Sierra Leone's child soldiers: war exposures and mental health problems by gender

Integrating Youth Readiness Intervention and Entrepreneurship in Sierra Leone: A Hybrid Type II Cluster Randomized Trial

OBJECTIVE

Conflict-affected youth are at risk for poor psychological and social outcomes, yet few receive mental health services. Strategies to expand access and sustain evidence-based interventions (EBIs) across novel delivery platforms must be tested. The present study was a hybrid type II implementation-effectiveness trial using a cluster randomized design. The primary goal was to evaluate feasibility and impact of using the collaborative team approach to deliver the Youth Readiness Intervention (YRI), an EBI, integrated into a youth entrepreneurship program (ENTR) with quality control in post-conflict Sierra Leone.

METHOD

Youth were screened and randomly assigned to control, ENTR, or combined YRI and ENTR (YRI+ENTR). Implementation outcomes were dissemination and implementation indicators, competence, and fidelity. Effectiveness outcomes were emotion regulation, psychological distress, and interpersonal functioning. Secondary outcomes were third-party reporter assessments of youth functioning and behavior.

RESULTS

Data were collected and analyzed from 1,151 youth participants and 528 third-party reporters. Scores on implementation constructs, competence, and fidelity demonstrated acceptable intervention response and quality. YRI+ENTR participants showed overall improvements in depression (β = -.081, 95% CI -0.124 to -0.038, d = -0.154) and anxiety (β = -.043, 95% CI -0.091 to -0.005, d = 0.082) symptoms compared with control participants. Community leaders indicated that YRI+ENTR participants demonstrated improvements in overall work or training performance compared with control participants (β = -.114, 95% CI 0.004 to 0.232, d = 0.374).

CONCLUSION

Integration of EBIs such as the YRI into youth employment programs has the potential to address limited reach of EBIs in conflict and post-conflict settings. A collaborative team implementation approach can facilitate integration and fidelity.

PLAIN LANGUAGE SUMMARY

In a Hybrid Type-II Implementation-Effectiveness trial conducted in Sierra Leone, researchers tested a Collaborative Team Approach (CTA) for delivering an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), within a youth entrepreneurship program. A total of 1,151 youth participated in the study, with outcomes measured on youth mental health indicators of emotional regulation, psychological distress, and interpersonal functioning, as well as implementation indicators, competence, and fidelity. Results demonstrated that the integrated YRI and entrepreneurship program led to significant improvements in depression and anxiety symptoms compared to the control group. Community leaders also noted enhanced overall performance in YRI participants, suggesting that integrating evidence-based interventions into youth employment programs can effectively address mental health challenges in low-resource regions.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. One or more of the authors of this paper received support from a program designed to increase minority representation in science.

CLINICAL TRIAL REGISTRATION INFORMATION

Youth FORWARD Phase 2 YRI and EPP Study; https://clinicaltrials.gov/; NCT03542500.

STUDY PREREGISTRATION INFORMATION

Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol; https://doi.org/10.1176/appi.ps.202000009.

Community voices on alcohol harm in Sierra Leone: Perceptions of prevention needs

Objective

The research purpose is to determine alcohol prevention needs in Sierra Leone.

Methods

We analyzed a cross-sectional survey from fall 2020, distributed by the West African Alcohol Policy Alliance to their partners across nine West African countries. The survey included questions on perceptions of alcohol harm, research priorities, and capacity and reach of the organizations represented. Only participants from Sierra Leone were included (n = 33).

Results

When asked if they thought measures taken to prevent alcohol-related harm in their country have been adequate, 66% answered inadequate (n = 32). Asked if heavy drinking of commercial alcohol is a concern in their community, 96% said yes (n = 25), and 92% said heavy drinking of traditional brew or distilled spirits is a concern in their community (n = 24). Finally, 91% said that their organization would be interested in implementing an alcohol counter-marketing campaign (n = 23).

Conclusions

Based on the perception of survey participants, efforts to prevent alcohol-related harm thus far are inadequate in Sierra Leone where heavy drinking is a critical concern. CBOs and NGOs already engaged in alcohol harm prevention are eager to support and adopt new strategies.

Innovation

This is the first research to seek direct input from CBOS and NGOs about alcohol harm prevention in Sierra Leone.

Navigating the Tension between Fatherhood Ideals and Realities of a Post-Conflict Setting: A Phenomenological Study of Former Child Soldiers in Sierra Leone

The concept of "fatherhood" in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and responses to recent crises such as the Ebola pandemic and the aftermath of a civil war. Very little is understood about how male former children associated with armed forces and armed groups (CAAFAG) are navigating fatherhood and understanding their roles as fathers, particularly as many have grown up without fathers or parents themselves and experienced violence. Our study builds upon previous ethnographic research in Sierra Leone, and uses a phenomenological approach to understand 1) the meaning and importance of fatherhood to former child soldiers in Sierra Leone, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care as well as violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG fathers in Sierra Leone are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially. CAAFAG fathers experienced the greatest tension between their ideals of fatherhood and their socio-economic circumstances in terms of financial support, such as paying school fees. In other words, fathers felt inhibited in becoming the types of fathers they hoped to be due to their experiences in a post-conflict, resource-constrained environment.

International humanitarian law violations in northern Uganda: victims' health, policy, and programming implications

Experience of serious violations of International Humanitarian Law (IHL) results in complex physical disability and psychosocial trauma amplifying poverty and multi-generational trauma and impeding long-term recovery. We use data from a representative sample of victims in the case Prosecutor V. Dominic Ongwen brought before the International Criminal Court. Thirteen years after the 2004 massacre, the victims were significantly worse off than the general war-affected population that did not experience serious violations of IHL. The differences in health and wellbeing persisted for individuals and their households, including children born after the massacre. The victims have significantly lower availability of appropriate health services and medications, including significantly greater distance to travel to these services. These findings call attention to the needs of people having experienced IHL violations, for provision of physical and emotional trauma care to allow for recovery, and better understanding of the short- and long-term impacts of IHL violations.

Area level indirect exposure to extended conflicts and early childhood anthropometric outcomes in India: a repeat cross-sectional analysis

BACKGROUND

Protracted, internal conflicts with geographic variations within countries, are an important understudied community exposure for adverse child health outcomes.

METHODS

Violent events from the Uppsala Conflict Data Program (UCDP) between January 2016-December 2020 and January 2010-December 2015, were included as exposure events for children sampled in National Family Health Surveys (NFHS) 5 (2019-21) and NFHS 4 (2015-16), respectively. Geocoded data from UCDP were merged with residential clusters from NFHS, to identify children living in villages or urban blocks situated at <= 50 km from conflict sites. Within these clusters, which we defined as conflict exposed, we studied risks of stunting, underweight and wasting in children, prenatally, and in 0-3 years. We assessed sensitivity on a subsample of siblings with discordant conflict exposures.

RESULTS

For NFHS 5, exposure to violence between 0 and 3 years was associated with 1.16 times (95% CI 1.11-1.20) higher risks of stunting, 1.08 (1.04, 1.12) times higher risks of underweight, and no change in wasting. In-utero violence exposure was associated with 1.11 times (95% CI 1.04-1.17) higher risks of stunting, 1.08 (95% CI 1.02-1.14) times higher risks of underweight, and no change in wasting, among children <= 2 years. In 17,760 siblings of 8333 mothers, exposure to violence during 0-3 years, was associated with a 1.19 times higher risk of stunting (95% CI - 0.24 to 0.084). Incremental quartiles of violence exposure had higher risks of stunting and underweight until quartile 3.

CONCLUSION

In-utero and early childhood indirect exposure to protracted conflicts were associated with increased stunting and underweight in India. Given the continued exposures of such historically and contextually rooted internal conflicts in many LMICs, chronic violence exposures should be targeted in public health policies as important social and political determinant of child health.

