The systematic review is registered with Prospective Register of Systematic Reviews (PROSPERO), CRD42020181638. Article selection will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Additional file 1) [30].
Literature search
A literature search of articles published between 1980 and June 2020 will be conducted on PubMed, PsychInfo, EMBASE and Cochrane Register of Controlled Trials electronic databases. The review will include studies from 1980 as this is the first time PTSD was described [31]. A search for grey literature will be conducted by searching for abstracts of conferences for relevant studies. Reference lists of included articles will be screened for relevant articles. The ClinicalTrials.gov website will also be checked for relevant studies.
Search terms:
PTSD OR posttrauma* OR post-trauma* OR post trauma* OR combat
OR disorder*
AND interventions OR *therapy OR psychotherapy
AND Sub-Saharan Africa OR Angola OR Benin OR Botswana OR Burkina Faso OR Burundi OR Cameroon OR Cape Verde Or Central African Republic OR Chad OR Comoros OR Congo OR Côte d'Ivoire OR Djibouti OR Guinea OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mauritius OR Mauritania OR Mozambique OR Namibia OR Niger OR Nigeria OR Réunion OR Rwanda OR Sao Tome and Principe OR Senegal OR Seychelles OR Sierra Leone OR Somalia OR South Africa OR Sudan OR Swaziland OR Tanzania OR Togo OR Uganda OR Sahara OR Zambia OR Zimbabwe.
Study eligibility criteria: The review will include all RCTs of psychological interventions for PTSD in populations in SSA. Eligible studies in all languages will be included.
Population: Studies will be included if they have participants aged 18 years and above and diagnosed with PTSD as a primary diagnosis according to DSM or ICD criteria. PTSD diagnosis will be considered if structured clinical interviews are used to make the diagnosis. This will include the use of PTSD diagnostic tools such as the Clinician-Administered PTSD Scale (CAPS), PTSD Symptom Scale Interview (PSS-I), Mini-International Neuropsychiatric Interview (MINI), and the Structured Clinical interview for DSM (SCID) [32-34].
Intervention: Studies on any psychological interventions found will be included in the review, these will include and not be limited to trauma-based interventions, cognitive based interventions, EMDR and relaxation-based interventions. The review will include individual and group administered psychological interventions.
Comparison: Studies with comparator groups such as treatment as usual, wait-listed groups or groups that have received other psychological therapies will be included.
Outcome: The primary outcome measure will be a reduction in PTSD symptoms (measured by a valid instrument). Point measure of the PTSD scores will be used. Secondary outcome measures will include dropout rates, other psychiatric comorbidities such as associated depression or substance use disorders, level of functioning, quality of life, as well as the level of training of individuals administering intervention.
Comorbidities: Participants with other comorbidities will be included in the study, as long as the interventions in question target PTSD symptomatology and not comorbidities.
Timing of outcome measures: Outcome measures will be assessed at period immediately after intervention, at one to 3 months, four to six months, six to 12 months and over 12 months after intervention.
Data collection
Study selection: A pilot database search has been conducted and the results can be found in Table 1. Articles obtained from the electronic search conducted by the lead author (VN) will be exported to an EndNote X9 library. Duplicates will be removed from the library and it will be shared with the second reviewer (KM). The two reviewers will independently read all abstracts of articles identified during the literature search, to identify abstracts potentially meeting inclusion criteria. Thereafter, full text articles of included abstracts will be screened for final inclusion in the study. Articles where reviewer discrepancies are found will be re-evaluated and a third reviewer (SM) will help reach a consensus.
Table 1
Keyword search
|
Date of search
|
Search engine used
|
Number of publications retrieved
|
((PTSD OR posttrauma* OR post-trauma* OR post trauma* OR combat OR disorder*[MeSH Terms]) AND (interventions OR *therapy OR psychotherapy[MeSH Terms])) AND (Sub-Saharan Africa OR Angola OR Benin OR Botswana OR Burkina Faso OR Burundi OR Cameroon OR Cape Verde Or Central African Republic OR Chad OR Comoros OR Congo OR Côte d'Ivoire OR Djibouti OR Guinea OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mauritius OR Mauritania OR Mozambique OR Namibia OR Niger OR Nigeria OR Réunion OR Rwanda OR Sao Tome and Principe OR Senegal OR Seychelles OR Sierra Leone OR Somalia OR South Africa OR Sudan OR Swaziland OR Tanzania OR Togo OR Uganda OR Sahara OR Zambia OR Zimbabwe) Filters: from 1980/1/31–2020/6/30
|
26 September 2020
|
PubMed
|
2285
|
Data extraction: Data from included studies will be extracted in duplicate by the reviewers onto Review Manager 5 Software (RevMan5). Data extracted will include participant demographic information, type of population (immigrants versus general population), urban versus rural, type of trauma, randomisation procedure, psychological intervention type and duration, information on outcomes and sources of funding. Authors will be contacted for missing information.
Critical appraisal of selected studies: The two reviewers will independently assess if the studies are reported according to the CONSORT Statement for Reporting Randomized Trials [35]
Data analysis: Review Manager Version 5 software will be used for pooled effect estimates where possible. Risk of publication bias assessment based on PTSD symptoms will be conducted using a funnel plot, where asymmetry of the plot may be indicative of bias. Individual studies will be assessed for selection bias by assessing how intervention allocation was conducted, information bias by assessing if outcome assessors were blinded, and if analysis was biased by assessing if intention to treat analysis was used. Data will be pooled where suitable and analysed for summary effects. Comparisons will be made between outcome measures (dependent variables) in the group that received the intervention (independent variable) and that did not. For dichotomous data such as PTSD present or not present at the end of the intervention, or response or no response to treatment, effect sizes will be calculated as the odds ratios. For continuous data such as PTSD scores, level of functioning and quality of life scores, mean differences between the intervention and control or wait listed groups will be calculated. Standardised mean differences will be calculated will be calculated where different measures or tools are used to measure outcomes. For crossover trials, data will be extracted from the first treatment period. Sub-analysis comparing the different kinds of interventions, mild versus severe PTSD, comorbid psychiatric conditions versus no comorbid condition will be conducted. Random effects meta-analysis and inverse variance weighting methods will be used to account for expected heterogeneity of included studies. A narrative description of studies and findings will also be undertaken. Interventions with similar core components or similar population groups will be pooled together to make informative clinical inferences. Sensitivity analysis will be conducted by conducting statistical tests with and without studies that may not meet the minimum criteria for risk of bias, and tests with and without grey literature. If findings remain consistent, then robustness of the findings will be assured, if findings change with exclusion of certain studies, then risk of reporting bias will be considered. Overall, the level of evidence for this review will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) [36]. The a priori level of evidence is high as the review will include only randomised controlled trials, but the ultimate quality will depend on other findings such as effect size and risk of bias assessment.