are collaboratively translated into an implementation facilitation plan by researchers and lay counselors to support TF-CBT delivery in subsequent sequences. For some trials, the process of modification spanned multiple research initiatives within the same setting or researcher-community partnership (See \u003cstrong\u003eTable 2)\u003c/strong\u003e. For instance, three trials (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; O\u0026rsquo;Donnell et al., 2014) reflect a series of projects conducted with the same longstanding community partners, wherein initial intervention modifications were tested in a feasibility study (O\u0026rsquo;Donnell et al., 2014), followed by an RCT testing intervention effectiveness (Dorsey, Lucid, et al., 2020), and a larger RCT testing tailored implementation strategies that may support feasibility and sustainability of TF-CBT (Dorsey, Gray, et al., 2020). Similarly, (Murray, Dorsey, et al., 2013) tested modified TF-CBT in a feasibility study, which informed further evaluation of implementation in usual care (Murray, Familiar, et al., 2013) and in a subsequent RCT (Murray et al., 2015). Another study implemented a tailored version of TF-CBT that was tested in the local setting in a prior study (Li et al., 2023).\u003c/p\u003e\n\u003cp\u003eA range of activities were used to identify and operationalize modifications pre-, during, and post-implementation. Pre-implementation, trials gathered preliminary recommendations and feedback on TF-CBT materials from local stakeholders (Dorsey, Lucid, et al., 2020; Li et al., 2023; O\u0026rsquo;Donnell et al., 2014; Wang et al., 2016), which some accomplished through focus groups (Dorsey, Gray, et al., 2020; Li et al., 2023; O\u0026rsquo;Donnell et al., 2014). During implementation, modifications were identified based on feedback from lay counselors who were delivering TF-CBT. Feedback was gathered during training and supervision (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; Murray, Dorsey, et al., 2013; Murray et al., 2015, p. 201; Murray, Familiar, et al., 2013; O\u0026rsquo;Callaghan et al., 2013; Wang et al., 2016), interviews (Murray, Dorsey, et al., 2013), and during a mixed methods evaluation of intervention acceptability, feasibility, appropriateness, and implementation determinants (Dorsey, Gray, et al., 2020). One trial also developed a comprehensive database of the identified modifications (Murray, Dorsey, et al., 2013). Some trials described activities to identify modifications post-implementation, including gathering feedback from participants who refused treatment (Murray, Familiar, et al., 2013), and feedback from counselors who continued delivering TF-CBT post-trial to identify modifications that they made to enhance sustainability in usual care (Dorsey, Gray, et al., 2020). Notably, all modification strategies involved engaging local personnel (e.g., lay counselors, staff from community organizations) as key informants given their role as experts of the local setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2) What intervention modifications are made to TF-CBT for lay counselor delivery?\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll trials reported modifications to TF-CBT for lay counselor delivery, which are further characterized as context (i.e., \u0026nbsp;how the intervention was delivered) or content (i.e., intervention components) (Wiltsey Stirman et al., 2019). Context modifications were more frequently reported (n = 9) than content modifications (n = 3). Additional detail on TF-CBT version, frequency, modality, and delivery setting are presented in \u003cstrong\u003eTable 3\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext Modifications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNine trials reported context modifications, including alterations to the setting, modality, frequency, and/or duration of treatment. Seven trials TF-CBT in non-specialty mental health settings, including schools, community organizations that provide other services to youth, and community spaces. In two trials, TF-CBT was implemented alongside usual services in the setting to facilitate sustainability, including 1-hour slots during the school day for lay counselors who were teachers (Dorsey, Gray, et al., 2020), and within programming in an organization that provides services to HIV-affected youth (Murray, Familiar, et al., 2013). Six trials implemented group-delivered TF-CBT. In one trial, this was informed by focus group interviews with counselors prior to trial start (Dorsey, Lucid, et al., 2020). Two studies used three-counselor \u0026ldquo;teams\u0026rdquo; to deliver TF-CBT (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020), where two counselors facilitated the child group, and one led the caregiver group. In terms of frequency, most trials (n = 8; 80%) implemented standard weekly sessions and two delivered three sessions per week. In one trial, the weekly frequency was modified during implementation. For some cases, multiple sessions were delivered per week to combat unexpected barriers (e.g., teacher strikes) (Wang et al., 2016). One trial reported that post-implementation, counselors who continued delivering TF-CBT in usual care changed the session frequency from weekly to two sessions per week to better accommodate their day-to-day roles (Dorsey, Gray, et al., 2020). Session length ranged from 30 to 120min, and the number of TF-CBT sessions ranged from 8 to 32, with most (80%) trials aiming for the standard 12-16 sessions. One trial implemented an abbreviated, 8-session version that was tested in a pilot study given the implementation and scale-up advantages of brief treatments (Dorsey, Gray, et al., 2020). Two trials described recommendations for contextual modifications based on their findings. Lay counselors in one trial recommended shortening session length (Murray, Dorsey, et al., 2013). During this trial, TF-CBT was intended to be delivered in 60min sessions but ranged from 30 \u0026ndash; 120min. Participants in another trial recommended adding counselor follow-up after completion of TF-CBT (Dorsey, Lucid, et al., 2020), although it was not clear if this recommendation is specific to task-shifting or generalizable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContent Modifications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree trials reported content modifications, all of which were surface-level language modifications that did not change core components of TF-CBT. For instance, one trial replaced technical language with more understandable terms (e.g., referring to sessions as \u0026ldquo;class\u0026rdquo; rather than therapy) (Dorsey, Lucid, et al., 2020). This trial also offered recommendations for content modifications, including embedding procedures for safety planning and resources to link participants to services for other psychosocial needs within the intervention (Dorsey, Lucid, et al., 2020). In another trial, lay counselors crafted the introduction to TF-CBT that was presented to clients at the beginning of treatment (Murray, Familiar, et al., 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3) What implementation strategies are used to support lay counselor delivery of TF-CBT?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTraining\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll trials reported that lay counselors received training in TF-CBT (see \u003cstrong\u003eTable 4\u003c/strong\u003e for training details). In nine trials, lay counselors attended TF-CBT training sessions prior to implementation. The frequency and duration of training sessions varied, including two days, three days, 5-6 days, and 10 days of training. Most trials (n = 6) modified training by implementing ongoing training activities beyond completion of the initial sessions. These activities included a post-training period of practicing TF-CBT delivery with feedback, booster training sessions midway through implementation, and a post-training assessment. Similarly, one trial lengthened training for future initiatives based on feedback from lay counselors that the initial training (two, five-day sessions) was too condensed (Murray, Dorsey, et al., 2013). One trial reported that booster training sessions were also useful in training replacement counselors, which was common due to high counselor turnover (Dorsey, Lucid, et al., 2020). Another modification to the structure of training was involving local trainers as lead trainers rather than intervention experts (n = 3). Local trainers were lay counselors who had experience in delivering TF-CBT in prior studies (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020) or leadership from the local organization who were involved in TF-CBT tailoring (Wang et al., 2016). In these trials, local trainers completed their own training, including a five-day Train-the-Trainer led by an experienced TF-CBT trainer or workshops that covered didactic techniques and demonstration of their teaching skills.\u003c/p\u003e\n\u003cp\u003eThe content of lay counselor trainings retained standard components of TF-CBT training (e.g., psychoeducation on trauma and PTSD, didactic instruction on intervention strategies, role-play and practice groups, and manual review). Modifications to training activities included adding components or modifying language of training materials. Following the Apprenticeship model (n = 5 trials), intervention tailoring was included as a component of training. Lay counselors discussed and piloted ways to enhance fit of TF-CBT with the local setting, and modifications were reviewed by trainers to check adherence to fidelity. Similarly, another study described training as a \u0026ldquo;dialectical process,\u0026rdquo; wherein counselors provided feedback on material as it was taught (Wang et al., 2016). Three studies also added training on basic counseling skills (Li et al., 2023; O\u0026rsquo;Donnell et al., 2014; Wang et al., 2016), although details on these activities were not reported. In terms of language modifications, two studies replaced technical terms with plain language. In one trial, the lead trainer tailored existing materials prior to lay counselor training and presented modifications to TF-CBT and local experts to ensure that they were both adherent and understandable (e.g., changed \u0026ldquo;affective modulation\u0026rdquo; to \u0026ldquo;talking about feelings\u0026rdquo;). Another trial described intervention fidelity to counselors as \u0026ldquo;following the recipe,\u0026rdquo; and encouraged modifications that \u0026ldquo;spice it up\u0026rdquo; to fit the local context (Dorsey, Lucid, et al., 2020).