The role of violence perpetration in driving externalizing problems and offending behavior among youth from eastern Democratic Republic of Congo

Youth in conflict-affected regions are exposed to a multitude of traumatic events. These individuals often witness violence; experience it firsthand; and, in some cases, become perpetrators. The interplay of events shapes systematic trauma histories that may have unique implications for youths' mental health. In a cross-sectional study conducted in eastern Democratic Republic of Congo (DRC), we interviewed 295 war-affected youth (63.4% boys, M_age = 16.70 years), including former child soldiers (n = 171), regarding their traumatic experiences and mental health. Using latent class analysis, we identified four common trauma history classes categorized by (a) low exposure, (b) medium exposure, (c) high exposure, and (d) high exposure/perpetration. Across the sample, gradual increases in trauma load corresponded with increased vulnerability to posttraumatic stress disorder (PTSD) symptoms, η_p ² = .36, and internalizing problems, η_p ² = .12; however, only youth from the high exposure/perpetration class differed significantly from other youth in their levels of externalizing problems, η_p ² = .13, and offending behaviors, η_p ² = .17. A longer time in armed groups was related to a higher risk of both experiencing and perpetrating violence. The results indicate that it is not child soldier status, per se, but the perpetration of violence that reinforces a cycle of violence in conflict-affected societies by contributing to increased externalizing problems and offending behaviors. In conflict regions, integrated approaches are needed to address both trauma and externalizing problems of war-affected youth.

Mental health problems among children in Sierra Leone: Assessing cultural concepts of distress

Globally, over 13% of children and adolescents are affected by mental disorders, yet relatively little scholarship addresses how risk factors, symptoms, and nosology vary by culture and context, especially in young children living in post-conflict and low-resource settings. To address this gap, we conducted a qualitative study to identify and describe the most salient mental health problems facing children aged 6 to 10 years in Sierra Leone, as well as the thoughts, feelings, and behaviors related to these problems. Free list interviews (N = 200) and semi-structured interviews (N = 66) were conducted among caregivers, children, and other relevant key informants to explore risk factors and locally meaningful concepts of distress. Our findings indicate that children are faced with a variety of challenges in their social environments that contribute to distress, including hunger, unmet material needs, and excessive work. Our research identifies five contextually defined mental health problems faced by young children: gbos gbos (angry, destructive behavior), poil at (sad, disruptive behavior), diskoraj (sad, withdrawn), wondri (excessive worry), and fred fred (abnormal fear). The manifestations of these distress concepts are described in detail and contextualized according to Sierra Leone's history of war and current backdrop of poverty and insecurity. Implications are discussed for locally relevant diagnosis and treatment as well as for the wider literature on global child mental health.

Alternate delivery platforms and implementation models for bringing evidence-based behavioral interventions to scale for youth facing adversity: a case study in West Africa

BACKGROUND

Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD) was launched as an implementation science collaboration focused on scaling out evidence-based mental health interventions for youth exposed to war and other adversities through novel delivery platforms. This implementation science case study examines the use of a collaborative team approach (CTA) as a scale-out strategy to foster the integration of an evidence-based group mental health intervention, the Youth Readiness Intervention, into youth employment programs tied to regional economic development in Sierra Leone.

METHODS

A case study methodology is used to explore the feasibility and acceptability of integrating an evidence-based intervention, the Youth Readiness Intervention (YRI), into youth entrepreneurship programs (ENTR) in Sierra Leone, facilitated by the CTA. The authors analyzed field notes logged during program implementation, 8 weeks of supervision notes, 20 interviews with agency leaders and front-line staff delivering the YRI within this alternate delivery platform. Quantitative dissemination and implementation interviews administered to youth, facilitators, and agency leaders were analyzed using descriptive statistics and mixed linear models. A linked Hybrid Type II effectiveness-implementation cluster randomized trial is evaluating the clinical effectiveness of the YRI within this delivery platform.

RESULTS

Extant data indicate the strong feasibility and acceptability of integrating the YRI into the ENTR program. Facilitators of integration of the YRI into the ENTR include mission alignment of the organizations with the delivery of psychosocial interventions, shared commitment to serving vulnerable youth, support from local District Youth Councils, and high interest from the youth served. Barriers include perceived competition between frontline organizations seeking funding for psychosocial interventions, and challenges in flexibility between donors and implementation partners operating in a fragile/post-conflict setting. The CTA was a feasible and acceptable strategy to support fidelity and quality improvement while scaling out the YRI.

CONCLUSIONS

Youth entrepreneurship and livelihood programs offer a promising mechanism for expanding the reach of evidence-based interventions to youth in fragile and post-conflict settings. Quality improvement and sustainment of evidence-based interventions are novel concepts in such settings. The CTA strategy institutionalizes the integration of an evidence-based intervention into youth entrepreneurship programs.

TRIAL REGISTRATION

NCT03603613 (phase 1 pilot, registered May 18, 2018) and NCT03542500 (phase 2 scale-out study, registered May 18, 2018).

Fear, distress, and perceived risk shape stigma toward Ebola survivors: a prospective longitudinal study

Background

During the 2014–15 Ebola Virus Disease (EVD) epidemic, thousands of people in Sierra Leone were infected with the devastating virus and survived. Years after the epidemic was declared over, stigma toward EVD survivors and others affected by the virus is still a major concern, but little is known about the factors that influence stigma toward survivors. This study examines how key personal and ecological factors predicted EVD-related stigma at the height of the 2014–2015 epidemic in Sierra Leone, and the personal and ecological factors that shaped changes in stigma over time.

Methods

Using three waves of survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines factors associated with self-reported personal stigma toward Ebola survivors (11 items, α = 0.77) among 1008 adults (74.6% retention rate) from 63 census enumeration areas of the Western Rural and Western Urban districts of Sierra Leone. Participants were randomly sampled at the height of the EVD epidemic and followed up as the epidemic was waning and once the epidemic had been declared over by the WHO. Three-level mixed effects models were fit using Stata 16 SE to examine cross-sectional associations as well as predictors of longitudinal changes in stigma toward EVD survivors.

Results

At the height of the EVD epidemic, female sex, household wealth, post-traumatic stress, EVD-related fear and perceived infection risk are a few of the factors which predicted higher levels of stigma toward survivors. On average, stigma toward EVD survivors decreased significantly as the epidemic declined in Sierra Leone, but female sex, EVD fear, and risk perceptions predicted a slower rate of change.

Conclusion

This study identified key individual and psychosocial characteristics which may predict higher levels of stigma toward infectious disease survivors. Future studies should pursue a better understanding of how personal characteristics and perceptions, including psychosocial distress, fear, and perceived infection risk serve as pathways for stigma in communities affected by infectious disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12146-0.

Mental health of women and children experiencing family violence in conflict settings: a mixed methods systematic review

BACKGROUND

Armed conflict has significant impacts on individuals and families living in conflict-affected settings globally. Scholars working to prevent violence within families have hypothesised that experiencing armed conflict leads to an increase in family violence and mental health problems. In this review, we assessed the prevalence of family violence in conflict settings, its association with the mental health of survivors, moderating factors, and the importance of gender relations.

METHODS

Following PRISMA guidelines, we systematically reviewed quantitative and qualitative studies that assessed the prevalence of family violence and the association between family violence and mental health problems, within conflict settings (PROSPERO reference CRD42018114443).

RESULTS

We identified 2605 records, from which 174 full text articles were screened. Twenty-nine studies that reported family violence during or up to 10 years after conflict were eligible for inclusion. Twenty one studies were quantitative, measuring prevalence and association between family violence and mental health problems. The studies were generally of high quality and all reported high prevalence of violence. The prevalence of violence against women was mostly in the range of 30-40%, the highest reported prevalence of physical abuse being 78.9% in Bosnia and Herzegovina. For violence against children, over three-quarters had ever experienced violence, the highest prevalence being 95.6% in Sri Lanka. Associations were found with a number of mental health problems, particularly post-traumatic stress disorder. The risk varied in different locations. Eight qualitative studies showed how men's experience of conflict, including financial stresses, contributes to their perpetration of family violence.

CONCLUSIONS

Family violence was common in conflict settings and was associated with mental health outcomes, but the studies were too heterogenous to determine whether prevalence or risk was greater than in non-conflict settings. The review highlights an urgent need for more robust data on perpetrators, forms of family violence, and mental health outcomes in conflict-affected settings in order to help understand the magnitude of the problem and identify potential solutions to address it.

Classifying childhood war trauma exposure: latent profile analyses of Sierra Leone's former child soldiers

BACKGROUND

Former child soldiers are at elevated risk for mental health problems (e.g., traumatic stress, emotion dysregulation, and internalizing and externalizing problems). To examine which groups of former child soldiers are more likely to have difficulties with emotion regulation, interpersonal relationships, and mental health postconflict, we explored patterns of war trauma exposure and their effects on subsequent mental health problems among former child soldiers in Sierra Leone.

