Culturally And Developmentally Adapting Group Interpersonal Therapy For .
Rose-Clarke et al. BMC Psychology(2020) ARCH ARTICLEOpen AccessCulturally and developmentally adaptinggroup interpersonal therapy foradolescents with depression in rural NepalKelly Rose-Clarke1* , Indira Pradhan2, Pragya Shrestha2, Prakash B.K.2, Jananee Magar2, Nagendra P. Luitel2,Delan Devakumar3, Alexandra Klein Rafaeli4, Kathleen Clougherty5, Brandon A. Kohrt6, Mark J. D. Jordans2,7 andHelen Verdeli5AbstractBackground: Evidence-based interventions are needed to reduce depression among adolescents in low- andmiddle-income countries (LMICs). One approach could be cultural adaptation of psychological therapies developedin high-income countries. We aimed to adapt the World Health Organization’s Group Interpersonal Therapy (IPT)Manual for adolescents with depression in rural Nepal.Methods: We used a participatory, multi-stage adaptation process involving: translation and clinical review of theWHO Manual; desk reviews of adaptations of IPT in LMICs, and literature on child and adolescent mental healthinterventions and interpersonal problems in Nepal; a qualitative study to understand experiences of adolescentdepression and preferences for a community-based psychological intervention including 25 interviews withadolescent boys and girls aged 13–18 with depression, four focus group discussions with adolescents, four withparents/caregivers and two with teachers, six interviews with community health workers and one with arepresentative from a local non-governmental organisation (total of 126 participants); training of IPT trainers andfacilitators and practice IPT groups; and consultation with a youth mental health advisory board. We used theEcological Validity Framework to guide the adaptation process.Results: We made adaptations to optimise treatment delivery and emphasise developmental and cultural aspectsof depression. Key adaptations were: integrating therapy into secondary schools for delivery by school nurses andlay community members; adding components to promote parental engagement including a pre-group sessionwith the adolescent and parent to mobilise parental support; using locally acceptable terms for mental illness suchas udas-chinta (sadness and worry) and man ko samasya (heart-mind problem); framing the intervention as atraining programme to de-stigmatise treatment; and including activities to strengthen relationships between groupmembers. We did not adapt the therapeutic goals of IPT and conserved IPT-specific strategies and techniques,making edits only to the way these were described in the Manual.(Continued on next page)* Correspondence: kelly.rose-clarke@kcl.ac.uk1Department of Global Health and Social Medicine, King’s College London,London WC2B 4BG, UKFull list of author information is available at the end of the article The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver ) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.
Rose-Clarke et al. BMC Psychology(2020) 8:83Page 2 of 15(Continued from previous page)Conclusions: Group IPT can be adapted for adolescents in Nepal and delivered through the education system. Arandomised controlled trial is needed to assess the impact and costs of the intervention in this setting. Futureresearch in LMICs to adapt IPT for adolescents could use this adapted intervention as a starting point.Keywords: Depression, Adolescent, Interpersonal therapy, Nepal, Cultural adaptationBackgroundDepression is a major cause of morbidity among adolescents [1]. Without intervention it can lead to severesocial and educational impairment in the short term,and comorbid chronic disease, further mental healthproblems and reduced earning potential in adulthood[2–5]. Adolescent mental health has been neglected bythe global health agenda and the treatment gap is large,especially in low- and middle-income countries (LMICs)where most adolescents live [5].The World Health Organization (WHO) recommendspsychological therapies as a possible first line treatmentfor depression [6]. Potential therapies are cognitive behaviour therapy, interpersonal therapy (IPT) and familytherapy which have been used in Europe and the US formore than a century [7]. In these countries there is substantial evidence for their effectiveness in clinical andcommunity settings, across different age groups andpopulations [8–11]. More recently psychological therapies have been tested in LMICs and found to be beneficial, though there is a paucity of research among childand adolescent populations [12, 13]. Logistical challengesto delivering therapies in these settings include the lackof trained personnel to refer patients, facilitate therapy,and train and supervise therapists. These challenges havebeen met by training non-specialised health workers andlay people to detect depressive symptoms [14] and deliver psychological therapy [15], and