Bringing order out of chaos: a culturally competent approach to managing the problems of refugees and victims of organized violence

PTSD, depression, and anxiety after the October 7, 2023 attack in Israel: a nationwide prospective study

Background

The magnitude of the Oct 7, 2023 attack in southern Israel was without precedent. More than 1300 civilians were murdered, and 240 civilians were kidnapped and taken hostage. In this national cohort study, for which baseline outcome data were established before the attacks, a prospective assessment of posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder (GAD) was conducted one month after the attack.

Methods

A representative sample of 710 Israeli adults (362 female, 51.1%), Jews (557, 79.9%) and Arabs (153, 20.1%), aged 18-85 years (mean = 41.01, SD = 13.72) completed the study at two timepoints: T1, on Aug 20-30, 2023 (6-7 weeks before the attack) and T2, on Nov 9-19, 2023 (5-6 weeks after the attack). 30 (4.2%) of the 710 participants had direct exposure to the attack, and 131 (18.5%) had loved ones who were murdered, kidnapped, or injured during the attack.

Findings

Probable PTSD prevalence almost doubled from 16.2% at T1 to 29.8% at T2 (p < 0.0001), with the prevalence of probable GAD and depression also increasing from 24.9% at T1 to 42.7% at T2, and from 31.3% at T1 to 44.8% at T2, respectively. Direct exposure to the attack was found to contribute to probable PTSD (OR = 3.15, 95% CI = 1.48-6.65) and probable depression (OR = 2.18, 95% CI = 1.02-4.87) at T2.

Interpretation

Our study suggests a broad and significant impact of the Oct 7, 2023 attack on the mental health of the Israeli population. The findings underscore the need to provide rapid, nationwide assessments and triage for interventions to address the mental health needs of Jewish and Arab citizens.

Funding

Not applicable.

Gender differences in Syrian refugees in Jordan: Psychological, self-esteem, family function, marital satisfaction, and life satisfaction

AIM

The current study examined gender differences in mental health, self-esteem, family function, marital satisfaction, and life satisfaction between men and women living in a refugee camp for Syrian refugees in Jordan.

METHOD

A snowball method used by local female and male students trained to collect data according to culturally competent methods. The following research instruments were deployed: Symptoms Checklist-SCL90, Self-esteem Scale, the McMaster Family Assessment Device, Marital Satisfaction Scale, and life Satisfaction Scale.

RESULTS

A sample of 290 adults (196 women and 94 men) living in a refugee camp in Jordan participated in the study. Findings revealed that marital satisfaction, self-esteem, and life satisfaction were significantly different between males and females, indicating less subjective well-being for women. Many of the mental health symptoms in this study were more common for women than men; particularly noteworthy were somatization, obsessive compulsive behavior, interpersonal sensitivity, depression, hostility, psychoticism, and higher scores on the Global Severity Index (GSI).

CONCLUSION

While some stressors are not gender-specific, there are unique factors that women face which place them at increased risk of mental health problems. Implications for practice include a greater understanding of the challenges and resilience mechanisms that are related to gender and culture.

Benefits and Challenges of Using a Participatory Approach with Community-based Mental Health and Psychosocial Support Interventions in Displaced Populations

The mental health burden of displaced communities is enormous and ever-increasing. Community-based Mental Health and Psychosocial Support (CB-MHPSS) interventions are seen as vital in addressing this challenge, and they have been lauded as being integral in the overall multi-level Mental Health and Psychosocial Support Intervention approach in humanitarian settings. This article assumes that CB-MHPSS innately require a participatory approach to truly benefit the targeted population. It explores important benefits and challenges of using a participatory approach with CB-MHPSS interventions, as well as identifying key considerations in their design and implementation. A literature review of the PubMed database, Web of Science, The Cochrane Library of Systematic Reviews, and defined 'grey literature' identified 42 relevant articles. Thematic analysis identified dilemmas raised by many of the authors, including: the disconnect between using a participatory community-based approach and evidence-based medicine; using locally derived versus standardised measures; incorporating local mental health expressions and idioms into the intervention versus using standardised diagnostic classifications; empowering communities versus falling into the hands of local power dynamics and agendas; and trying to allow for sufficient time to develop relationships and build trust with the targeted community. The findings can serve to encourage reflexivity and critical thinking in the design and implementation of future CB-MHPSS interventions, which will be required to develop robust evidence that supports CB-MHPSS interventions in displaced communities.