METHODS

Participants were 415 (23.86% female) Sierra Leonean former child soldiers participating in a 15-year, four-wave longitudinal study. At T1 (2002), 282 former child soldiers (aged 10-17) were recruited. T2 (2004) included 186 participants from T1 and an additional cohort of self-reintegrated former child soldiers (NT2 = 132). T3 (2008) and T4 (2016/2017) participants were youth enrolled in previous waves (NT3 = 315; NT4 = 364). Latent profile analysis (LPA) was used to classify participants based on the first-time reports of eight forms of war exposure (separation and loss of assets, parental loss, loss of loved ones, witnessing violence, victimization, perpetrating violence, noncombat activities, and deprivation). ANOVA examined whether patterns of war exposure were associated with sociodemographic characteristics and mental health outcomes between T1 and T4.

RESULTS

LPA identified two profiles: higher exposure versus lower exposure, using cumulative scores of eight forms of war-related trauma exposure. The 'higher war exposure' group comprised 226 (54.5%) former child soldiers and the 'lower war exposure' group included 189 (45.5%). Significantly higher levels of violence-related and combat experiences characterized the group exposed to more traumatic events. The 'higher war exposure' group reported more PTSD symptoms at T2, more hyperarousal symptoms across all waves, and more difficulties in emotion regulation at T4.

CONCLUSIONS

Former child soldiers exposed to higher levels of war-related traumatic events and loss should be prioritized for mental health services immediately postconflict and as they transition into adulthood.

Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol

BACKGROUND

This article describes the incorporation of an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), into a youth entrepreneurship training program in Sierra Leone. A collaborative team approach (CTA) was used as the implementation strategy to address the human resource shortage and related challenges associated with capacity and access to care.

METHODS

A cluster randomized quasi-experimental pilot trial (N=175) was conducted in one rural district of Sierra Leone. Pilot data assessed implementation feasibility and clinical effectiveness when using a CTA. A larger hybrid type-2 effectiveness-implementation cluster randomized trial is underway (N=1,151) in three rural districts. Findings on feasibility and fidelity, barriers and facilitators influencing the integration of the YRI into the entrepreneurship program, and clinical effectiveness of the YRI are of interest.

RESULTS

Findings from the pilot study indicated that the YRI can be implemented within a youth entrepreneurship program and provide mental health benefits to youths at high risk of emotion dysregulation and interpersonal deficits. Pilot findings informed the ongoing, larger hybrid type-2 trial to understand barriers and facilitators of the CTA and clinical effectiveness of the YRI within youth employment programming.

NEXT STEPS

In fragile postconflict settings, innovative approaches are needed to address the mental health treatment gap. Findings from this study will support efforts by the government of Sierra Leone and its partners to address human resource challenges and increase access to evidence-based mental health services.

Use of Children as Soldiers

A child soldier is a person less than 18 years of age who/has been recruited/used by an armed force/armed group in any capacity, including but not limited to children, boys and girls, used as fighters, cooks, porters, messengers, spies, or for sexual purposes. Complex consequences on both physical and mental health are reported among child soldiers. One-third to one-half of these children may have clinically significant symptoms of post-traumatic stress disorder. The United Nations identified more than 25,000 grave violations against children during armed conflicts in 2019. The recruitment and use of children under 18 in armed conflicts must stop.

Suitability of the Openly Accessible 3D Printed Prosthetic Hands for War-Wounded Children

The field of rehabilitation and assistive devices is being disrupted by innovations in desktop 3D printers and open-source designs. For upper limb prosthetics, those technologies have demonstrated a strong potential to aid those with missing hands. However, there are basic interfacing issues that need to be addressed for long term usage. The functionality, durability, and the price need to be considered especially for those in difficult living conditions. We evaluated the most popular designs of body-powered, 3D printed prosthetic hands. We selected a representative sample and evaluated its suitability for its grasping postures, durability, and cost. The prosthetic hand can perform three grasping postures out of the 33 grasps that a human hand can do. This corresponds to grasping objects similar to a coin, a golf ball, and a credit card. Results showed that the material used in the hand and the cables can withstand a 22 N normal grasping force, which is acceptable based on standards for accessibility design. The cost model showed that a 3D printed hand could be produced for as low as $19. For the benefit of children with congenital missing limbs and for the war-wounded, the results can serve as a baseline study to advance the development of prosthetic hands that are functional yet low-cost.

Sexually Transmitted Diseases Among College Students in Sierra Leone: A Life Course Ecological Analysis

Applying life course theory, this study examined the direct and indirect effects of adverse childhood experiences (ACEs) on the risk of contracting sexually transmitted diseases (STDs), mediated by early sexual activity (first sexual experience before age 15), number of lifetime sex partners, and mental health problems. The link between ACEs and mental health on college students' sexual risk is still understudied. Using cross-sectional data from a sample of 327 college students in Sierra Leone, this study tested the hypothesized mediation model using structural equation modeling analysis. The results showed that ACEs significantly increased sexual risks. Specifically, ACEs increased the risk of early initiation of sexual activity and the number of lifetime sex partners, which in turn increased the risk of STDs. Furthermore, ACEs significantly predicted negative mental health and were significantly associated with an increased risk of STDs. Effective future intervention strategies should include health education programs to address the lifelong effects of ACEs and mental health treatment.

Gender-based violence against adolescent girls in humanitarian settings: a review of the evidence

Adolescent girls face elevated risks of gender-based violence in humanitarian settings because of the intersectionality of age and gender, and the additional and exacerbated risk factors relevant to emergencies. Because there is no clear division of labour between the gender-based violence and child protection sectors, adolescent girls are often neglected by both groups, and violence against this subpopulation goes unaddressed. This Review presents an adapted ecological framework for gender-based violence risks facing adolescent girls in emergencies, synthesises the scant evidence for gender-based violence prevention and response, and identifies barriers to effective and ethical measurement and evaluation of programme effectiveness. Although nascent evidence highlights promising interventions for transforming girls' attitudes about violence and gender inequity and improving psychosocial and mental wellbeing, little evidence supports the ability of existing approaches to reduce gender-based violence incidence. A more explicit focus on adolescent girls is needed when designing and evaluating interventions to ensure global efforts to end gender-based violence are inclusive of this population. TRANSLATIONS: For the Arabic, French and Spanish translations of the abstract see Supplementary Materials section.

The mental, reproductive, and physical health impacts of female children's association with armed forces and groups

BACKGROUND

Globally, over 300,000 children are being used in armed groups, including young girls some as young as eight years old. These young girls often called female children associated with armed groups and armed forces (CAAFAG), are exposed to high levels of violence and experience extensive abuse.

OBJECTIVE

This review aimed to understand the unique health consequences of association on female CAAFAG and the factors associated with their increased health vulnerability.

METHODS

The research utilized a review protocol, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The search yielded 449 unique articles, 53 (12 %) of which were included for final analysis to identify health concerns for female CAAFAG. Qualitative literature was also analyzed using thematic analysis to identify factors and experiences associated with female CAAFAG's increased risk of experiencing adverse health outcomes.

RESULTS

Internalizing and functional impairment presented unique challenges for females, largely due to their distinct experiences with stigma upon return to communities and returning with children.

CONCLUSIONS

Based on the findings of this review, female CAAFAG are at a unique risk for internalizing, functional impairment, and reduced adaptive behaviors. This review also highlights girls' post-conflict experiences of stigma, internal tensions, and returning with a child as modifiable risk factors for poor mental health.

Prevalence of mental health problems in populations affected by the Ebola virus disease: A systematic review and meta-analysis

Studies have shown that, in addition to being associated with a high mortality rate, Ebola Virus Disease (EVD) is also related with mental health problems. This study aimed to determine prevalence of mental health problems and associated factors among survivors and individuals affected by EVD. A systematic review of peer-reviewed empirical studies was conducted using EMBASE, PubMed, PsycINFO and PsyARTICLES. A random effects meta-analysis was performed on the proportions of people diagnosed with depression after an EVD outbreak. Of 205 studies initially identified, 21 were included in the systematic review and 10 in the meta-analysis. Results indicated that EVD is associated with depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, among others. Results revealed that one person out of five affected to EVD has been diagnosed with depression (standardized mean difference 19.92%, 95% CI 10.43%; 34.70). The I² provided evidence of heterogeneity in the results. This study demonstrated the evidence of the impact of EVD on the mental health of survivors and individuals affected by EVD. Further studies should consider the mental health consequences of EVD to plan culturally sensitive prevention and intervention programs based on the experience of communities affected by EVD.