by providing clinicalsupervision via teleconference or online supervision forums [16]. Group-based rather than individual therapiescould also be more cost-effective. Moreover, the WHOpublished a manual for the delivery of IPT by lay facilitators in low-resource community settings using a groupbased approach [17].Aside from the logistical challenges of deliveringtherapies in LMICs, critics have questioned the applicability of psychological therapies developed in so-called“Western” settings, their cultural relevance, and their potential to undermine local healing practices [7]. Twometa-analyses reported that therapies that have beenadapted to the local culture may be more effective thanthose that have not [18, 19], though a third found noevidence for an association between adaptation to thelocal situation and effect size [20]. The level of culturaladaptation can vary from mainly logistical or peripheralmodifications, to deeper changes to core content [21].Common areas for adaptation include language (literaltranslation and the use of colloquial expressions in placeof technical terminology), use of stories, idioms and localsymbols to convey meaning, and integration of localremedies and practices into the therapy [22]. Studieshave adopted a variety of approaches to cultural adaptation, ranging from haphazard, non-empirical methods,to more systematic approaches using a conceptualframework and engaging local practitioners and community members [22–24].There are few detailed descriptions of evidence-basedcultural adaptations of psychological therapies in LMICs,and even fewer describing adaptations for adolescents inthese settings [22, 25]. In this study we conducted thefirst cultural adaption of the WHO Group IPT Manualfor adolescents with depression in Nepal. Using a multistage, participatory process we aimed to adapt groupIPT for a rural population through a scalable and sustainable delivery platform. Here we describe the theoryand methods involved in the process and detail the adaptations made.MethodsResearch was conducted between October 2018 andNovember 2019 and implemented by TransculturalPsychosocial Organization (TPO) Nepal, a nongovernmental organisation (tponepal.org). We obtainedethical approval from the Nepal Health ResearchCouncil and King’s College London Research EthicsCommittee.SettingAdolescents in Nepal are at high risk of depression dueto a complex picture of recent and historical trauma(two major earthquakes in 2015 and a 10-year civil warbetween 1996 and 2006) on a background of socioeconomic deprivation. Mental health services arelimited, and mainly located in secondary and tertiarycare centres in Kathmandu [26]. Specialised child andadolescent mental health services are virtually nonexistent.Our research took place in Sindhupalchowk, a mountainous district on the Nepal-Tibetan border. Most of itspopulation (c.288,000) live in remote villages accessed by
Rose-Clarke et al. BMC Psychology(2020) 8:83underdeveloped roads or on foot. Agriculture is themain source of income. Remittances from internal andinternational labour migrants are also important [27].The main religions are Hinduism (59.0%) and Buddhism(38.0%) [28]. Reflecting the broader national picture, thepopulation in Sindhupalchowk is hierarchical and stratified according to caste/ethnic group. The largest groupis Tamang (34.2%), followed by Chhetri (18.2%), Newar(11.1%) and Brahman (10.3%) [29]. Across the districtaccess to public health facilities is limited: there is onegovernment hospital, three primary health care centresand 76 health posts which are mainly accessible to urbancommunities and those living close to a major road [30].Net enrollment rates for primary, lower secondary andsecondary level school are 95.3, 78.0, and 42.9% respectively; rates are higher among urban compared to ruralpopulations [29]. Sindhupalchowk was one of the districts most severely affected by the 2015 earthquakes:2071 people were reportedly killed and many lost familyand friends as well as their homes, schools and livelihoods [31]. Research conducted in the district followingthe earthquakes found that 40% of adolescents reportedsymptoms of depression [32].Interpersonal therapyIPT is a manualised, time-limited therapy developed inthe US in the 1970s to treat depression [33]. Therapy focuses on addressing difficulties linked to four commonproblems that trigger depression: grief, interpersonal disputes, role transitions and social isolation. IPT has twokey principles: (i) depression is a treatable medical condition and not the patient’s fault; and (ii) there is a reciprocal relationship between depression and interpersonalproblems. Through therapy the patient is taught varioustechniques to help them analyse their interpersonal context, such as linking mood to event and event to moodand understanding how the style and content of communication can affect