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSupervision\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn all trials, lay counselors received ongoing supervision throughout TF-CBT delivery. Supervision details are presented in \u003cstrong\u003eTable 4.\u003c/strong\u003e Of the eight trials that reported frequency, most (n = 7) implemented weekly supervision, and one implemented pre- and post-session meetings. Three trials used a combination of in-person and virtual modalities, and one implemented virtual-only supervision. Virtual supervision took place via skype/phone call, texting support (e.g., SMS/WhatsApp), or listening to an audio or video role play. One trial described a plan to modify the frequency and modality of supervision in the intervention sustainment phase, during which supervision would occur less frequently (once per month) and less often in-person (Dorsey, Gray, et al., 2020). This trial also developed implementation guidelines and conducted educational outreach visits with lay counselors beforehand to enhance success of the virtual modality. In six trials, supervision was led by local supervisors rather than external TF-CBT experts. Local supervisors were the local trainers described above (Dorsey, Gray, et al., 2020; Dorsey, Lucid, et al., 2020; Wang et al., 2016), or lay counselors who demonstrated strong skill uptake and leadership during training or in a prior study (Murray, Dorsey, et al., 2013; Murray et al., 2015; Murray, Familiar, et al., 2013). In all these trials, local supervisors received their own training and supervision, including regular virtual meetings with TF-CBT experts, local leadership, and/or completing workshops in supervision skills and models of clinical supervision. Lay counselor supervision included review of intervention fidelity, discussion of cultural modifications, case presentation, session planning, and addressing logistical barriers. During their supervision, local supervisors presented cases from lay counselor supervision to TF-CBT experts to ensure intervention fidelity. One trial reported that as local supervisors gained experience, the focus of their supervision shifted towards monitoring participant safety and logistics (Dorsey, Gray, et al., 2020).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFidelity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost studies (n = 8) described procedures for fidelity monitoring to ensure counselor adherence to TF-CBT. Fidelity assessments included self-report checklists, detailed counselor-completed session notes, review of session audio/video recordings, observation of sessions by local supervisors or researchers, and/or local supervisor meetings with TF-CBT experts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOther Implementation Strategies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOther implementation strategies were broadly defined as any activities beyond training and supervision that supported lay counselor delivery of TF-CBT. Some strategies focused on enhancing feasibility. For instance, two trials developed simplified step-by-step guidelines of session tasks to aid counselors in adhering to core components of fidelity (Dorsey, Lucid, et al., 2020; Li et al., 2023). Other strategies targeted implementation barriers that interfered with counselor\u0026rsquo;s ability to deliver TF-CBT. One trial described developing an \u0026ldquo;implementation coaching\u0026rdquo; plan (i.e., external facilitation in implementation science; Stetler et al., 2006), which involved local leaders and lay counselors meeting to generate workplans aimed at resolving anticipated implementation barriers (Dorsey, Gray, et al., 2020). Three trials reported that because lay counselors often had roles and jobs outside of TF-CBT delivery, their competing responsibilities posed challenges to implementation (Dorsey, Gray, et al., 2020; Murray et al., 2015; Murray, Familiar, et al., 2013). To address this, one trial described the need for monetary incentives for counselor time (Dorsey, Gray, et al., 2020) and two trials increased time dedicated to participating in TF-CBT delivery (Dorsey, Gray, et al., 2020; Murray, Familiar, et al., 2013). Collaborating with leadership in the local setting was an effective strategy to generate solutions for workload adjustments and promote implementation. Collaboration included inviting local leadership to the TF-CBT training to enhance their knowledge of the program and facilitate buy-in (Dorsey, Gray, et al., 2020), disseminating a training program tailored to the local organization that included TF-CBT materials and a summary of the evidence base (Wang et al., 2016), and obtaining support from the local school to facilitate recruitment and implementation (Li et al., 2023). Finally, another category of implementation strategies focused on lay counselor wellbeing. In one trial, lay counselors were given a list of resources and protocol to refer clients for non-mental health related needs (Dorsey, Lucid, et al., 2020). This was reported to be effective in helping counselors manage the impact of being exposed to hardships faced by the families that was outside of the scope of TF-CBT. Similarly, one trial outlined strategies that were specifically aimed at enhancing counselors\u0026rsquo; confidence (e.g., encouragement, rewards) (Dorsey, Gray, et al., 2020). Another trial developed a detailed safety protocol to ensure provider self-efficacy in conducting risk assessments (Murray, Familiar, et al., 2013).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This review provides the first synthesis of modifications and strategies to support TF-CBT for delivery by lay counselors. In total, 10 trials were located that reported components of the modification process, intervention modifications, or implementation strategies (e.g., training and supervision) to support lay counselor delivered-TF-CBT. All trials were conducted in LMICs and implemented culturally tailored TF-CBT in non-specialty mental health settings. The location, participant sample, and lay counselor characteristics varied. The process of tailoring TF-CBT commonly consisted of multiphasic collaborations between researchers and local experts, sometimes spanning multiple research initiatives. All modification activities involved engagement of community members in the identification and operationalization of modifications. Modifications to TF-CBT included contextual (e.g., multiple sessions per week) and surface-level content modifications (e.g., language tailoring). Notably, no adaptations to core components of TF-CBT were reported. Training and supervision were modified to reduce involvement of external experts (e.g., reliance on local trainers) and to facilitate an ongoing learning process for lay counselors (e.g., post-training periods, booster sessions). Finally, additional implementation strategies targeted feasibility and logistical barriers (e.g., workload adjustments, fostering buy-in from community partners), and lay counselor wellbeing.\u003c/p\u003e \u003cp\u003eConsistent with prior research testing the effectiveness lay counselor-delivered treatments (Barnett, Lau, et al., 2018; Connolly et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), TF-CBT was reported to be feasible and effective when delivered by lay counselors. When access to training and implementation supports are available, it appears that lay personnel can effectively deliver TF-CBT without prior specialized mental health training. Investigators have successfully adopted task shifting models to increase access to TF-CBT in LMIC\u0026rsquo;s. However, no studies were found that attempted to implement lay counselor-delivered TF-CBT in under-resourced settings in non-LMICs. Task-shifting remains an under-utilized approach to closing trauma-related health disparities in the US, where youth face high rates of trauma exposure and, in some communities, have limited access to treatment in a manner comparable to LMICs (Derr, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Although prior reviews have demonstrated the effectiveness of task-shifted delivery of TF-CBT (Barnett, Lau, et al., 2018; Connolly et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), none have synthesized modifications that are needed to inform future research and implementation efforts. This review fills this gap as the first aimed at characterizing strategies to facilitate dissemination of lay counselor-delivered TF-CBT, with potential utility that may extend beyond LMICs.