Identifying the impact of social networks on mental and emotional health seeking behaviours amongst women who are refugees from Syria living in Canada

Between 2015 and 2017, over 24,000 Syrian women came to Canada as refugees. Refugees are two to three times more likely than native Canadians to suffer from depression and other mental health challenges. A qualitative approach was taken to understand roles of social networks in shaping the mental and emotional health resource-seeking behaviours of twelve Syrian women who are refugees. Semi-structured telephone interviews were conducted in both English and Arabic. Interviews were audio-recorded, transcribed, and thematically coded using NVivo 12. Findings reveal that (1) families play large roles in teaching and providing information about Canada's health system, including mental health services; (2) Social networks influence assumptions about mental and physical health services; (3) women feel more welcomed into social networks in Canada than in countries of first asylum; and (4) social networks act as alternatives to seeking formal mental and emotional health care. Through first-hand stories and experiences of Syrian women's transitions into Canada, this study identifies the ways in which social networks may help or hinder engagement with mental and emotional health services.

Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence

Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

Collaborative health education for Somali Bantu refugee women in Kansas City

Objective

To partner with and understand the health of Somali Bantu refugee women, small group sessions were designed and conducted using a community-based collaborative action research (CBCAR) approach. Health topics identified by this community were presented in 42 sessions with eleven women. Follow-up individual interviews with the women were used to ask questions about health experiences and plan for future health education. The objective of this qualitative study was to provide refugee women with knowledge to help them adjust to new health challenges in the United States, and to share personal narratives in a safe environment.

Results

The process of sharing health information with the women resulted in a collaborative exchange of culture and community. Individual interviews allowed women to voice their opinions outside of the influence of their community elders. CBCAR is an effective tool to involve refugee communities, and other populations small in number, in addressing their unique health challenges. Results from this study demonstrated that small group sessions and a CBCAR approach can be effective in sharing knowledge within small communities of refugee women. Findings from the study will assist in the future planning of health education programs for refugee women and their families in this community.

What are the barriers to, and facilitators of, implementing and receiving MHPSS programmes delivered to populations affected by humanitarian emergencies? A qualitative evidence synthesis

BACKGROUND

Humanitarian emergencies can impact people's psychosocial well-being and mental health. Providing mental health and psychosocial support (MHPSS) is an essential component of humanitarian aid responses. However, factors influencing the delivery MHPSS programmes have yet to be synthesised. We undertook a systematic review on the barriers to, and facilitators of, implementing and receiving MHPSS programmes delivered to populations affected by humanitarian emergencies in low- and middle-income countries.

METHODS

A comprehensive search of 12 bibliographic databases, 25 websites and citation checking was undertaken. Studies published in English from 1980 onwards were included if they contained evidence on the perspectives of adults or children who had engaged in or programmes providers involved in delivering, MHPSS programmes in humanitarian settings. Thirteen studies were critically appraised and analysed thematically.

RESULTS

Community engagement was a key mechanism to support the successful implementation and uptake of MHPSS programmes. Establishing good relationships with parents may also be important when there is a need to communicate the value of children and young people's participation in programmes. Sufficient numbers of trained providers were essential in ensuring a range of MHPSS programmes were delivered as planned but could be challenging in resource-limited settings. Programmes need to be socially and culturally meaningful to ensure they remain appealing. Recipients also valued engagement with peers in group-based programmes and trusting and supportive relationships with providers.

CONCLUSION

The synthesis identified important factors that could improve MHPSS programme reach and appeal. Taking these factors into consideration could support future MHPSS programmes achieve their intended aims.

Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review

Background

Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs).

Methods

We searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability.

Results

When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed.

Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality.

Conclusions

Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it.