the outcome of a conversation. Theyare encouraged to use specific strategies to address theirinterpersonal problems. These include adjusting to lifewithout the deceased (grief), appreciating both sides ofan argument (dispute), mourning the loss of an old role(role transition), and changing habits to promote socialengagement (social isolation). IPT was developed as anindividual therapy for depressed adults, to be deliveredby mental health specialists. Since then it has beenadapted for a variety of clinical disorders including posttraumatic stress disorder, bipolar disorder and eatingdisorders. Adaptations for adolescents include schoolbased group therapy for adolescents with subclinical depressive symptoms [34], individual and group-basedinterpersonal psychotherapy for adolescents aged 12 to18 (IPT-A and IPT-AG) [35, 36], and a practical self-Page 3 of 15help guide [37]. IPT has also been adapted for preadolescents aged 7–12 years (Family-Based IPT) [38].We selected IPT for Nepal for several reasons. IPT hasbeen shown to be beneficial for adolescents in otherlow-income country settings [39]. IPT’s focus on interpersonal triggers for depression is particularly relevantduring adolescence when mental illness is often drivenby interpersonal difficulties [11]. Based on previous research in Nepal, IPT is highly compatible with local conceptualisations of identity where people see themselvesas part of a family and community before they see themselves as individuals [40]. Non-specialists can facilitateIPT and, given the dearth of mental health specialists inrural Nepal, task-shifting to non-specialists is essentialfor scalability [39]. IPT can also be delivered in a groupformat. In Nepal, group therapy may be a more culturally appropriate strategy as adolescents, especially girls,are likely to feel more comfortable meeting in a peerenvironment than with unfamiliar adult facilitators in aone-to-one setting.The WHO Group IPT Manual outlines a simplifiedversion of IPT for treating depression among adults [17].Therapy is implemented in groups by supervised nonmental health specialists and comprises nine sessions instead of the usual 12–16 typical of individual and groupIPT for adults and adolescents [41–43]. It involves one90-min pre-group session between the patient andfacilitator, followed by eight 90-min group sessions with6–10 patients, organised into initial, middle and termination group phases. The Manual was developed tocomplement the WHO mental health Gap ActionProgramme (mhGAP), a package of care that aims to increase the availability of treatment for priority mental,neurological and substance use disorders, especially inLMICs [6]. The Manual uses simple language and includes practical exercises and case examples to illustrateIPT techniques and strategies. The brevity and groupformat of the IPT intervention, coupled with the accessibility of the Manual to non-specialists make it a suitablestarting point for the cultural adaptation of IPT in alow-resource setting like Nepal.Cultural adaptation approachVarious theoretical frameworks for cultural adaptationexist [23, 44–47]. We selected the Ecological ValidityFramework because it has been widely used to adaptpsychological therapies including IPT for Puerto Ricanadolescents [48], and in Nepal to guide the adaptation ofProblem Management Plus (PM ) [49]. The Frameworkoutlines eight domains for adaptation: context (thesocio-economic and political environment in whichtherapy occurs), persons (the patient-therapist relationship), treatment goals, methods (how goals areachieved), language, concepts (how mental health
Rose-Clarke et al. BMC Psychology(2020) 8:83problems are conceptualised and communicated),metaphors (concepts and symbols) and content (values,customs and traditions) [45, 50]. We added a ‘developmental’ domain to account for the developmental needsand preferences of adolescents. We made adaptations tothe WHO Group IPT Manual under each of these ninedomains.Our adaptation procedure is outlined in Fig. 1 andincluded the following steps:1. Translation and clinical review of the WHOGroup IPT Manual: A Nepali bilingualpsychosocial counsellor translated the Manual fromEnglish into Nepali. Project clinical supervisorscritically reviewed the translated Manual andidentified potential adaptations under eachadaptation domain.2. Desk review: We conducted three desk reviews.The first aimed to review Nepali anthropologicalliterature pertaining to the four IPT problem areasto understand how these problems are experiencedand conceptualised in Nepali society. We identifiedand extracted data from 10 papers in total. Thesecond sought to establish the evidence base forchild and adolescent mental health interventions inFig. 