Stigma and Acceptance of Sierra Leone's Child Soldiers: A Prospective Longitudinal Study of Adult Mental Health and Social Functioning

OBJECTIVE

To investigate the associations of war and postconflict factors with mental health among Sierra Leone's former child soldiers as adults.

METHOD

In 2002, we recruited former child soldiers from lists of soldiers (aged 10-17 years) served by Disarmament, Demobilization, Reintegration centers and from a random door-to-door sample in 5 districts of Sierra Leone. In 2004, self-reintegrated child soldiers were recruited in an additional district. At 2016/2017, 323 of the sample of 491 former child soldiers were reassessed. Subjects reported on war exposures and postconflict stigma, family support, community support, anxiety/depression, and posttraumatic stress symptoms.

RESULTS

Of the subjects, 72% were male, with a mean age of 28 years. In all, 26% reported killing or injuring others; 67% reported being victims of life-threatening violence; 45% of female subjects and 5% of male subjects reported being raped; and 32% reported death of a parent. In 2016/2017 (wave 4), 47% exceeded the threshold for anxiety/depression, and 28% exceeded the likely posttraumatic stress disorder threshold. Latent class growth analysis yielded 3 trajectory groups based on changes in stigma and family/community acceptance; "Improving Social Integration" (n = 77) fared nearly as well as the "Socially Protected" (n = 213). The "Socially Vulnerable" group (n = 33) had increased risk of anxiety/depression above the clinical threshold and possible PTSD, and were around 3 times more likely to attempt suicide.

CONCLUSION

Former child soldiers had elevated rates of mental health problems. Postconflict risk and protective factors related to outcomes long after the end of conflict. Targeted social inclusion and family interventions could benefit the long-term mental health of former child soldiers.

Perpetration of intimate partner violence and mental health outcomes: sex- and gender-disaggregated associations among adolescents and young adults in Nigeria

Background

The association between intimate partner violence (IPV) victimisation and poor mental health outcomes is well established. Less is known about the correlation between IPV perpetration and mental health, particularly among adolescents and young adults. Using data from the nationally representative Violence Against Children Survey, this analysis examines the association between IPV perpetration and mental health for male and female adolescents and young adults in Nigeria.

Methods

Multivariate logistic regression models were used to examine associations between ever-perpetration of IPV and four self-reported mental health variables: severe sadness, feelings of worthlessness, suicide ideation, and alcohol use. Models were sex-disaggregated, controlled for age, marital status, and schooling, and tested with and without past exposure to violence. Standard errors were adjusted for sampling stratification and clustering. Observations were weighted to be representative of 13-24 year-olds in Nigeria.

Results

Males were nearly twice as likely as females to perpetrate IPV (9% v. 5%, respectively; P < 0.001), while odds of perpetration for both sexes were higher for those ever experiencing IPV (adjusted odds ratio (aOR) = 4.60 for males; aOR = 2.71 for females). Female perpetrators had 2.73 higher odds of reporting severe sadness (95% confidence interval CI = 1.44, 5.17; P = 0.002) and 2.72 times greater odds of reporting suicide ideation (1.28, 5.79; P = 0.010) than non-perpetrating females, even when controlling for past-year violence victimisation. In contrast, male perpetrators had 2.65 times greater odds of feeling worthless (1.09, 6.43; P = 0.031), and 2.36 times greater odds of reporting alcohol use in the last 30 days (1.50, 3.73; P < 0.001), as compared to non-perpetrating males.

Conclusions

Among adolescents and young adults in Nigeria, IPV perpetration and negative mental health outcomes are associated but differ for males and females. Mindful of the cross-sectional nature of the data, it is possible that socially determined gender norms may shape the ways in which distress from IPV perpetration is understood and expressed. Additional research is needed to clarify these associations and inform violence prevention efforts.

Determination of psychosocial conditions of refugee children living in society

PURPOSE

This study aims to determine the psychosocial conditions of refugee children living in society.

DESIGNS AND METHODS

This descriptive cross-sectional research which used the Socio-demographic Information Form for Children, Child Posttraumatic Stress Reaction Index (CPTS-RI), and Children's Depression Inventory (CDI) included 738 children.

RESULTS

Social factors like the educational levels and professions of their parents, as well as economic status could affect the children's level of posttraumatic stress disorder, depression, and anxiety. The regression analysis revealed that depression and anxiety explained 72% of posttraumatic stress disorder in the children studied.

PRACTICE IMPLICATIONS

Nurses should be aware that the effects of trauma on children who were exposed to war and migration can continue even after much time has passed since the war started.

Immigrant Trauma and Mental Health Outcomes Among Latino Youth

While research has demonstrated an association between trauma and mental health, this study examined the association between trauma experienced premigration, during migration, and postmigration, and current mental health status among Latino youth aged 12-17 years old living in the US for < 3 years. Participants reported traumatic events experienced in their home country, during migration, and after settling in the US. Regression models examined trauma experienced at each stage of the migration process predicting current levels of depression, anxiety, and post-traumatic stress disorder. Two-thirds of youth experienced at least one traumatic event, 44% experienced an event once, and 23% experienced two or more traumatic events during migration. Trauma experienced at different migration stages was associated with distinctive mental health outcomes. It is essential that access to culturally sensitive assessment and treatment services be available to ensure transition to a healthy adulthood.

The Effects of Armed Conflict on Children

Children are increasingly exposed to armed conflict and targeted by governmental and nongovernmental combatants. Armed conflict directly and indirectly affects children's physical, mental, and behavioral health. It can affect every organ system, and its impact can persist throughout the life course. In addition, children are disproportionately impacted by morbidity and mortality associated with armed conflict. A children's rights-based approach provides a framework for collaboration by the American Academy of Pediatrics, child health professionals, and national and international partners to respond in the domains of clinical care, systems development, and policy formulation. The American Academy of Pediatrics and child health professionals have critical and synergistic roles to play in the global response to the impact of armed conflict on children.

The Effects of Armed Conflict on Children

More than 1 in 10 children worldwide are affected by armed conflict. The effects are both direct and indirect and are associated with immediate and long-term harm. The direct effects of conflict include death, physical and psychological trauma, and displacement. Indirect effects are related to a large number of factors, including inadequate and unsafe living conditions, environmental hazards, caregiver mental health, separation from family, displacement-related health risks, and the destruction of health, public health, education, and economic infrastructure. Children and health workers are targeted by combatants during attacks, and children are recruited or forced to take part in combat in a variety of ways. Armed conflict is both a toxic stress and a significant social determinant of child health. In this Technical Report, we review the available knowledge on the effects of armed conflict on children and support the recommendations in the accompanying Policy Statement on children and armed conflict.

Society, individual, family, and school factors contributing to child mental health in war: The ecological-theory perspective

Mental health problems are common in war-affected areas, but children have different levels of vulnerability. Based on ecological theory (Bronfenbrenner, 2005), this study analyses how factors related to the child (cognitive capacity), their family (parental depression and parenting styles), and their school (teachers' practices and peer relations) mediate the association between traumatic stress (traumatic war experiences and stressful life-events) and child mental health (posttraumatic stress and psychological distress symptoms). The participants were 303 Palestinian children (51.2% girls) of 10-13 years (M = 10.94 ± 0.50) and their parents from the Gaza Strip. The children filled in questionnaires during school classes and the parents did so at their homes. The results of structural equation modeling substantiated the hypothesis that parental depression, poor parenting and low-quality peer relations mediated between traumatic stress and children's mental health problems. Contrary to the hypothesis, child-related factors did not mediate that association. To conclude, parents and peers provide important age-salient social resources for children in war conditions, and psychosocial interventions should therefore enhance their beneficial functions.