Community Participation in Health Systems Research: A Systematic Review Assessing the State of Research, the Nature of Interventions Involved and the Features of Engagement with Communities

BACKGROUND

Community participation is a major principle of people centered health systems, with considerable research highlighting its intrinsic value and strategic importance. Existing reviews largely focus on the effectiveness of community participation with less attention to how community participation is supported in health systems intervention research.

OBJECTIVE

To explore the extent, nature and quality of community participation in health systems intervention research in low- and middle-income countries.

METHODOLOGY

We searched for peer-reviewed, English language literature published between January 2000 and May 2012 through four electronic databases. Search terms combined the concepts of community, capability/participation, health systems research and low- and middle-income countries. The initial search yielded 3,092 articles, of which 260 articles with more than nominal community participation were identified and included. We further excluded 104 articles due to lower levels of community participation across the research cycle and poor description of the process of community participation. Out of the remaining 160 articles with rich community participation, we further examined 64 articles focused on service delivery and governance within health systems research.

RESULTS

Most articles were led by authors in high income countries and many did not consistently list critical aspects of study quality. Articles were most likely to describe community participation in health promotion interventions (78%, 202/260), even though they were less participatory than other health systems areas. Community involvement in governance and supply chain management was less common (12%, 30/260 and 9%, 24/260 respectively), but more participatory. Articles cut across all health conditions and varied by scale and duration, with those that were implemented at national scale or over more than five years being mainstreamed by government. Most articles detailed improvements in service availability, accessibility and acceptability, with fewer efforts focused on quality, and few designs able to measure impact on health outcomes. With regards to participation, most articles supported community's in implementing interventions (95%, n = 247/260), in contrast to involving communities in identifying and defining problems (18%, n = 46/260). Many articles did not discuss who in communities participated, with just over a half of the articles disaggregating any information by sex. Articles were largely under theorized, and only five mentioned power or control. Majority of the articles (57/64) described community participation processes as being collaborative with fewer describing either community mobilization or community empowerment. Intrinsic individual motivations, community-level trust, strong external linkages, and supportive institutional processes facilitated community participation, while lack of training, interest and information, along with weak financial sustainability were challenges. Supportive contextual factors included decentralization reforms and engagement with social movements.

CONCLUSION

Despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how much communities can participate and cognizant of who decides that.

Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature

Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners' assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs - i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry - as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward's method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.

Labor migration and mental health in Cambodia: a qualitative study

Labor migration is thought to have significant mental and physical health impacts, given the risks for exploitation and abuse of migrant workers, particularly among those in semiskilled and unskilled positions, although empirical data are limited. This qualitative study, conducted in July 2010 in Banteay Meanchey Province, Cambodia, focused on psychosocial and mental health signs and symptoms associated with labor migration among Cambodian migrant workers to Thailand. Two qualitative methods identified a number of mental health problems faced by Cambodian migrant workers in Thailand, including the presence of anxiety and depression-like problems among this population, described in local terminology as pibak chet (sadness), keut chreun (thinking too much), and khval khvay khnong chet (worry in heart). Key informants revealed the extent to which psychosocial well-being is associated with conditions of poverty, including debt and lack of access to basic services.

Validating the Center for Epidemiological Studies Depression Scale for Children in Rwanda

OBJECTIVE

We assessed the validity of the Center for Epidemiological Studies Depression Scale for Children (CES-DC) as a screen for depression in Rwandan children and adolescents. Although the CES-DC is widely used for depression screening in high-income countries, its validity in low-income and culturally diverse settings, including sub-Saharan Africa, is unknown.

METHOD

The CES-DC was selected based on alignment with local expressions of depression-like problems in Rwandan children and adolescents. To examine criterion validity, we compared CES-DC scores to depression diagnoses on a structured diagnostic interview, the Mini International Neuropsychiatric Interview for Children (MINI KID), in a sample of 367 Rwandan children and adolescents aged 10 through 17 years. Caregiver and child or adolescent self-reports endorsing the presence of local depression-like problems agahinda kenshi (persistent sorrow) and kwiheba (severe hopelessness) were also examined for agreement with MINI KID diagnosis.