1 Intervention adaptation processPage 4 of 15Nepal in order to identify components of successfulinterventions which could be relevant for IPT. Weidentified four relevant papers. The last reviewexplored previous IPT interventions in LMICs tounderstand how the therapy had beenimplemented, including the delivery agents, trainingand supervision procedures, therapy structure andmeasures. We identified eight studies using IPT inLMICs. In all reviews, we used key terms (e.g.‘depression’, ‘interpersonal therapy’, ‘adolescents’) tosearch online databases and consulted withmembers of the project team who have publishedextensively in national and international journals onthe topic of mental health in Nepal.3. Qualitative research: We conducted a qualitativestudy to understand experiences of depressionamong adolescents in Sindhupalchowk and toexplore local community perspectives on grouppsychological therapy. Data were transcripts from:25 semi-structured interviews (SSIs) with adolescentboys and girls aged 13–18 with depression; fourfocus group discussions with adolescents aged 11–19, four with parents/caregivers, and two withteachers; six SSIs with community health workersand one with a representative from a local non-
Rose-Clarke et al. BMC Psychology(2020) 8:83governmental organisation (total of 126participants). Participants were identified throughschool teachers or local community stakeholders.Adolescents with depression were those thatscored 14 or more on the Depression Self RatingScale and four or more on a local functionalimpairment tool [51]. Topic guides includedquestions to elucidate feelings, mood andbehaviour related to depression, coping strategies,potential intervention facilitators and barriers,and preferred intervention delivery platforms. SSIand focus groups were conducted in Nepali.Transcripts were transcribed in Nepali thentranslated into English. We used the FrameworkMethod to manage and analyse the data [52]. Wecoded transcripts for deductive codes related toidentifying adolescents, scheduling sessions,involvement of health workers, teachers andparents, obtaining consent, and facilitators andbarriers to participation.4. Training of IPT trainers and trainer practicegroups: Master trainers and authors of the WHOGroup IPT Manual HV and KC led a programmeto train clinical supervisors and 12 other localpsychosocial counsellors, psychologists and mentalhealth researchers. Training was competency-basedand followed the apprenticeship model codeveloped by HV and KC and elaborated elsewhere[53]. It included four two-hour sessions by videoconference and 4 days in person covering IPTprinciples, techniques and strategies, interventionstructure and risk management. After this weconducted a focus group to gather feedback on thetraining, the content of IPT, and its appropriatenessfor adolescents in Nepal. Clinical supervisorsconducted three practice IPT groups and nineindividual cases. Master trainers provided twiceweekly supervision via teleconference. Weinterviewed clinical supervisors to explore theirexperiences of training in and conducting IPT.5. Read-through workshop with the project team:We held a workshop in Kathmandu for members ofthe project team during which we reviewed findingsfrom Steps 1 to 4 and proposed changes to theManual based on these findings.6. Training of IPT facilitators and facilitatorpractice groups: Clinical supervisors trained IPTfacilitators in Sindhupalchowk. In pairs, facilitatorsled practice groups with four to seven adolescents,supervised on a weekly basis by the clinicalsupervisors. We ran two focus group discussionswith facilitators to explore key challenges ofdelivering IPT in Sindhupalchowk andrecommendations for further adaptation.Page 5 of 157. Youth consultation: TPO Nepal regularly convenesa Nepali youth mental health advisory board toprovide feedback on organisational programmes.We invited board members aged 20 and younger toa consultation about IPT. To ensure representationof younger adolescents we also invited twoadolescents through TPO Nepal staff members.Two males and three females aged 13 to 20participated in the consultation, three of whom hadlived experience of depression. We sought theiropinions on how to describe IPT to adolescents andthe wider community, and how to address issuesrelated to confidentiality, absenteeism, and parents’concerns about the therapy.We proposed further changes to the Manual based onevidence from Steps 6 and 7. Adaptations were thenshared among the project team for review and incorporated into a final version of the Manual.ResultsWe made a total of 152 adaptations to the WHO GroupIPT Manual. The largest number of changes were underthe methods domain (n 45), and the least under concepts(n 7), goals (n 7) and metaphors (n 7). Changes weremainly adaptations to optimise treatment delivery, or to emphasise developmental and cultural aspects of depression.We did not adapt the goals of IPT beyond clarifying theaims of each phase. We conserved IPT strategies and techniques, making edits only to the way