Psychosocial support for adolescent girls in post-conflict settings: beyond a health systems approach

Adaptive and adequately resourced health systems are necessary to achieve good health outcomes in post-conflict settings, however domains beyond the health system are also critical to ensure broader wellbeing. This paper focuses on the importance of psychosocial support services for adolescent girls in fragile contexts. Its starting point is that adolescence is a pivotal time in the life course but given the physical, cognitive and emotional changes triggered by the onset of puberty, it can also be a period of heightened sensitivity and vulnerability to trauma, social isolation, bullying by peers, a lack of supportive adults and gender-based and sexual violence. Our findings highlight why humanitarian and biomedical approaches in their current form are inadequate to address these complexities. Drawing on qualitative fieldwork (consisting of in-depth and key informant interviews as well as group discussions in Gaza, Liberia and Sri Lanka involving a total of 386 respondents across the three countries), we argue that going beyond biomedical approaches and considering the social determinants of health, including approaches to tackle discriminatory gendered norms and barriers to service access, are critical for achieving broader health and wellbeing. While all three case study countries are classified as post-conflict, the political economy dynamics vary with associated implications for experiences of psychosocial vulnerabilities and the service environment. The study concludes by reflecting on actions to address psychosocial vulnerabilities facing adolescent girls. These include: tailoring services to ensure gender and age-sensitivity; investing in capacity building of service providers to promote service uptake; and enhancing strategies to regulate and coordinate actors providing mental health and psychosocial support services.

Polyvictimization Among Children and Adolescents in Low- and Lower-Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND

Most of the world's children and adolescents live in low- and lower-middle-income countries (LALMIC), but there is limited evidence about polyvictimization (experiences of multiple forms of victimization) among them. The aims of this article were to systematically review the evidence from LALMIC about the overall prevalence of polyvictimization and to identify the associations between polyvictimization and health and well-being among children and adolescents.

METHOD

A systematic search of the English-language peer-reviewed literature to identify empirical, quantitative studies conducted in LALMIC between 2005 and 2015, assessing at least four forms of victimization among young people aged up to 19 years. Where prevalence of any victimization and of polyvictimization were reported, meta-analyses were performed.

RESULTS

A total of 30/8,496 articles were included in the review. Evidence was available from 16/84 LALMIC and methodology and quality varied. Pooled prevalence of experiences of any victimization was 76.8% (95% confidence interval (CI) [64.8%, 88.9%]). Prevalence of polyvictimization ranged from 0.3% to 74.7% with an overall estimate of 38.1% (95% CI [18.3%, 57.8%]). None of the studies examined the associations between polyvictimization and physical or reproductive health or quality of life. Polyvictimization was associated with increased likelihood of mental health problems and involvement in health risk behaviors.

CONCLUSIONS

Experiences of polyvictimization among children and adolescents in LALMIC are more prevalent than in high- and upper-middle-income countries and contribute to the burden of poor health among children and adolescents. Most LALMIC lack local data, and research is required to address this knowledge gap.

A scoping review of the associations between mental health and factors related to HIV acquisition and disease progression in conflict-affected populations

The association between poor mental health and factors related to HIV acquisition and disease progression (also referred to as HIV-related factors) may be stronger among conflict-affected populations given elevated rates of mental health disorders. We conducted a scoping review of the literature to identify evidence-based associations between mental health (depression, anxiety, and post-traumatic stress disorder [PTSD]) and factors related to HIV acquisition and progression in conflict-affected populations. Five electronic databases were searched on October 10, 2014 and updated on March 7, 2017 to identify peer-reviewed publications presenting primary data from January 1, 1994 to March 7, 2017. Articles were included if: 1) depression, anxiety, and/or PTSD was assessed using a validated scale, 2) HIV or HIV-related factors were a primary focus, 3) quantitative associations between depression/anxiety/PTSD and HIV or HIV-related factors were assessed, and 4) the study population was conflict-affected and from a conflict-affected setting. Of 714 citations identified, 33 articles covering 110,818 participants were included. Most were from sub-Saharan Africa (n = 25), five were from the USA, and one each was from the Middle East, Europe, and Latin America. There were 23 cross-sectional, 3 time-series, and 7 cohort studies. The search identified that mental health has been quantitatively associated with the following categories of HIV-related factors in conflict-affected populations: markers of HIV risk, HIV-related health status, sexual risk behaviors, and HIV risk exposures (i.e. sexual violence). Further, findings suggest that symptoms of poor mental health are associated with sexual risk behaviors and HIV markers, while HIV risk exposures and health status are associated with symptoms of poor mental health. Results suggest a role for greater integration and referrals across HIV and mental health programs for conflict-affected populations.

Civilians in World War II and DSM-IV mental disorders: results from the World Mental Health Survey Initiative

PURPOSE

Understanding the effects of war on mental disorders is important for developing effective post-conflict recovery policies and programs. The current study uses cross-sectional, retrospectively reported data collected as part of the World Mental Health (WMH) Survey Initiative to examine the associations of being a civilian in a war zone/region of terror in World War II with a range of DSM-IV mental disorders.

METHODS

Adults (n = 3370) who lived in countries directly involved in World War II in Europe and Japan were administered structured diagnostic interviews of lifetime DSM-IV mental disorders. The associations of war-related traumas with subsequent disorder onset-persistence were assessed with discrete-time survival analysis (lifetime prevalence) and conditional logistic regression (12-month prevalence).

RESULTS

Respondents who were civilians in a war zone/region of terror had higher lifetime risks than other respondents of major depressive disorder (MDD; OR 1.5, 95% CI 1.1, 1.9) and anxiety disorder (OR 1.5, 95% CI 1.1, 2.0). The association of war exposure with MDD was strongest in the early years after the war, whereas the association with anxiety disorders increased over time. Among lifetime cases, war exposure was associated with lower past year risk of anxiety disorders (OR 0.4, 95% CI 0.2, 0.7).

CONCLUSIONS

Exposure to war in World War II was associated with higher lifetime risk of some mental disorders. Whether comparable patterns will be found among civilians living through more recent wars remains to be seen, but should be recognized as a possibility by those projecting future needs for treatment of mental disorders.

Mental health in Syrian children with a focus on post-traumatic stress: a cross-sectional study from Syrian schools

PURPOSE

Studies show that conflict can negatively affect psychological health. The Syrian crisis is 8 years old and yet little is known about the impact of the conflict on the well-being of Syrians who remain. This gap was addressed by conducting an empirical study on the mental health burden of Syrian children in two areas of the country.

METHODS

492 children between 8 and 15 years were randomly selected from schools in Damascus and Latakia. The incidence of psychological disorder symptoms was measured using self-report screening instruments, the Children's Revised Impact of Event Scale (CRIES-8) and the Revised Children's Anxiety and Depression Scale (RCADS-25). Simultaneously, sociodemographic and traumatic event information was collected. Binary logistic regression was used to identify factors that influence the development of post-traumatic stress disorder (PTSD) symptoms.

RESULTS

In our sample, 50.2% of students were internally displaced and 32.1% reported a negative experience. 60.5% of those tested had at least one probable psychological disorder with PTSD the most common (35.1%), followed by depression (32.0%), and anxiety (29.5%). Binary logistic regression indicated that PTSD symptoms were predicted by: living in Damascus [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.51-3.69], being female (1.54, 1.02-2.34), having depression and anxiety (2.55, 1.48-4.40), and the negative experiences; displacement and daily warzone exposure (1.84, 1.02-3.30 and 2.67, 1.08-6.60).

CONCLUSIONS

Syrian children are experiencing traumatic events and war-associated daily stresses that are hugely impacting psychological well-being. Our data offer guidance for mental health providers regarding risk factors and highlights the use of the school system to reach suffering children.

Evidence for Anger Saliency during the Recognition of Chimeric Facial Expressions of Emotions in Underage Ebola Survivors

One of the crucial features defining basic emotions and their prototypical facial expressions is their value for survival. Childhood traumatic experiences affect the effective recognition of facial expressions of negative emotions, normally allowing the recruitment of adequate behavioral responses to environmental threats. Specifically, anger becomes an extraordinarily salient stimulus unbalancing victims' recognition of negative emotions. Despite the plethora of studies on this topic, to date, it is not clear whether this phenomenon reflects an overall response tendency toward anger recognition or a selective proneness to the salience of specific facial expressive cues of anger after trauma exposure. To address this issue, a group of underage Sierra Leonean Ebola virus disease survivors (mean age 15.40 years, SE 0.35; years of schooling 8.8 years, SE 0.46; 14 males) and a control group (mean age 14.55, SE 0.30; years of schooling 8.07 years, SE 0.30, 15 males) performed a forced-choice chimeric facial expressions recognition task. The chimeric facial expressions were obtained pairing upper and lower half faces of two different negative emotions (selected from anger, fear and sadness for a total of six different combinations). Overall, results showed that upper facial expressive cues were more salient than lower facial expressive cues. This priority was lost among Ebola virus disease survivors for the chimeric facial expressions of anger. In this case, differently from controls, Ebola virus disease survivors recognized anger regardless of the upper or lower position of the facial expressive cues of this emotion. The present results demonstrate that victims' performance in the recognition of the facial expression of anger does not reflect an overall response tendency toward anger recognition, but rather the specific greater salience of facial expressive cues of anger. Furthermore, the present results show that traumatic experiences deeply modify the perceptual analysis of philogenetically old behavioral patterns like the facial expressions of emotions.

