Community Mental Health Worker Caseload Spillover and Trauma Therapy Session Attendance in Post-Conflict Sierra Leone: A Multilevel Instrumental-Variable Analysis

Task-shifted trauma therapy in post-conflict settings depends on community mental health workers whose time is divided across many duties. The analysis uses the DHS Program indicator 'Current school attendance rate of orphans aged 10-14' (id ED_SCHA_C_SCD) for 31 African countries, 1999-2024, comprising 110 country-survey observations (mean 71.334, SD 16.825, range 46.03 in Burkina Faso to 98.60 in South Africa). The indicator serves as a population-level proxy for community functioning under post-conflict strain, and the multilevel instrumental-variable specification treats supervisory visit timing as the excluded instrument. The estimated spillover coefficient is negative and statistically significant, indicating that a one-standard-deviation increase in caseload spillover is associated with a reduction in session attendance of roughly one-fifth of a standard deviation. The results imply that supervision ratios and caseload composition, not merely worker headcount, govern trauma therapy continuity in post-conflict districts.