these were emphasisedor explained in the Manual. Key examples of adaptationsunder each domain are described below and in Table 1.Context: enhancing accessibility, feasibility, acceptabilityand complianceWe adapted the therapy for delivery through the government secondary school system for several reasons. First, inthe qualitative study parents told us that they were morelikely to be supportive and trusting of an intervention delivered through schools, especially if it was perceived tosupport their children’s education. In-school adolescentssaid it would be easy for them to attend sessions at schoolbecause it is where they spend most of their time, and outof school adolescents said they felt comfortable attendingsessions in schools. Second, delivering the interventionthrough schools is potentially de-stigmatising as adolescents do not have to visit mental health services to obtaintreatment. Third, the education system is a potential wayto scale up IPT across Nepal and previous mental healthinterventions have been successfully delivered throughschools in this setting [54, 55].Through the qualitative study we obtained informationabout adolescents’ preferences concerning the composition of groups. They felt that groups should be single
Rose-Clarke et al. BMC Psychology(2020) 8:83Page 6 of 15Table 1 Key adaptations to group interpersonal therapy using the Ecological Validity FrameworkDomainDescriptionExamples of adaptationsRationale (and evidence base)ContextIncrease accessibility; enhance feasibility,acceptability and complianceIntegrate group IPT into the governmentsecondary education system.Parents are more likely to trust anintervention if it is linked to their children’sschool. There are also private roomsavailable in schools to hold the sessions,and supportive staff to help organisesessions and recruit adolescents. Mostadolescents in the study area are in schooland so it will be convenient for them toattend. Out of school adolescents saidthey do not have a problem attendingsessions held in schools. (Qualitative study)In rural Nepal there are more schools thanhealth posts. Locating the intervention ingovernment schools ensures an equitableand sustainable delivery platform, andavoids potential stigma associated withvisiting health services for treatment.Previous mental health interventions inNepal have been successfully deliveredthrough schools. (Desk review)Groups should be single gender but caninclude adolescents from different caste/ethnic groups, and younger and older, inand out of school, and married andunmarried adolescents. The preferredgroup size is six to 10.Group composition: Adolescents feelembarrassed to talk about heart-mindproblems in front of members of othergenders but are comfortable to joingroups with adolescents from differentsocio-economic backgrounds. (Qualitativestudy)Group size: A group of six to 10adolescents is large enough for someadolescents to be absent from sessionswithout leaving those attending feelingexposed. It is also manageable for twofacilitators. (Trainer practice groups) Thisnumber is in line with the WHO Group IPTManual and an adaptation of group IPT foradolescents in Uganda. (Desk review)PersonsGoalsEngaging non-mental health professionalsand promoting the therapist-patientrelationshipClarifying and extending goals; identifyinggoals relevant to adolescents in NepalDevelopmental Accounting for abrupt changes in mentalstate and high reactivity amongadolescents; engaging parents andcaregivers; ensuring content is relevant foradolescent age groupRecruit and train school nurses to facilitate The One School, One Nurse governmentIPT. Male facilitators will also be recruitedpolicy seeks to appoint a nurse at everyfrom the local community.government school. The role of thesenurses could be expanded to includefacilitation of IPT groups. In Nepal mostnurses are female however, adolescentsprefer a facilitator of the same genderhence male facilitators must also berecruited from the local community.(Qualitative study)Facilitators work in pairsTwo facilitators are needed to manage thedocuments and assessments and ensureall session content is covered. (Trainer andfacilitator practice groups)Include aims for each phase of groupsessions (Table 2)Aims are missing from the WHO Manualand it would be helpful to clarify these tofocus the sessions and support facilitators.(Read-through and workshop with theproject team)Include a second pre-group session withthe adolescent and their parent/caregiver,ideally at the adolescent’s home. The session will use a strengths-based approachand take on the following structure: describe group IPT as a life skills programme,explain how will it help and state that itdoes not involve money, tuition or medical care; highlight the importance of confidentiality and that the adolescent willParents were anxious about what washappening in the groups, unaware of thepotential benefits, and not supportingtheir children to attend. Engaging parentsearly in the intervention will help tomobilise their support and reassure them.(Trainer practice groups)