\u003c/p\u003e \u003cp\u003eThe process is the \u0026ldquo;how\u0026rdquo; of intervention tailoring and is critical in translating research to practice by providing a blueprint for future initiatives. This review answers calls in the field for enhanced transparency and reporting of the modification process (Wiltsey Stirman et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) by describing strategies that researchers have employed to identify and operationalize modifications for lay counselor-delivered TF-CBT. Although specific frameworks (e.g., DIME, Apprenticeship model), activities (e.g., focus groups, interviews), and timepoints (e.g., pre-, during, and post-implementation) of modifications varied, a ubiquitous component of the process was community engagement. Many studies anchored the process of tailoring TF-CBT in community-based participatory research (CBPR) approaches to ensure that adaptations and implementation centered the needs and voices of those being served. Because evidence-based interventions were developed and tested in controlled research environments that may differ from real-world settings, CBPR approaches can help ensure the effectiveness and sustainability of such interventions (Collins et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Wallerstein \u0026amp; Duran, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Consistent with CBPR, community members (e.g., lay counselors, local leadership) guided adaptations pre-, during, and post-implementation through focus groups, interviews, and feedback during training and implementation. By empowering community members as equal partners in research and experts of their context, researchers built trusting community-researcher partnerships that laid the foundation for implementation, refinement, and scale-up of TF-CBT.\u003c/p\u003e \u003cp\u003eThis review examined if components of TF-CBT warrant modification to enhance feasibility and sustainability of lay counselor delivery. This expands the literature on modifications to both TF-CBT and task-shifting, which have focused on cultural adaptations (Mabunda et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Metzger et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), toward those specific to the sustainment of task-shifting models. All modifications to TF-CBT were either contextual, to enhance fit with the local setting, or surface-level content modifications. The absence of core content adaptations is an important finding given that identification of intervention adaptations was a goal in many studies. This suggests that TF-CBT is overall a highly acceptable, appropriate, and feasible intervention for lay counselor delivery. The active ingredients of TF-CBT may not need changing, but rather, peripheral components can be refined to enhance success of task-shifting. Contextual modifications were most common and included embedding TF-CBT in existing lay counselor schedules (e.g., during 1-hour school breaks), implementing an abbreviated 8-session version, delivering multiple sessions per week, and allowing flexibility in session duration (30-120min). TF-CBT typically includes approximately 12\u0026ndash;16, 60-minute individual weekly sessions (Cohen et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) yet most studies did not fully adhere to this structure. Researchers recognized that the standard format of TF-CBT may be incompatible with the competing roles and responsibilities of counselors, and tailored delivery to fit the local context while adhering to the core intervention components. This underscores the importance of adopting a \u0026ldquo;flexibility within fidelity\u0026rdquo; approach to EBT implementation (Cohen et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Kendall \u0026amp; Beidas, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), particularly in task-shifting models that introduce unique implementation barriers (e.g., counselor jobs outside of mental health delivery). Recommendations for content modifications included adding resources in TF-CBT to link clients to services for other ongoing stressors, which was implemented to ensure counselor wellbeing. Task-shifting is a particularly useful strategy for increasing access to mental health services in low-resource communities, where workforce shortages are concentrated. In addition to high trauma-related mental health needs, clients in these settings are likely to experience co-occurring psychosocial stressors (e.g., housing, financial, and food insecurity) that are relevant to their wellbeing and the ability to engage in mental health services. Ensuring TF-CBT considers the holistic needs of clients is important in not only meeting client needs, but also for preserving counselor wellbeing.\u003c/p\u003e \u003cp\u003eEffective training and supervision are critical to successful implementation of evidence-based practice. Most adaptations to TF-CBT training reflected strategies to enhance counselor learning and ensure their preparedness and competency in delivering TF-CBT. TF-CBT training required for certification in the US comprises a 10-hour online asynchronous web-course, participation in a live two-day TF-CBT training led by a certified trainer, and a series of consultation sessions to support intervention delivery. In this review, most studies implemented initial training sessions and ongoing supervision. None implemented the web-course, which may be due to language barriers and/or limited technology access. Of the nine studies that implemented initial TF-CBT training sessions, eight increased the number of days (up to 10), and one study receive direct feedback from counselors that the initial training (two five-day sessions) was too condensed. Dividing the components of standard TF-CBT training to be delivered over a longer duration may be more digestible for lay counselors, thereby enhancing their learning and self-efficacy. Similarly, training was often described as an ongoing process with recurring training activities throughout implementation (e.g., post-training practice, booster sessions mid-implementation). Many studies followed the Apprenticeship Model of training, which provides specific guidelines on ongoing training and supervision activities for lay counselors (Murray et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). These insights highlight the importance of ongoing training for lay counselors, with implications for advancing the quality of training in evidence-based treatments broadly. While initial training sessions are necessary, \u0026ldquo;one-off\u0026rdquo; trainings do not result in sustained behavioral change, even among mental health specialists (Beidas \u0026amp; Kendall, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Herschell et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Murray et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Implementing recurring training activities, such as those outlined in TF-CBT (e.g., ongoing consultation) and the Apprenticeship Model (e.g., practice groups) may enhance uptake and sustainability of evidence-based treatments. Lastly, studies enhanced the content of training by teaching basic counseling skills prior to intervention-specific components; however, details of these components were not provided. This modification warrants further attention given its importance in bridging the inherent the gaps in knowledge between lay counselors, who do not have prior formal training in mental health services.\u003c/p\u003e \u003cp\u003eModifications to training and supervision also targeted capacity building by equipping local personnel to serve as trainers and supervisors and using technology to reduce the resource burden of supervision. Despite the centrality of training and supervision to effective implementation of evidence-based interventions, the resource-intensiveness of ongoing provider supports pose challenges for sustainability, even in mental health care settings (Marques et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Identifying strategies to build local capacity for training and supervision is necessary for intervention uptake. This may be particularly important in task-shifting because mental health delivery is not central to counselors\u0026rsquo; day-to-day roles. Findings suggest that not only can lay counselors be effectively trained to deliver TF-CBT, but with adequate support, they can also become effective trainers and supervisors themselves, thereby reducing the need for external involvement.\u003c/p\u003e \u003cp\u003eThis review elucidated multi-level implementation determinants, including barriers unique to task-shifting models that will require additional solutions. For instance, the competing responsibilities of lay counselors was as a barrier that could not fully be remediated through modifications to training, supervision, and TF-CBT. Organizational-level factors are salient determinants of implementation (Damschroder et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Consistent with existing recommendations (Powell et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), engaging gatekeepers of the local setting (i.e., those with decision-making authority) in research emerged as an important strategy to resolve organizational barriers. By collaborating with local leadership, researchers fostered community buy-in which enabled workload adjustments and increased counselor time allocated to TF-CBT delivery. Counselor wellbeing also emerged as an important consideration. The intensity of trauma therapy can have negative impacts on counselor wellbeing, and these impacts may be more severe for therapists with personal trauma histories (Pearlman \u0026amp; Mac Ian, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Because lay counselors are often members of the communities they serve, they may be more susceptible to the negative impacts of trauma-focused work. Developing context-specific supports (e.g., safety protocol, resource list for psychosocial stressors) and ensuring open communication with lay counselors (e.g., during supervision) is important to facilitate their own coping and processing of trauma-focused work.