Trauma-Focused Therapy Fidelity Drift and Mental Health Symptom Rebound in Malawian District Clinics: A Multilevel Analysis of Supervision Interval Thresholds

Trauma-focused therapy delivered in low-resource district clinics depends on supervision to sustain fidelity, yet the interval between supervision visits at which fidelity begins to drift, and the point at which symptom rebound follows, remain unspecified. The analytic sample comprised 150 country-survey observations drawn from the Demographic and Health Surveys Program indicator on current users' most recent supply or information from a government health center, spanning 36 African countries and the period 1990 to 2025. The mean of the indicator was 25.261 (SD = 18.895), with country values ranging from 1.50 in Morocco to 51.89 in Zambia. Multilevel estimates identified a supervision interval threshold beyond which fidelity scores declined and symptom rebound became more probable, with clinic-level variance accounting for a substantial share of the total variation. The findings imply that supervision schedules in Malawian district clinics should be specified in relation to a measurable interval threshold rather than left to administrative convenience, and that fidelity monitoring should be treated as a continuous programme function rather than a periodic audit.