Rose-Clarke et al. BMC Psychology(2020) 8:83Page 7 of 15Table 1 Key adaptations to group interpersonal therapy using the Ecological Validity Framework (Continued)DomainDescriptionExamples of adaptationsRationale (and evidence base)not be able to discuss problems thatothers bring to the group with membersof their family; obtain permission for theadolescent’s participation in the group; describe how the parent or caregiver cansupport the adolescent.Chapter 4, Middle group phase: Include aAbsenteeism can be an issue if the parentsecond meeting with parents or caregivers is not supportive of the adolescent’sif the adolescent is absent for twoparticipation. (Facilitator practice groups)consecutive group sessions. The aims ofthe meeting are to identify the barrier toadolescents attending sessions and towork together to find a solution.Chapter 4, Middle group phase: Addition of Adolescents had difficulty expressing theirthe Bhitri-Bahiri Bhawana (meaning inside/ emotions during group sessions.outside feelings) technique which prompts (Facilitator practice groups)adolescents to differentiate between thefeelings they project to others and their‘true’ inner feelings.Chapter 4, Middle group phase: In the thirdgroup session each group member shoulddevelop a severe distress safety plan akinto a suicide safety plan. Facilitators shouldbe reminded that suicide may be one ofthe first topics they have to discuss,possibly even in the pre-group sessions.Due to potential abrupt changes in themental state of adolescents, suicidalitymay present suddenly and adolescentsshould have a plan in place to help themmanage such thoughts. Completing asevere distress safety plan as a groupactivity will help to ensure that all groupmembers understand and are prepared.(Training of trainers)Chapter 5, Strategies for disputes: The WHOManual describes three stages of disputes:still negotiating, being stuck or ending therelationship. Where it is desirable for arelationship to end, the individual isencouraged to end it, mourn and moveon. Among adolescents we should expandthe definition of ‘ending the relationship’to include shifting the caring responsibility(e.g. from a parent to an aunt) andaccepting the situation and finding copingstrategies.Ending the relationship betweenadolescents and their parents may not bepossible or appropriate, and othersolutions are required. (Read-through andworkshop with the project team)Chapter 5, Strategies for disputes: Add aManaging anger is one of the mainstrategy to help adolescents managebarriers adolescents face when trying toanger. Ask the participant what they doresolve disputes (Trainer practice groups)when they are angry. Explain that anger isa natural emotion. Ask the participant iftheir anger had a positive or a negativeeffect. If negative, ask the group membersfor tips about how the participant canmanage their anger so that it has apositive effect. Use role-play to practiceanger management. The Gestalt EmptyChair Technique can also be used. This involves participants imagining the personwith whom they have a conflict and thinking about what they would say to them.LanguageEnsuring translation is harmonious withNepali language; use of local idioms ofdepression; replacement of technicalterms with colloquialismsThroughout the Manual, change the worddepression to udas-chinta. Introduce udaschinta as one type of heart-mind problem.Although some adolescents understandthe term depression, udas-chinta (meaningsadness-worry) is preferred because it: i) isNepali, (ii) reflects the high prevalence ofdepression/anxiety comorbidity in thispopulation, (iii) parents may link anxiety tothe upcoming school exams and be morelikely to support adolescents’ attendance.Heart-mind problem is a local, nonstigmatising term for psychosocial
Rose-Clarke et al. BMC Psychology(2020) 8:83Page 8 of 15Table 1 Key adaptations to group interpersonal therapy using the Ecological Validity Framework (Continued)DomainDescriptionExamples of adaptationsRationale (and evidence base)problems. (Qualitative study)ConceptsMethodsUsing Nepali concepts of mental ill health,including somatic, social and religiousconcepts; addressing locally relevantstressorsPromoting adolescent engagement;adapting the intervention structure;adapting how depression is monitored;adapting IPT techniques and strategiesChapte
based group therapy for adolescents with subclinical de-pressive symptoms [34], individual and group-based interpersonal psychotherapy for adolescents aged 12 to 18 (IPT-A and IPT-AG) [35, 36], and a practical self-help guide [37]. IPT has also been adapted for pre-adolescents aged 7-12years (Family-Based IPT) [38].
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