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e This review provides the first synthesis of modifications to TF-CBT for lay counselor delivery. We note several limitations of this work. First, only studies published in English were included in this review. Second, because we aimed to synthesize modifications, we are unable to draw conclusions about the efficacy of specific strategies. Future research should examine the relative importance of modifications and implementation strategies to better understand which are essential for lay counselor-delivery. The detail of adaptations varied widely across studies and were not systematically reported, which further limited this review. It is possible that some modification activities were omitted from papers due to various reasons (e.g., were not the main aim of the paper, length limitations of journals), and as a result would be missing from the present review. Similarly, this review was focused on characterizing adaptations that were relevant to task-shifting models and cultural adaptations were not included. All studies included in the review implemented culturally modified versions of TF-CBT and in some cases, it was difficult to discern whether the process and modifications reported were aimed at enhancing cultural relevance of the intervention or fit with the lay counselor treatment model. We attempted to resolve this through double-coding and consensus meetings during data extraction, but it is possible that relevant modifications were not included in this review if they were described by authors as cultural adaptations. These limitations underscore the importance of systematic reporting of key details of modifications (e.g., the purpose of each modification). Consistent with calls in the field, we recommend that researchers anchor reporting of modifications in established frameworks that have been developed to enhance consistency, such as FRAME (Wiltsey Stirman et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGiven the known health consequences of childhood trauma, strategies to close the mental health treatment gap and increase access to evidence-based interventions such as TF-CBT are urgently needed. The current review sought to synthesize how TF-CBT has been modified for delivery by lay counselors. Trials reported activities from the modification process, modifications made to TF-CBT, and implementation strategies (e.g., training and supervision) to support lay counselor delivery. Findings provide critical insights on how researchers and clinicians, both internationally and within the US, may apply task-shifting to increase access to TF-CBT in usual care settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNo funding was received for conducting this study. The authors have no relevant financial or non-financial interests to disclose. This study is a systematic review and did not involve human participants, therefore ethical approval and informed consent were not needed. The data from this review are not publicly available but may be made available upon request. This systematic review was pre-registered on PROSPERO (CRD#).\u003c/p\u003e\n\u003cp\u003eAuthors 1 and 3 developed the idea for the study. Author 1 developed the research questions, pre-registration, protocol, and data analytic plan, and oversaw study activities. Authors 1 and 2 performed the literature search and data analysis. Author 1 wrote the main manuscript, and all authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eL.G. and A.H.L. developed the idea for the study. L.G. developed the research questions, pre-registration, protocol, and data analytic plan, and oversaw study activities. L.G. and N.G. performed the literature search and data analysis. L.G. wrote the main manuscript and all authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndrews, A. R., Jobe-Shields, L., L\u0026oacute;pez, C. M., Metzger, I. W., de Arellano, M. A. R., Saunders, B., \u0026amp; Kilpatrick, D. (2015). Polyvictimization, Income, and Ethnic Differences in Trauma-Related Mental Health During Adolescence. \u003cem\u003eSocial Psychiatry and Psychiatric Epidemiology\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(8), 1223\u0026ndash;1234. https://doi.org/10.1007/s00127-015-1077-3\u003c/li\u003e\n\u003cli\u003eBarnett, M. L., Gonzalez, A., Miranda, J., Chavira, D. A., \u0026amp; Lau, A. S. (2018). Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review. \u003cem\u003eAdministration and Policy in Mental Health\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(2), 195\u0026ndash;211. https://doi.org/10.1007/s10488-017-0815-0\u003c/li\u003e\n\u003cli\u003eBarnett, M. L., Lau, A. S., \u0026amp; Miranda, J. (2018). Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care. \u003cem\u003eAnnual Review of Clinical Psychology\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(Volume 14, 2018), 185\u0026ndash;208. https://doi.org/10.1146/annurev-clinpsy-050817-084825\u003c/li\u003e\n\u003cli\u003eBeidas, R. S., \u0026amp; Kendall, P. C. (2010). Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective. \u003cem\u003eClinical Psychology : A Publication of the Division of Clinical Psychology of the American Psychological Association\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(1), 1\u0026ndash;30. https://doi.org/10.1111/j.1468-2850.2009.01187.x\u003c/li\u003e\n\u003cli\u003eCohen, D. J., Crabtree, B. F., Etz, R. S., Balasubramanian, B. A., Donahue, K. E., Leviton, L. C., Clark, E. C., Isaacson, N. F., Stange, K. C., \u0026amp; Green, L. W. (2008). Fidelity Versus Flexibility: Translating Evidence-Based Research into Practice. \u003cem\u003eAmerican Journal of Preventive Medicine\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(5, Supplement), S381\u0026ndash;S389. https://doi.org/10.1016/j.amepre.2008.08.005\u003c/li\u003e\n\u003cli\u003eCohen, J. A., Mannarino, A. P., \u0026amp; Deblinger, E. (2017). \u003cem\u003eTreating Trauma and Traumatic Grief in Children and Adolescents\u003c/em\u003e. Guilford Publications.\u003c/li\u003e\n\u003cli\u003eCollins, S. E., Clifasefi, S. L., Stanton, J., Straits, K. J. E., Espinosa, P. R., Andrasik, M. P., Miller, K. A., Orfaly, V. E., Gil-Kashiwabara, E., Nicasio, A. V., Hawes, S. M., Nelson, L. A., Duran, B. M., \u0026amp; Wallerstein, N. (2018). Community-based Participatory Research (CBPR): Towards Equitable Involvement of Community in Psychology Research. \u003cem\u003eThe American Psychologist\u003c/em\u003e, \u003cem\u003e73\u003c/em\u003e(7), 884\u0026ndash;898. https://doi.org/10.1037/amp0000167\u003c/li\u003e\n\u003cli\u003eConnolly, S. M., Vanchu-Orosco, M., Warner, J., Seidi, P. A., Edwards, J., Boath, E., \u0026amp; Irgens, A. (2021). Mental health interventions by lay counsellors: A systematic review and meta-analysis. \u003cem\u003eBulletin of the World Health Organization\u003c/em\u003e, \u003cem\u003e99\u003c/em\u003e(8), 572\u0026ndash;582. https://doi.org/10.2471/BLT.20.269050\u003c/li\u003e\n\u003cli\u003eCook, B. L., Doksum, T., Chen, C.-N., Carle, A., \u0026amp; Alegr\u0026iacute;a, M. (2013). The role of provider supply and organization in reducing racial/ethnic disparities in mental health care in the U.S. \u003cem\u003eSocial Science \u0026amp; Medicine (1982)\u003c/em\u003e, \u003cem\u003e84\u003c/em\u003e, 102\u0026ndash;109. https://doi.org/10.1016/j.socscimed.2013.02.006\u003c/li\u003e\n\u003cli\u003eCook, B. L., Trinh, N.-H., Li, Z., Hou, S. S.-Y., \u0026amp; Progovac, A. M. (2017). Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004\u0026ndash;2012. \u003cem\u003ePsychiatric Services\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e(1), 9\u0026ndash;16. https://doi.org/10.1176/appi.ps.201500453\u003c/li\u003e\n\u003cli\u003eCummings, J. R., Wen, H., \u0026amp; Druss, B. G. (2013). Improving Access to Mental Health Services for Youth in the United States. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e309\u003c/em\u003e(6), 553. https://doi.org/10.1001/jama.2013.437\u003c/li\u003e\n\u003cli\u003eDamschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., \u0026amp; Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. \u003cem\u003eImplementation Science\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(1), 50. https://doi.org/10.1186/1748-5908-4-50\u003c/li\u003e\n\u003cli\u003eDe Bellis, M. D., Hooper, S. R., Spratt, E. G., \u0026amp; Woolley, D. P. (2009). Neuropsychological findings in childhood neglect and their relationships to pediatric PTSD. \u003cem\u003eJournal of the International Neuropsychological Society: JINS\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(6), 868\u0026ndash;878. https://doi.org/10.1017/S1355617709990464\u003c/li\u003e\n\u003cli\u003eDerr, A. S. (2016). Mental Health Service Use Among Immigrants in the United States: A Systematic Review. \u003cem\u003ePsychiatric Services (Washington, D.C.)\u003c/em\u003e, \u003cem\u003e67\u003c/em\u003e(3), 265\u0026ndash;274. https://doi.org/10.1176/appi.ps.201500004\u003c/li\u003e\n\u003cli\u003eDinwiddie, G. Y., Gaskin, D. J., Chan, K. S., Norrington, J., \u0026amp; McCleary, R. (2013). Residential segregation, geographic proximity and type of services used: Evidence for racial/ethnic disparities in mental health. \u003cem\u003eSocial Science \u0026amp; Medicine (1982)\u003c/em\u003e, \u003cem\u003e80\u003c/em\u003e, 67\u0026ndash;75. https://doi.org/10.1016/j.socscimed.2012.11.024\u003c/li\u003e\n\u003cli\u003eDorsey, S., Gray, C. L., Wasonga, A. I., Amanya, C., Weiner, B. J., Belden, C. M., Martin, P., Meza, R. D., Weinhold, A. K., Soi, C., Murray, L. K., Lucid, L., Turner, E. L., Mildon, R., \u0026amp; Whetten, K. (2020). Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): Protocol for a stepped wedge cluster randomized trial. \u003cem\u003eBMC Psychiatry\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 10. https://doi.org/10.1186/s12888-019-2364-4\u003c/li\u003e\n\u003cli\u003eDorsey, S., Lucid, L., Martin, P., King, K. M., O\u0026rsquo;Donnell, K., Murray, L. K., Wasonga, A. I., Itemba, D. K., Cohen, J. A., Manongi, R., \u0026amp; Whetten, K. (2020). Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial. \u003cem\u003eJAMA Psychiatry\u003c/em\u003e, \u003cem\u003e77\u003c/em\u003e(5), 464\u0026ndash;473. https://doi.org/10.1001/jamapsychiatry.2019.4475\u003c/li\u003e\n\u003cli\u003eDorsey, S., McLaughlin, K. A., Kerns, S. E. U., Harrison, J. P., Lambert, H. K., Briggs, E. C., Revillion Cox, J., \u0026amp; Amaya-Jackson, L. (2017). Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events. \u003cem\u003eJournal of Clinical Child \u0026amp; Adolescent Psychology\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(3), 303\u0026ndash;330. https://doi.org/10.1080/15374416.2016.1220309\u003c/li\u003e\n\u003cli\u003eDrisko, J., \u0026amp; Maschi, T. (2015). \u003cem\u003eContent Analysis\u003c/em\u003e. Oxford University Press.