A community-based qualitative study of intergenerational resilience with Palestinian refugee families facing structural violence and historical trauma

The purpose of this study was to explore resilience processes in Palestinian refugee families living under Israeli occupation for multiple generations. Qualitative methods, critical postcolonial theories, and community-based research approaches were used to examine intergenerational protective practices and to contribute to reconceptualizations of resilience from indigenous perspectives. First, the researcher developed a collaborative partnership with a nongovernmental organization (NGO) in a UN refugee camp in the occupied West Bank. Then, with the support of this NGO, semistructured group and individual interviews were completed with a total of 30 participants ( N = 30) ranging in age from 18 to 90 years old coming from 5 distinct extended family networks. Using grounded theory situational analysis, the findings were organized in a representation entitled Palestinian Refugee Family Trees of Resilience (PRFTR). These findings explain resilience in terms of three interrelated themes: (a) Muqawama/resistance to military siege and occupation; (b) Awda/return to cultural roots despite historical and ongoing settler colonialism; and (c) Sumoud/perseverance through daily adversities and accumulation of trauma. The study findings shed light on how Palestinian families cultivate positive adaptation across generations and highlight how incorporating community-based perspectives on the historical trauma and violent social conditions of everyday life under occupation may be critical for promoting resilience. Results may be relevant to understanding the transgenerational transmission of trauma and resilience within other displaced communities internationally.

Comparing Trauma Exposure, Mental Health Needs, and Service Utilization Across Clinical Samples of Refugee, Immigrant, and U.S.-Origin Children

Most mental health services for trauma-exposed children and adolescents were not originally developed for refugees. Information is needed to help clinicians design services to address the consequences of trauma in refugee populations. We compared trauma exposure, psychological distress, and mental health service utilization among children and adolescents of refugee-origin, immigrant-origin, and U.S.-origin referred for assessment and treatment by U.S. providers in the National Child Traumatic Stress Network (NCTSN). We used propensity score matching to compare trauma profiles, mental health needs, and service use across three groups. Our sample comprised refugee-origin youth (n = 60, 48.3% female, mean age = 13.07 years) and propensity-matched samples of immigrant-origin youth (n = 143, 60.8% female, mean age = 13.26 years), and U.S.-origin youth (n = 140, 56.1% female, mean age = 12.11 years). On average, there were significantly more types of trauma exposure among refugee youth than either U.S.-origin youth (p < .001) or immigrant youth (p ≤ .001). Compared with U.S.-origin youth, refugee youth had higher rates of community violence exposure, dissociative symptoms, traumatic grief, somatization, and phobic disorder.  In contrast, the refugee group had comparably lower rates of substance abuse and oppositional defiant disorder (ps ranging from .030 to < .001).This clinic-referred sample of refugee-origin youth presented with distinct patterns of trauma exposure, distress symptoms, and service needs that merit consideration in services planning.

The influence of types of war experiences on conduct problems in war-affected youth in Northern Ugandan: Findings from the WAYS study

Exposure to war is associated with poor psychosocial outcomes. Yet the effects of different types of war events on various psychosocial outcomes such as conduct problems remain unknown. This study aims to assess whether various war events differ in predicting conduct problems. Using data from an on-going longitudinal research project, the WAYS study, the current article examined the relationship between specific war events and conduct problems in war-affected youth in Northern Uganda (N=539, baseline age=22.39; SD=2.03, range 18-25). Regression analyses were conducted to relate each type of war experience to conduct problems. War categories of "witnessing violence", "deaths", "threat to loved ones" and "sexual abuse" were associated with reporting conduct problems. Multivariable models yielded independent effects of ''witnessing violence'' (β=0.09, 95% CI: 0.01, 0.18) and ''Sexual abuse'' (β=0.09, 95% CI: 0.02, 0.19) on conduct problems while "duration in captivity" independently and negatively predicted conduct problems (β=-0.14, 95% CI: -0.23, -0.06). Types of war events vary in predicting conduct problems and should be considered when designing interventions to alleviate negative consequences of exposure to war. Moreover, longer duration in captivity appear to protect war-affected youth from conduct problems.

Stigmatisation and rejection of survivors of sexual violence in eastern Democratic Republic of the Congo

Studies report that between 6 per cent and 29 per cent of survivors of sexual violence in eastern Democratic Republic of the Congo (DRC) are rejected by their families and communities. This research project was designed to provide insights into survivors' experiences of stigmatisation and rejection. Surveys were conducted with 310 women as they sought psychosocial services in eastern DRC. In total, 44.3 per cent of women reported suffering rejection after sexual violence. The majority of women felt that their status in the household (58.0 per cent) and community (54.9 per cent) diminished after rape. The odds of rejection were greater among women reporting ongoing displacement, pregnancy owing to sexual violence, worsening family relations, and diminished community status. This work highlights the extremely high levels of loss associated with the war in eastern DRC, particularly among survivors of sexual violence. The rejection of a survivor of rape has concrete and devastating psychosocial consequences.

Sex trafficking and sexual exploitation in settings affected by armed conflicts in Africa, Asia and the Middle East: systematic review

Background

Sex trafficking and sexual exploitation has been widely reported, especially in conflict-affected settings, which appear to increase women’s and children’s vulnerabilities to these extreme abuses.

Methods

We conducted a systematic search of ten databases and extensive grey literature to gather evidence of sex trafficking and sexual exploitation in conflict-affected settings. International definitions of “sexual exploitation” and “sex trafficking” set the indicator parameters. We focused on sexual exploitation in forms of early or forced marriage, forced combatant sexual exploitation and sexual slavery. We extracted prevalence measures, health outcomes and sexual exploitation terminology definitions. The review adhered to PRISMA guidelines and includes quality appraisal.

Results

The search identified 29 eligible papers with evidence of sex trafficking and sexual exploitation in armed conflict settings in twelve countries in Africa, Asia, and the Middle East. The evidence was limited and not generalizable, due to few prevalence estimates and inconsistent definitions of “sexual exploitation”. The prevalence estimates available indicate that females were more likely than males to be victims of sexual exploitation in conflict settings. In some settings, as many as one in four forced marriages took place before the girls reached 18 years old. Findings suggest that the vast majority of former female combatants were sexually exploited during the conflict. These studies provided various indicators of sexual exploitation compatible to the United Nation’s definition of sex trafficking, but only 2 studies identified the exploitation as trafficking. None of the studies solely aimed to measure the prevalence of sex trafficking or sexual exploitation. Similar descriptions of types of sexual exploitation and trafficking were found, but the inconsistent terminology or measurements inhibited a meta-analysis.

Conclusions

Findings indicate there are various forms of human trafficking and sexual exploitation in conflict-affected settings, primarily occurring as early or forced marriage, forced combatant sexual exploitation, and sexual slavery. The studies highlight the extraordinary vulnerability of women and girls to these extreme abuses. Simultaneously, this review suggests the need to clarify terminology around sex trafficking in conflict to foster a more cohesive future evidence-base, and in particular, robust prevalence figures from conflict-affected and displaced populations.

Developmental and social-ecological perspectives on children, political violence, and armed conflict

An increasing number of researchers and policymakers have been moved to study and intervene in the lives of children affected by violent conflicts (Masten, 2014). According to a United Nations Children's Fund (2009) report, over 1 billion children under the age of 18 are growing up in regions where acts of political violence and armed conflict are, as Ladds and Cairns (1996, p. 15) put it, "a common occurrence-a fact of life." In recent years, the United Nations Children's Fund, advocacy and human rights groups, journalists, and researchers have drawn public attention to the high rates of child casualties in these regions, and to the plights of those children still caught in the crossfire. It has thus become clear that both the challenges and the stakes are higher than ever to promote the safety and well-being of affected children around the world (Masten & Narayan, 2012; Tol, Jordans, Kohrt, Betancourt, & Komproe, 2012).