RESULTS

The CES-DC exhibited good internal reliability (α = .86) and test-retest reliability (r = .85). The area under the receiver operating characteristic curve for the CES-DC was 0.825 when compared to MINI KID diagnoses, indicating a strong ability to distinguish between depressed and nondepressed children and adolescents in Rwanda. A cut point of≥30 corresponded with a sensitivity of 81.9% and a specificity of 71.9% in this referred sample. MINI KID diagnosis was well aligned with local expressions of depression-like problems.

CONCLUSION

The CES-DC demonstrates good psychometric properties for clinical screening and evaluation in Rwanda, and should be considered for use in this and other low-resource settings. Population samples are needed to determine a generalizable cut point in nonreferred samples.

Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers

BACKGROUND

Often new arrivals from refugee backgrounds have experienced poor health and limited access to healthcare services. The maternal and child health (MCH) service in Victoria, Australia, is a joint local and state government operated, cost-free service available to all mothers of children aged 0-6 years. Although well-child healthcare visits are useful in identifying health issues early, there has been limited investigation in the use of these services for families from refugee backgrounds. This study aims to explore experiences of using MCH services, from the perspective of families from refugee backgrounds and service providers.

METHODS

We used a qualitative study design informed by the socioecological model of health and a cultural competence approach. Two geographical areas of Melbourne were selected to invite participants. Seven focus groups were conducted with 87 mothers from Karen, Iraqi, Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese backgrounds, who had lived an average of 4.7 years in Australia (range one month-18 years). Participants had a total of 249 children, of these 150 were born in Australia. Four focus groups and five interviews were conducted with MCH nurses, other healthcare providers and bicultural workers.

RESULTS

Four themes were identified: facilitating access to MCH services; promoting continued engagement with the MCH service; language challenges; and what is working well and could be done better. Several processes were identified that facilitated initial access to the MCH service but there were implications for continued use of the service. The MCH service was not formally notified of new parents arriving with young children. Pre-arranged group appointments by MCH nurses for parents who attended playgroups worked well to increase ongoing service engagement. Barriers for parents in using MCH services included access to transportation, lack of confidence in speaking English and making phone bookings. Service users and providers reported that continuity of nurse and interpreter is preferred for increasing client-provider trust and ongoing engagement.

CONCLUSIONS

Although participants who had children born in Melbourne had good initial access to, and experience of, using MCH services, significant barriers remain. A systems-oriented, culturally competent approach to service provision would improve the service utilisation experience for parents and providers, including formalising links and notifications between settlement services and MCH services.

Group Interventions were not Effective for Female Turkish Migrants with Recurrent Depression - Recommendations from a Randomized Controlled Study

We tested group interventions for women with a Turkish migration background living in Austria and suffering from recurrent depression. N = 66 participants were randomized to: (1) Self-Help Groups (SHG), (2) Cognitive Behavior Therapy (CBT) Groups, and (3) a Wait-List (WL) Control condition. Neither SHG nor CBT were superior to WL. On an individual basis, about one third of the participants showed significant improvements with respect to symptoms of depression. Younger women, women with a longer duration of stay in Austria and those who had encountered a higher number of traumatic experiences, showed increased improvement of depressive symptoms. The results suggest that individual treatment by ethnic, female psychotherapists should be preferred to group interventions.

Mental health of newly arrived Burmese refugees in Australia: contributions of pre-migration and post-migration experience

OBJECTIVE

This study documents the mental health status of people from Burmese refugee backgrounds recently arrived in Australia, then examines the contributions of gender, pre-migration and post-migration factors in predicting mental health.

METHOD

Structured interviews, including a demographic questionnaire, the Harvard Trauma Questionnaire, the Post-migration Living Difficulties Checklist and Hopkins Symptom Checklist assessed pre-migration trauma, post-migration living difficulties, depression, anxiety, somatization and traumatization symptoms in a sample of 70 adults across five Burmese ethnic groups.