\u003c/li\u003e\n\u003cli\u003eFelitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., \u0026amp; Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. \u003cem\u003eAmerican Journal of Preventive Medicine\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(4), 245\u0026ndash;258. https://doi.org/10.1016/s0749-3797(98)00017-8\u003c/li\u003e\n\u003cli\u003eGary, F. A. (2005). Stigma: Barrier to mental health care among ethnic minorities. \u003cem\u003eIssues in Mental Health Nursing\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(10), 979\u0026ndash;999. https://doi.org/10.1080/01612840500280638\u003c/li\u003e\n\u003cli\u003eGlaser, B., \u0026amp; Strauss, A. (2017). \u003cem\u003eDiscovery of Grounded Theory: Strategies for Qualitative Research\u003c/em\u003e. Routledge. https://doi.org/10.4324/9780203793206\u003c/li\u003e\n\u003cli\u003eHarrison, R., Jones, B., Gardner, P., \u0026amp; Lawton, R. (2021). Quality assessment with diverse studies (QuADS): An appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies. \u003cem\u003eBMC Health Services Research\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 144. https://doi.org/10.1186/s12913-021-06122-y\u003c/li\u003e\n\u003cli\u003eHatch, S. L., \u0026amp; Dohrenwend, B. P. (2007). Distribution of Traumatic and Other Stressful Life Events by Race/Ethnicity, Gender, SES and Age: A Review of the Research. \u003cem\u003eAmerican Journal of Community Psychology\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(3\u0026ndash;4), 313\u0026ndash;332. https://doi.org/10.1007/s10464-007-9134-z\u003c/li\u003e\n\u003cli\u003eHerschell, A. D., Kolko, D. J., Baumann, B. L., \u0026amp; Davis, A. C. (2010). The Role of Therapist Training in the Implementation of Psychosocial Treatments: A Review and Critique with Recommendations. \u003cem\u003eClinical Psychology Review\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(4), 448\u0026ndash;466. https://doi.org/10.1016/j.cpr.2010.02.005\u003c/li\u003e\n\u003cli\u003eJavadi, D., Feldhaus, I., Mancuso, A., \u0026amp; Ghaffar, A. (2017). Applying systems thinking to task shifting for mental health using lay providers: A review of the evidence. \u003cem\u003eGlobal Mental Health\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e, e14. https://doi.org/10.1017/gmh.2017.15\u003c/li\u003e\n\u003cli\u003eKataoka, S. H., Zhang, L., \u0026amp; Wells, K. B. (2002). Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. \u003cem\u003eAmerican Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e159\u003c/em\u003e(9), 1548\u0026ndash;1555. https://doi.org/10.1176/appi.ajp.159.9.1548\u003c/li\u003e\n\u003cli\u003eKendall, P. C., \u0026amp; Beidas, R. S. (2007). Smoothing the trail for dissemination of evidence-based practices for youth: Flexibility within fidelity. \u003cem\u003eProfessional Psychology: Research and Practice\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(1), 13\u0026ndash;20. https://doi.org/10.1037/0735-7028.38.1.13\u003c/li\u003e\n\u003cli\u003eLange, B. C. L., Nelson, A., Lang, J. M., \u0026amp; Stirman, S. W. (2022). Adaptations of evidence-based trauma-focused interventions for children and adolescents: A systematic review. \u003cem\u003eImplementation Science Communications\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e, 108. https://doi.org/10.1186/s43058-022-00348-5\u003c/li\u003e\n\u003cli\u003eLaVeist, T. A., Isaac, L. A., \u0026amp; Williams, K. P. (2009). Mistrust of Health Care Organizations Is Associated with Underutilization of Health Services. \u003cem\u003eHealth Services Research\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(6), 2093\u0026ndash;2105. https://doi.org/10.1111/j.1475-6773.2009.01017.x\u003c/li\u003e\n\u003cli\u003eLi, J., Li, J., Zhang, W., Wang, G., \u0026amp; Qu, Z. (2023). Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: A randomized controlled trial. \u003cem\u003eThe Lancet Regional Health. Western Pacific\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e, 100699. https://doi.org/10.1016/j.lanwpc.2023.100699\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez, C. M., Andrews III, A. R., Chisolm, A. M., de Arellano, M. A., Saunders, B., \u0026amp; Kilpatrick, Dean. G. (2017). Racial/ethnic differences in trauma exposure and mental health disorders in adolescents. \u003cem\u003eCultural Diversity and Ethnic Minority Psychology\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(3), 382\u0026ndash;387. https://doi.org/10.1037/cdp0000126\u003c/li\u003e\n\u003cli\u003eMabunda, D., Oliveira, D., Sidat, M., Cavalcanti, M. T., Cumbe, V., Mandlate, F., Wainberg, M., Cournos, F., \u0026amp; de Jesus Mari, J. (2022). Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: Scoping review and expert consultation. \u003cem\u003eInternational Journal of Mental Health Systems\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(1), 14. https://doi.org/10.1186/s13033-022-00526-x\u003c/li\u003e\n\u003cli\u003eMarques, L., Dixon, L., Valentine, S. E., Borba, C. P. C., Simon, N. M., \u0026amp; Wiltsey Stirman, S. (2016). Providers\u0026rsquo; Perspectives of Factors Influencing Implementation of Evidence-Based Treatments in a Community Mental Health Setting: A Qualitative Investigation of the Training-Practice Gap. \u003cem\u003ePsychological Services\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(3), 322\u0026ndash;331. https://doi.org/10.1037/ser0000087\u003c/li\u003e\n\u003cli\u003eMcLaughlin, K. A., Koenen, K. C., Hill, E. D., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., \u0026amp; Kessler, R. C. (2013). Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. \u003cem\u003eJournal of the American Academy of Child and Adolescent Psychiatry\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(8), 815-830.e14. https://doi.org/10.1016/j.jaac.2013.05.011\u003c/li\u003e\n\u003cli\u003eMerikangas, K. R., He, J., Burstein, M. E., Swendsen, J., Avenevoli, S., Case, B., Georgiades, K., Heaton, L., Swanson, S., \u0026amp; Olfson, M. (2011). Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey Adolescent Supplement (NCS-A). \u003cem\u003eJournal of the American Academy of Child and Adolescent Psychiatry\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(1), 32\u0026ndash;45. https://doi.org/10.1016/j.jaac.2010.10.006\u003c/li\u003e\n\u003cli\u003eMetzger, I. W., Anderson, R. E., Are, F., \u0026amp; Ritchwood, T. (2021). Healing Interpersonal and Racial Trauma: Integrating Racial Socialization Into Trauma-Focused Cognitive Behavioral Therapy for African American Youth. \u003cem\u003eChild Maltreatment\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(1), 17\u0026ndash;27. https://doi.org/10.1177/1077559520921457\u003c/li\u003e\n\u003cli\u003eMongelli, F., Georgakopoulos, P., \u0026amp; Pato, M. T. (2020). Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States. \u003cem\u003eFocus\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), 16\u0026ndash;24. https://doi.org/10.1176/appi.focus.20190028\u003c/li\u003e\n\u003cli\u003eMurray, L. K., Dorsey, S., Bolton, P., Jordans, M. J., Rahman, A., Bass, J., \u0026amp; Verdeli, H. (2011). Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers. \u003cem\u003eInternational Journal of Mental Health Systems\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(1), 30. https://doi.org/10.1186/1752-4458-5-30\u003c/li\u003e\n\u003cli\u003eMurray, L. K., Dorsey, S., Skavenski, S., Kasoma, M., Imasiku, M., Bolton, P., Bass, J., \u0026amp; Cohen, J. A. (2013). Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: The use of TF-CBT in Zambia. \u003cem\u003eInternational Journal of Mental Health Systems\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 24. https://doi.org/10.1186/1752-4458-7-24\u003c/li\u003e\n\u003cli\u003eMurray, L. K., Familiar, I., Skavenski, S., Jere, E., Cohen, J., Imasiku, M., Mayeya, J., Bass, J. K., \u0026amp; Bolton, P. (2013). An evaluation of trauma focused cognitive behavioral therapy for children in Zambia. \u003cem\u003eChild Abuse \u0026amp; Neglect\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(12), 1175\u0026ndash;1185. https://doi.org/10.1016/j.chiabu.2013.04.017\u003c/li\u003e\n\u003cli\u003eMurray, L. K., Skavenski, S., Kane, J. C., Mayeya, J., Dorsey, S., Cohen, J. A., Michalopoulos, L. T. M., Imasiku, M., \u0026amp; Bolton, P. A. (2015). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial. \u003cem\u003eJAMA Pediatrics\u003c/em\u003e, \u003cem\u003e169\u003c/em\u003e(8), 761\u0026ndash;769. https://doi.org/10.1001/jamapediatrics.2015.0580\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Callaghan, P., McMullen, J., Shannon, C., \u0026amp; Rafferty, H. (2015). Comparing a trauma focused and non trauma focused intervention with war affected Congolese youth: A preliminary randomised trial. \u003cem\u003eIntervention Journal of Mental Health and Psychosocial Support in Conflict Affected Areas\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(1), 28.