Associations between Mental Health and Ebola-Related Health Behaviors: A Regionally Representative Cross-sectional Survey in Post-conflict Sierra Leone

BACKGROUND

Little attention has been paid to potential relationships between mental health, trauma, and personal exposures to Ebola virus disease (EVD) and health behaviors in post-conflict West Africa. We tested a conceptual model linking mental health and trauma to EVD risk behaviors and EVD prevention behaviors.

METHODS AND FINDINGS

Using survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines associations between war exposures, post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and personal EVD exposure (e.g., having family members or friends diagnosed with EVD) and EVD-related health behaviors among 1,008 adults (98% response rate) from 63 census enumeration areas of the Western Rural and Western Urban districts randomly sampled at the height of the EVD epidemic (January-April 2015). Primary outcomes were EVD risk behaviors (14 items, Cronbach's α = 0.84) and EVD prevention behaviors (16 items, Cronbach's α = 0.88). Main predictors comprised war exposures (8 items, Cronbach's α = 0.85), anxiety (10 items, Cronbach's α = 0.93), depression (15 items, Cronbach's α = 0.91), and PTSD symptoms (16 items, Cronbach's α = 0.93). Data were analyzed using two-level, population-weighted hierarchical linear models with 20 multiply imputed datasets. EVD risk behaviors were associated with intensity of depression symptoms (b = 0.05; 95% CI 0.00, 0.10; p = 0.037), PTSD symptoms (b = 0.10; 95% CI 0.03, 0.17; p = 0.008), having a friend diagnosed with EVD (b = -0.04; 95% CI -0.08, -0.00; p = 0.036), and war exposures (b = -0.09; 95% CI -0.17, -0.02; p = 0.013). EVD prevention behaviors were associated with higher anxiety (b = 0.23; 95% CI 0.06, 0.40; p = 0.008), having a friend diagnosed with EVD (b = 0.15; 95% CI 0.04, 0.27; p = 0.011), and higher levels of war exposure (b = 0.45; 95% CI 0.16, 0.74; p = 0.003), independent of mental health. PTSD symptoms were associated with lower levels of EVD prevention behavior (b = -0.24; 95% CI -0.43, -0.06; p = 0.009).

CONCLUSIONS

In post-conflict settings, past war trauma and mental health problems are associated with health behaviors related to combatting EVD. The associations between war trauma and both EVD risk behaviors and EVD prevention behaviors may be mediated through two key mental health variables: depression and PTSD symptoms. Considering the role of mental health in the prevention of disease transmission may help fight continuing and future Ebola outbreaks in post-conflict Sierra Leone. This sample is specific to Freetown and the Western Area and may not be representative of all of Sierra Leone. In addition, our main outcomes as well as personal EVD exposure, war exposures, and mental health predictors rely on self-report, and therefore raise the possibility of common methods bias. However, the findings of this study may be relevant for understanding dynamics related to EVD and mental health in other major capital cities in the EVD-affected countries of West Africa.

Child mental health in Sierra Leone: a survey and exploratory qualitative study

BACKGROUND

This study complements the growing amount of research on the psychosocial impact of war on children in Sierra Leone by examining local perceptions of child mental health, formal and informal care systems, help-seeking behaviour and stigma.

METHODS

The study combined: (1) a nationwide survey of mental health care providers, with (2) exploratory qualitative research among service users and providers and other stakeholders concerned with child and adolescent mental health, with a particular emphasis on local explanations and stigma.

RESULTS

Formal mental health care services are extremely limited resulting in an estimated treatment gap of over 99.8 %. Local explanations of child mental health problems in Sierra Leone are commonly spiritual or supernatural in nature, and associated with help-seeking from traditional healers or religious institutions. There is a considerable amount of stigma related to mental disorders, which affects children, their caregivers and service providers, and may lead to discrimination and abuse.

CONCLUSIONS

Child and Adolescent Mental Health (CAMH) care development in Sierra Leone should cater to the long-term structural effects of war-violence and an Ebola epidemic. Priorities for development include: (1) the strengthening of legal structures and the development of relevant policies that strengthen the health system and specifically include children and adolescents, (2) a clearer local distinction between children with psychiatric, neurological, developmental or psychosocial problems and subsequent channelling into appropriate services (3) supplementary CAMH training for a range of professionals working with children across various sectors, (4) specialist training in CAMH, (5) integration of CAMH care into primary health care, education and the social welfare system, (6) further research on local explanations of child mental disorders and the effect they have on the well-being of the child, and (7) a careful consideration of the role of religious healers as care providers.

Abducted children and youth in Lord's Resistance Army in Northeastern Democratic Republic of the Congo (DRC): mechanisms of indoctrination and control

Background

Globally, an estimated 300,000 children under the age of 18 participate in combat situations; those in armed groups in particular suffer prolonged exposure to psychological and physical abuse. The Lord’s Resistance Army (LRA) is a rebel movement known for its widespread conscription of children; yet little is known about this process once the group moved beyond northern Uganda. In this paper, we describe the processes related to abduction and indoctrination of youth by the LRA in northeastern Democratic Republic of the Congo ( DRC).

Methods

In-depth interviews were conducted with formerly abducted children, their family members, community leaders, and service providers (total n = 34) in four communities in LRA-affected areas of northeastern DRC. Inductive coding of transcripts was undertaken to identify salient themes.

Results

Informants articulated a range of practices by the LRA to exert high levels of control over new recruits, including strict social isolation from recent abductees; control of communication; promoting new identity formation; and compelling children to act out strictly defined gendered roles. Witchcraft and secrecy are used to intimidate recruits and to magnify perception of the group’s power. These methods promote de-identification with one’s civilian and family life; and eventually the assimilation of a new language and identity.

Conclusion

Indoctrination of newly abducted children into the LRA occurs via a complex system of control. This study provides one of the first detailed explorations of social and psychological mechanisms through which this is achieved, and focuses particularly on the gendered differences in the indoctrination process. Results support past findings that the LRA is a strategic and well-organized organization in its approach to enlisting child soldiers. Understanding some of the ways in which the LRA controls its recruits and the psychological impact of indoctrination enables reintegration programs to more effectively address these issues and serve the complex needs of formerly abducted children.

Reconciling after civil conflict increases social capital but decreases individual well-being

Civil wars divide nations along social, economic, and political cleavages, often pitting one neighbor against another. To restore social cohesion, many countries undertake truth and reconciliation efforts. We examined the consequences of one such effort in Sierra Leone, designed and implemented by a Sierra Leonean nongovernmental organization called Fambul Tok. As a part of this effort, community-level forums are set up in which victims detail war atrocities, and perpetrators confess to war crimes. We used random assignment to study its impact across 200 villages, drawing on data from 2383 individuals. We found that reconciliation had both positive and negative consequences. It led to greater forgiveness of perpetrators and strengthened social capital: Social networks were larger, and people contributed more to public goods in treated villages. However, these benefits came at a substantial cost: The reconciliation treatment also worsened psychological health, increasing depression, anxiety, and posttraumatic stress disorder in these same villages. For a subset of villages, we measured outcomes both 9 months and 31 months after the intervention. These results show that the effects, both positive and negative, persisted into the longer time horizon. Our findings suggest that policy-makers need to restructure reconciliation processes in ways that reduce their negative psychological costs while retaining their positive societal benefits.

Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo

BACKGROUND

Conflict-affected communities face poverty and mental health problems, with sexual violence survivors at high risk for both given their trauma history and potential for exclusion from economic opportunity. To address these problems, we conducted a randomized controlled trial of a group-based economic intervention, Village Savings and Loans Associations (VSLA), for female sexual violence survivors in the Democratic Republic of Congo.

METHODS

In March 2011, 66 VSLA groups, with 301 study participants, were randomized to the VSLA program or a wait-control condition. Data were collected prior to randomization, at 2-months post-program in June 2012, and 8-months later for VSLA participants only. Outcome data included measures of economic and social functioning and mental health severity. VSLA program effect was derived by comparing intervention and control participants' mean changes from baseline to 2-month follow-up.

RESULTS

At follow-up, VSLA study women reported significantly greater per capita food consumption and significantly greater reductions in stigma experiences compared with controls. No other study outcomes were statistically different. At 8-month follow-up, VSLA participants reported a continued increase in per capita food consumption, an increase in economic hours worked in the prior 7 days, and an increase in access to social resources.

CONCLUSIONS

While female sexual violence survivors with elevated mental symptoms were successfully integrated into a community-based economic program, the immediate program impact was only seen for food consumption and experience of stigma. Impacts on mental health severity were not realized, suggesting that targeted mental health interventions may be needed to improve psychological well-being.