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., \u0026amp; Black, A. (2013). A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. \u003cem\u003eJournal of the American Academy of Child and Adolescent Psychiatry\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(4), 359\u0026ndash;369. https://doi.org/10.1016/j.jaac.2013.01.013\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donnell, K., Dorsey, S., Gong, W., Ostermann, J., Whetten, R., Cohen, J. A., Itemba, D., Manongi, R., \u0026amp; Whetten, K. (2014). Treating maladaptive grief and posttraumatic stress symptoms in orphaned children in Tanzania: Group-based trauma-focused cognitive-behavioral therapy. \u003cem\u003eJournal of Traumatic Stress\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(6), 664\u0026ndash;671. https://doi.org/10.1002/jts.21970\u003c/li\u003e\n\u003cli\u003ePadmanathan, P., \u0026amp; De Silva, M. J. (2013). The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: A systematic review. \u003cem\u003eSocial Science \u0026amp; Medicine (1982)\u003c/em\u003e, \u003cem\u003e97\u003c/em\u003e, 82\u0026ndash;86. https://doi.org/10.1016/j.socscimed.2013.08.004\u003c/li\u003e\n\u003cli\u003ePearlman, L. A., \u0026amp; Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. \u003cem\u003eProfessional Psychology: Research and Practice\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(6), 558\u0026ndash;565. https://doi.org/10.1037/0735-7028.26.6.558\u003c/li\u003e\n\u003cli\u003ePopay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., \u0026amp; Britten, N. (n.d.). \u003cem\u003eGuidance on the Conduct of Narrative Synthesis in Systematic Reviews\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003ePowell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., \u0026amp; Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. \u003cem\u003eImplementation Science\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(1), 21. https://doi.org/10.1186/s13012-015-0209-1\u003c/li\u003e\n\u003cli\u003eProctor, E. K., Powell, B. J., \u0026amp; McMillen, J. C. (2013). Implementation strategies: Recommendations for specifying and reporting. \u003cem\u003eImplementation Science\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(1), 139. https://doi.org/10.1186/1748-5908-8-139\u003c/li\u003e\n\u003cli\u003eSilverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., \u0026amp; Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. \u003cem\u003eJournal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(1), 156\u0026ndash;183. https://doi.org/10.1080/15374410701818293\u003c/li\u003e\n\u003cli\u003eSingla, D. R., Kohrt, B. A., Murray, L. K., Anand, A., Chorpita, B. F., \u0026amp; Patel, V. (2017). Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries. \u003cem\u003eAnnual Review of Clinical Psychology\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e, 149\u0026ndash;181. https://doi.org/10.1146/annurev-clinpsy-032816-045217\u003c/li\u003e\n\u003cli\u003eThielemann, J. F. B., Kasparik, B., K\u0026ouml;nig, J., Unterhitzenberger, J., \u0026amp; Rosner, R. (2022). A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents. \u003cem\u003eChild Abuse \u0026amp; Neglect\u003c/em\u003e, \u003cem\u003e134\u003c/em\u003e, 105899. https://doi.org/10.1016/j.chiabu.2022.105899\u003c/li\u003e\n\u003cli\u003eTrickett, P. K., Noll, J. G., \u0026amp; Putnam, F. W. (2011). The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. \u003cem\u003eDevelopment and Psychopathology\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(2), 453\u0026ndash;476. https://doi.org/10.1017/S0954579411000174\u003c/li\u003e\n\u003cli\u003eTurner, H. A., Finkelhor, D., \u0026amp; Ormrod, R. (2010). Poly-victimization in a national sample of children and youth. \u003cem\u003eAmerican Journal of Preventive Medicine\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(3), 323\u0026ndash;330. https://doi.org/10.1016/j.amepre.2009.11.012\u003c/li\u003e\n\u003cli\u003eBureau of Health Workforce. (2024). \u003cem\u003eHealth professional shortage areas statistics: First quarter of fiscal year 2025, designated HPSA quarterly summary\u003c/em\u003e [Report]. Health Resources and Services Administration, U.S. Department of Health \u0026amp; Human Services. https://www.hrsa.gov\u003c/li\u003e\n\u003cli\u003evan Ginneken, N., Tharyan, P., Lewin, S., Rao, G. N., Meera, S. M., Pian, J., Chandrashekar, S., \u0026amp; Patel, V. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. \u003cem\u003eThe Cochrane Database of Systematic Reviews\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, CD009149. https://doi.org/10.1002/14651858.CD009149.pub2\u003c/li\u003e\n\u003cli\u003eWallerstein, N. B., \u0026amp; Duran, B. (2006). Using community-based participatory research to address health disparities. \u003cem\u003eHealth Promotion Practice\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(3), 312\u0026ndash;323. https://doi.org/10.1177/1524839906289376\u003c/li\u003e\n\u003cli\u003eWang, D. C., Aten, J. D., Boan, D., Jean-Charles, W., Griff, K. P., Valcin, V. C., Davis, E. B., Hook, J. N., Davis, D. E., Van Tongeren, D. R., Abouezzeddine, T., Sklar, Q., \u0026amp; Wang, A. (2016). Culturally adapted spiritually oriented trauma-focused cognitive\u0026ndash;behavioral therapy for child survivors of restavek. \u003cem\u003eSpirituality in Clinical Practice\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(4), 224\u0026ndash;236. https://doi.org/10.1037/scp0000101\u003c/li\u003e\n\u003cli\u003eWiltsey Stirman, S., Baumann, A. A., \u0026amp; Miller, C. J. (2019). The FRAME: An expanded framework for reporting adaptations and modifications to evidence-based interventions. \u003cem\u003eImplementation Science\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), 58. https://doi.org/10.1186/s13012-019-0898-y\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, PEPFAR, \u0026amp; UNAIDS. (2007). \u003cem\u003eTask shifting: Rational redistribution of tasks among health workforce teams : global recommendations and guidelines\u003c/em\u003e. 88. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eSearch Terms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003e1. (\u0026ldquo;lay worker\u0026rdquo; OR \u0026ldquo;lay health worker\u0026rdquo; OR LHW OR \u0026ldquo;lay mental health worker\u0026rdquo; OR \u0026ldquo;lay counselor\u0026rdquo; OR \u0026ldquo;lay health counselor\u0026rdquo; OR \u0026ldquo;lay counsellor\u0026rdquo; OR \u0026ldquo;community health worker\u0026rdquo; OR CHW OR \u0026ldquo;task shift*\u0026rdquo; OR \u0026ldquo;peer deliver*\u0026rdquo; OR \u0026ldquo;peer support\u0026rdquo; OR \u0026ldquo;nonprofessional\u0026rdquo; OR \u0026ldquo;community volunteer\u0026rdquo;)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003cp\u003e2. (Adapt* OR tailor* OR implement* OR \u0026ldquo;implementation strateg*\u0026rdquo; OR \u0026ldquo;implementation facilitation\u0026rdquo; OR optimiz* OR modif* OR train* OR supervis* )\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003cp\u003e3. (\u0026ldquo;trauma focused cognitive behavioral therapy\u0026rdquo; OR \u0026ldquo;trauma focused CBT\u0026rdquo; OR \u0026ldquo;TF CBT\u0026rdquo; OR \u0026ldquo;trauma focused cognitive behavioural therapy\u0026rdquo;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"954\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\" style=\"width: 948px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eCharacteristics of studies included in systematic review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 21.9839%;\" colspan=\"3\"\u003e\u003cstrong\u003eTrial Characteristics\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 21.4477%;\" colspan=\"2\"\u003e\u003cstrong\u003eTrial Participants\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 42.2252%;\" colspan=\"7\"\u003e\u003cstrong\u003eLay Counselor Characteristics\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN; Condition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, Sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN; Role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelection \u0026amp; Qualifications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e1. Dorsey et al. (2019)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey, Gray, et al., (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey et al., (2023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Johnson et al., (2024)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Martin (2022)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Meza et al. (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett et al. (2021)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett, Mbwayo et al. (2023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett, Johnson, et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eStepped wedge cluster RCT\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1280; TF-CBT in health or education sector\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 11-14; 50% girls/boys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 240 teachers and community health volunteers.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eNominated by local leadership; Good with children, may have counseling experience (not required), have time to deliver the program, no plans for leaving the area.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e2.\u003csup\u003e\u0026nbsp;\u003c/sup\u003eDorsey et al., (2022)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey, Lucid et al. (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Woods-Jaeger et al., (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eRCT\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eTanzania \u0026amp; Kenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e640; TF-CBT (320), usual care (320)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 7-13; 50% girls/boys\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 12; NR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eHired by local organization. Expected to have experience/interest working with children/families, did not need mental health training, all had undergraduate degrees.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e3. Murray, Dorsey et al. (2013)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Murray et al., (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eFeasibility study\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eZambia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 4-18; 100% girls (N = 21 treatment completers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 19 university students, staff from university, organizations, and hospitals.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eExperience and education varied; 3 had some clinical training.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e4. Li et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e234; TF-CBT (118), TAU (116)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 9-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 15 college students\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eRecruited from university; None had experience in mental health treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e5. Murray, Familiar et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eFeasibility study\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eZambia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 5-18 (N = 58 completers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 18; NR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eCounselors with minimal formal training.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e6. Murray et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eRCT\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eZambia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e257; TF-CBT (131), TAU (126)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 5-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 20; NR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eBackgrounds varied; All had high school education and basic communication/social skills.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e7. O\u0026apos;Callaghan et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eDemocratic Republic of Congo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e52; TF-CBT (24), waitlist (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 12-17; 100% girls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eNR; Social workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eStaff from the local organization who provide psychosocial support to youth.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e8. O\u0026apos;Callaghan et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eRCT\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eDemocratic Republic of Congo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e50; TF-CBT (26, non-trauma focused (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 8-17; 29 boys, 21 girls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eOne teacher with assistance from two social workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eTeacher from prior trial and social workers from organization/funder.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e9. O\u0026apos;Donnell et al. (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eFeasibility study\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eTanzania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e64\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 7-13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 4; NR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eHired by local organizations; Desired capabilities were experience working with children and/or counseling, bilingual in English, willingness to be trained and work with the US investigators; 3 had some university education, 3 had prior work with children, none had mental health experience.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e10. Wang et al. (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eHaiti\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eN = 58; TF-CBT (38), control (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAges 6-20; 68% girls (TF-CBT group)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN = 24; community members from local churches, organizations, or university students.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eMust be part of a local organization that supports participation. Counselors from churches: leader endorsement, 6\u003csup\u003eth\u003c/sup\u003e grade education, some prior training, and \u0026nbsp; \u0026nbsp; \u0026sup3;3 years working with local youth. Organization volunteers: bachelor\u0026rsquo;s degree and \u0026sup3;1 year working with local youth. Students: \u0026sup3;2 years of undergraduate work and some training.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 936px;\"\u003e\n \u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e NR = not reported, RCT = randomized controlled trial, TF-CBT = trauma-focused cognitive behavioral therapy, TAU = treatment as usual. Superscripts are used to indicate trials that were conducted by the same researcher-community partnerships over multiple research initiatives.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"942\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 870px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eIntervention characteristics across trials of lay counselor delivered TF-CBT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModifications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTF-CBT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelivery Setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency \u0026amp; Duration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e1. Dorsey et al. (2019)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey, Gray, et al., (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey et al., (2023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Johnson et al., (2024)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Martin (2022)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Meza et al. (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett et al. (2021)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett, Mbwayo et al. (2023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett, Johnson, et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored (Pamoja Tunaweza)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026ldquo;Village clusters\u0026rdquo;: Schools and their surrounding community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eGroup and individual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 weekly 60min sessions.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting, modality, number of sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e2. Dorsey et al., (2022)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey, Lucid et al. (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Woods-Jaeger et al., (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored (Pamoja Tunaweza)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGroup and individual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e30-120min sessions over 12 consecutive weeks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eModality, duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLanguage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e3. Murray, Dorsey et al. (2013)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Murray et al., (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eIndividual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eWeekly sessions (range 12 \u0026ndash; 32 sessions).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLanguage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e4. Li et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored (Power up Children\u0026rsquo;s Psychological Immunity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFour public schools and two private schools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGroup and individual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e50min sessions over 9 consecutive weeks (10-12 sessions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting, modality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e5. Murray, Familiar et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eSeven local centers (hospices, centers for street youth, childcare for HIV-affected youth, health clinic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eIndividual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eWeekly 30-120min sessions over an average of 11 weeks (range 8\u0026ndash;23).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting, duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLanguage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e6. Murray et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFive local sites (home-based care, center for street youth, health clinic, school/residential)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eIndividual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eWeekly 60-90min sessions (10-16 sessions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e7. O\u0026apos;Callaghan et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHall in the local secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGroup and individual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e120min/day, 3 days/week for 5 weeks (15 sessions).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting, modality, frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e8. O\u0026apos;Callaghan et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eUnder a tent set up in a field attached to a local school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGroup\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eThree 90min sessions per week.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting, modality, frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e9. O\u0026apos;Donnell et al. (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored TF-CBT for Traumatic Grief\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eCommunity buildings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGroup and individual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e12 weekly 60min sessions.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSetting, modality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e10. Wang et al. (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCulturally tailored spiritually-oriented TF-CBT\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eIndividual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e12 weekly sessions. Some required up to 6 months and \u0026gt; 1 session/week.