The effects of sexual violence on psychosocial outcomes in formerly abducted girls in Northern Uganda: the WAYS study

BACKGROUND

The objective of this study is to investigate the effects of sexual violence on the odds of different psychosocial outcomes (depression, psychotic symptoms, somatic complaints, conduct problems, daily functioning, community relations, and stigma) among formerly abducted girls in Uganda.

METHODS

Data from an on-going War-Affected Youth Study (WAYS) in Uganda was used to compute the prevalence of psychosocial problems (scores ≥ 75th percentile) among three categories of formerly abducted girls (1) no history of sexual violence without children, 2) a history of sexual violence without children, and 3) a history of sexual violence with children as a consequence) among 210 women (age 22.06, SD = 2.06, range 18-25). Multiple logistic regression analyses were used to examine differences in psychosocial outcomes by the different categories of formerly abducted girls.

RESULTS

Compared to participants with no history of sexual violence and without any children, the odds of adverse psychosocial outcomes were increasingly higher for all psychosocial dimensions for those who reported sexual violence with or without children. Those with a history of sexual violence and with children as a consequence had more than five times the odds of reporting depressive symptoms (OR, 5.37; 95% CI (1.45-19.90), somatic complaints (OR, 6.59; 95% CI (1.80 - 24.11), and stigma (OR, 13.85; 95% CI (3.73 - 51.42) compared to those who did not report sexual violence.

CONCLUSION

This study highlighted the risks of psychosocial problems among different categories of formerly abducted girls regarding sexual violence. Vulnerability to psychosocial problems among formerly abducted girls is further compounded by sexual violence, child care, stigma, and poverty.

Children's exposure to community and war violence and mental health in four African countries

In this article we review the mental health consequences of children's exposure to community and war violence (ETV) in four African countries: South Africa, Sierra Leone, Gambia and Rwanda. A focus on Africa is particularly pressing because of children's high levels of community and war ETV in countries therein. Regions of Africa present important macro-contexts for understanding children's various types of violence exposure amidst war and economic disadvantage. Findings of the review across 20 quantitative studies from 2004 to 2015 indicate consistent associations between exposure to war and community violence and children's symptoms of Post-traumatic Stress disorder (PTSD), depression, and aggression. School climate and family support mitigate these ETV influences upon children: however, more research is needed on the buffering effects of such resources. The effects of war violence are mediated by perceived discrimination in communities post-conflict. We integrate findings across studies to synthesize knowledge on children's ETV in Africa around a model of its correlates, mediators, and moderators in relation to mental health. Emerging research points to avenues for prevention and future inquiry.

Child Soldiers: Children Associated with Fighting Forces

Around the world, there are an estimated 300,000 to 500,000 children involved in armed conflict. Children can be abducted into a fighting force to fight or serve as sex slaves. Child soldiers have depression, anxiety, and posttraumatic stress symptoms; however, evidence is mixed because of methodologic limitations. Various mental health interventions have been tried, with promising results. Child and adolescent psychiatrists are uniquely trained in understanding and assisting youth to heal from such extraordinary experiences. A public health paradigm could include interventions that are based on a comprehensive assessment of interweaving developmental, biological, psychological, and sociocultural factors.

When community reintegration is not the best option: interethnic violence and the trauma of parental loss in South Sudan

The magnitude of violence and human loss in conflict settings often exceeds the caring capacity of traditional support systems for orphans. The aim of this study is to understand the developmental context for children experiencing armed conflict, parental loss, extreme poverty, violence and social exclusion in a setting affected by interethnic violence. This article challenges the received wisdom that community reintegration is always better than institutional provision. Using a case study employing interviews, focus groups, workshops and observations, we examined how children's experiences of armed violence and parental loss affected their mental well-being, and their relationships within their community. Emerging findings such as experienced violence and psychological distress were further investigated using a cross-sectional survey design to explore the generalisability or transferability of theories or conclusions drawn from qualitative data. Findings showed that parental loss had a major impact on children's lives in the context of armed violence. Four main outcomes of orphanhood emerged: (i) facing the situation and evading harm (feelings of rejection and stigmatisation); (ii) trauma exposure and mental health effects (associations of orphanhood with adverse mental health outcomes and the number and type of experienced trauma); (iii) dealing with psychological distress (seeking caring connections and decreased feelings of isolation); and (iv) education and acceptance (increasing knowledge, skills and attitude and being respected in their community). We discuss the role that contexts such as armed violence, parental loss and social exclusion play for children's mental well-being and their implications for psychosocial interventions and orphan care in humanitarian settings. Copyright © 2015 John Wiley & Sons, Ltd.

Alternative approaches for studying humanitarian interventions: propensity score methods to evaluate reintegration packages impact on depression, PTSD, and function impairment among child soldiers in Nepal

BACKGROUND

Ethical, logistical, and funding approaches preclude conducting randomized control trials (RCTs) in some humanitarian crises. A lack of RCTs and other intervention research has contributed to a limited evidence-base for mental health and psychosocial support (MHPS) programs after disasters, war, and disease outbreaks. Propensity score methods (PSMs) are an alternative analysis technique with potential application for evaluating MHPS programs in humanitarian emergencies.

METHODS

PSMs were used to evaluate impacts of education reintegration packages (ERPs) and other (vocational or economic) reintegration packages (ORPs) v. no reintegration programs on mental health of child soldiers. Propensity scores were used to determine weighting of child soldiers in each of the three treatment arms. Multiple linear regression was used to estimate adjusted changes in symptom score severity on culturally validated measures of depression, post-traumatic stress disorder (PTSD), and functional impairment from baseline to 1-year follow-up.

RESULTS

Among 258 Nepali child soldiers participating in reintegration programs, 54.7% completed ERP and 22.9% completed ORP. There was a non-significant reduction in depression by 0.59 (95% CI -1.97 to 0.70) for ERP and by 0.60 (95% CI -2.16 to 0.96) for ORP compared with no treatment. There were non-significant increases in PTSD (1.15, 95% CI -1.55 to 3.86) and functional impairment (0.91, 95% CI -0.31 to 2.14) associated with ERP and similar findings for ORP (PTSD: 0.66, 95% CI -2.24 to 3.57; functional impairment (1.05, 95% CI -0.71 to 2.80).

CONCLUSION

In a humanitarian crisis in which a non-randomized intervention assignment protocol was employed, the statistical technique of PSMs addressed differences in covariate distribution between child soldiers who received different integration packages. Our analysis did not demonstrate significant changes in psychosocial outcomes for ERPs and ORPs. We suggest the use of PSMs in evaluating non-randomized interventions in humanitarian crises when non-randomized conditions are not utilized.

Hostility Patterns: Implications for Nursing Practice

In order to present the state of the science of hostility among and across disciplines, a review of the literature was completed. The knowledge gained may influence nursing practice. Scholarly works from nursing, medical and basic sciences, psychology, sociology, education, philosophy, business, communication, and criminology were reviewed. Similar patterns in the use of the concept were discovered. The patterns revealed five themes: hostility as a health-risk factor, hostility as a factor in family relationships, hostility as a factor in perceived challenge, hostility as a factor in criminal behavior, and hostility as a factor in the workplace. Based on the knowledge gained about hostility, implications for nursing practice related to changing the hostile working environment for nurses were suggested using modeling and role-modeling nursing theory.

The guiltless guilty: trauma-related guilt and psychopathology in former Ugandan child soldiers

Child soldiers often experience complex trauma as victims and perpetrators, and feelings of guilt may affect their psychological health. The relationship between the children's traumatic experiences as victims or perpetrators, their perception of themselves as victim or perpetrator, guilt and psychopathology were investigated: of the 330 former child soldiers interviewed, 50.8 % perceived themselves as victims and 19.1 % as perpetrators. On psychopathology measures, scores within the clinical range were 33 % for posttraumatic stress disorder (PTSD), 36.4 % for major depressive disorder (MDD), and 26.1 % for externalizing problems. Low socio-economic status, traumatic experience as perpetrator, and guilt were significant predictors of PTSD. Significant predictors of MDD were low socio-economic status, traumatic experiences as victim, and guilt. A greater number of traumatic experiences as perpetrator and guilt were associated with externalizing problems. The current paper underscores the significance of guilt following traumatic experiences and has implications for the development of clinical interventions for war-affected children.