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 942px;\"\u003e\n \u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e NR = not reported, TF-CBT = trauma-focused cognitive behavioral therapy.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"936\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 936px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eTraining and supervision characteristics across trials of lay counselor-delivered TF-CBT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTraining\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupervision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFidelity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e1. Dorsey et al. (2019)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey, Gray, et al., (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey et al., (2023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Johnson et al., (2024)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Martin (2022)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Meza et al. (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett et al. (2021)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett, Mbwayo et al. (2023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Triplett, Johnson, et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e5-6 day in-person training led by local trainer followed by 2-3 weeks practice delivering TF-CBT (Apprenticeship model). Local trainers complete Train-the-Trainer led by TF-CBT expert followed by 2 months practice.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eWeekly in-person or virtual (e.g., phone call, text) meetings with local supervisors. Local supervisors attend weekly virtual consultation with TF-CBT experts (1-1.5hr).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eSelf-report fidelity checklist, supervisor observation of sessions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e2. Dorsey et al., (2022)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Dorsey, Lucid et al. (2020)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Woods-Jaeger et al., (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e10-day in-person training led by local trainers followed by practice delivering TF-CBT and booster training sessions (Apprenticeship model). Local trainers complete 5-day in-person Train-the-Trainer led by experienced TF-CBT trainer.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eWeekly in-person or virtual (skype/telephone) meetings with local supervisors. Local supervisors attend weekly consultation calls with TF-CBT experts.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eCounselor reports, session audio recordings, and discussion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e3. Murray, Dorsey et al. (2013)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Murray et al., (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eTwo five-day live trainings led by lead author followed by practice groups (Apprenticeship model).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eGroup supervision (2hr/week) with local supervisors. Local supervisors attend weekly (2hr) consultation calls with TF-CBT experts.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eCounselor-completed case notes of components delivered, logistics, details on implementation strategy.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e4. Li et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e3-day group training led by three manual developers from local institution followed by test of knowledge/ skills, 1.5 days of booster training in the midterm, and detailed intervention manual.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eWeekly virtual supervision from three manual developers.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eVideo-recorded therapy sessions and review of counselor reports from sessions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e5. Murray, Familiar et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eIn-person training followed by practice groups (Apprenticeship model).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eWeekly (2-4hr/week) meetings with local supervisors. Local supervisors attend weekly consultation calls with trainers (2hr/week).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eSelf-report fidelity checklist\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e6. Murray et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e10-day on-site training led by TF-CBT experts (Apprenticeship model).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eWeekly group meetings with local supervisors. Local supervisors attend weekly consultation with TF-CBT experts.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eCounselor-completed detailed session notes reviewed by supervisors and TF-CBT experts during supervisor supervision.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e7. O\u0026apos;Callaghan et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eFacilitators received the manualized intervention to study before each session and raise questions or suggest modifications.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePre- and post-session meetings with the lead authors.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eLead researcher monitored each session.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e8. O\u0026apos;Callaghan et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eSix training sessions on how to deliver the intervention; received intervention manuals.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eCounselors received prior \u0026ldquo;in-the-field\u0026rdquo; supervision while delivering the intervention.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e9. O\u0026apos;Donnell et al. (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e10-day in-person training led by TF-CBT trainer followed by 1-month practice with expert oversight.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eWeekly calls with US investigators and four in-person meetings.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eSelf-report fidelity checklists reviewed by US investigators.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e10. Wang et al. (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eTwo-day workshop (Day 1 basic helping skills, Day 2 TF-CBT and modifications) led by local staff who were involved in cultural adaptation and completed their own training.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eMeetings with local supervisors who completed workshops on supervision models and attend their own ongoing supervision with the organization director.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 936px;\"\u003e\n \u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e NR = not reported, TF-CBT = trauma-focused cognitive behavioral therapy.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"TF-CBT, lay counselors, implementation, modification, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-6702006/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6702006/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLay counselor delivery of trauma-focused cognitive behavioral therapy (TF-CBT) is a promising strategy to increase access to trauma-focused care and prevent trauma-related health disparities among youth in low-resource settings in the United States. This pre-registered systematic review sought to synthesize \u003cem\u003ehow\u003c/em\u003e TF-CBT has been tailored for lay counselor delivery, which can inform broader dissemination. Specifically, we examined (1) the modification process, (2) treatment modifications, and (3) implementation strategies (e.g., training and supervision) to support lay counselor delivery of TF-CBT. In June 2024, a literature search was conducted across PsycINFO, PubMed, MEDLINE, and PILOTS. Grey literature was identified through Google Scholar and ProQuest. A narrative synthesis summarized findings by research question. Ten trials (21 articles) met inclusion criteria and described modifications or implementation strategies for lay counselor-delivered TF-CBT. All trials implemented culturally tailored versions of TF-CBT in low- and middle-income countries. The modification process relied on input from local experts through community-researcher collaborations. TF-CBT modifications were contextual (e.g., modality) or surface-level (e.g., language) and no trials reported modifications to core components. Implementation strategies included enhancing training and supervision, addressing implementation barriers, and preserving counselor wellbeing. Findings suggest that TF-CBT can be successfully delivered by lay counselors through peripheral modifications, enhanced counselor supports, and strong community partnerships. This review provides a foundation for future research aimed at disseminating lay counselor-delivered TF-CBT in low-resource settings \u0026ndash; a critical direction to close the mental health treatment gap and promote health equity in the United States and globally.\u003c/p\u003e","manuscriptTitle":"Lay Counselor Delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-28 11:04:20","doi":"10.21203/rs.3.rs-6702006/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"619c3b7f-0693-4c07-a5ac-e66d50d4ae0b","owner":[],"postedDate":"May 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:33:16+00:00","versionOfRecord":{"articleIdentity":"rs-6702006","link":"https://doi.org/10.1007/s40653-026-00852-z","journal":{"identity":"journal-of-child-and-adolescent-trauma","isVorOnly":false,"title":"Journal of Child \u0026 Adolescent Trauma"},"publishedOn":"2026-03-26 16:11:51","publishedOnDateReadable":"March 26th, 2026"},"versionCreatedAt":"2025-05-28 11:04:20","video":"","vorDoi":"10.1007/s40653-026-00852-z","vorDoiUrl":"https://doi.org/10.1007/s40653-026-00852-z","workflowStages":[]},"version":"v1","identity":"rs-6702006","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6702006","identity":"rs-6702006","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}