RESULTS

Substantial proportions of participants reported psychological distress in symptomatic ranges including: post-traumatic stress disorder (9%), anxiety (20%) and depression (36%), as well as significant symptoms of somatization (37%). Participants reported multiple and severe pre-migration traumas. Post-migration living difficulties of greatest concern included communication problems and worry about family not in Australia. Gender did not predict mental health. Level of exposure to traumatic events and post-migration living difficulties each made unique and relatively equal contributions to traumatization symptoms. Post-migration living difficulties made unique contributions to depression, anxiety and somatization symptoms.

CONCLUSIONS

While exposure to traumatic events impacted on participants' mental well-being, post-migration living difficulties had greater salience in predicting mental health outcomes of people from Burmese refugee backgrounds. Reported rates of post-traumatic stress disorder symptoms were consistent with a large review of adults across seven western countries. High levels of somatization point to a nuanced expression of distress. Findings have implications for service provision in terms of implementing appropriate interventions to effectively meet the needs of this newly arrived group in Australia.

Integrating mental health services into humanitarian relief responses to social emergencies, disasters, and conflicts: a case study

Utilizing lessons learned from development and implementation of "Project Liberty" in New York City, created in response to the attacks of September 11, 2001, this paper explores the importance of integrating structured mental health services with community-based social service programs offered in large-scale humanitarian relief responses. Relevant international research studies illustrating similar integrated programs are also reviewed. The primary approach is community-based and resilience-enhancement focused, offering structure, stability, support, and community cohesion, with an added integrated screening component to identify persons with severe treatable mental health conditions. Because there is thus far little evidence that resilience-enhancing programs are effective for severe mental health conditions, a secondary program initiated in parallel would be staffed with more specialized providers offering services for those referred from the primary program. The key implication supports the establishment of more effective links between programs and professionals from different disciplines, who then can more effectively implement integrated program responses to large-scale disasters.

Developing a logic model for youth mental health: participatory research with a refugee community in Beirut

Although logic models are now touted as an important component of health promotion planning, implementation and evaluation, there are few published manuscripts that describe the process of logic model development, and fewer which do so with community involvement, despite the increasing emphasis on participatory research. This paper describes a process leading to the development of a logic model for a youth mental health promotion intervention using a participatory approach in a Palestinian refugee camp in Beirut, Lebanon. First, a needs assessment, including quantitative and qualitative data collection was carried out with children, parents and teachers. The second phase was identification of a priority health issue and analysis of determinants. The final phase in the construction of the logic model involved development of an intervention. The process was iterative and resulted in a more grounded depiction of the pathways of influence informed by evidence. Constructing a logic model with community input ensured that the intervention was more relevant to community needs, feasible for implementation and more likely to be sustainable.

Agricultural cycle and the prevalence of posttraumatic stress disorder: a longitudinal community study in postwar Mozambique

The influence of physical activity on the prevalence and remission of war-related mental disturbances has never been systematically evaluated. This study examined the influence of participation in the agricultural cycle on the posttraumatic stress disorder (PTSD) prevalence and correlated symptoms longitudinally in post civil war Mozambique. Prevalence rates were examined in the end and the outset of the agricultural cycle in a community population (N = 240). The agricultural cycle, which is characterized by fluctuations in physical activities, social connectedness, and the sense of purpose in life influences the PTSD prevalence and correlated symptoms. By studying the influence of the agricultural cycle on PTSD prevalence, severe PTSD cases that fail to respond to the agricultural cycle can be identified, and subsequently evaluated regarding the need for specialized care.

What research tells us about the mental health and psychosocial wellbeing of Sudanese refugees: a literature review

Sudan has long been one of the world's chief refugee-producing nations. Many researchers and practitioners have developed considerable interest in culturally-specific information on the mental health and wellbeing of Sudanese refugees. In this selective review of studies with Sudanese refugees, on mental health and psychosocial wellbeing, coping strategies and interventions, most quantitative studies found high rates of psychopathology, particularly PTSD and depression. However, some studies using mixed methods cautioned that while many Sudanese refugees have symptoms of traumatic stress, their functioning was not necessarily reduced, and they themselves often reported more concern with current stressors such as family problems than with past trauma. Some qualitative studies suggest that many Sudanese refugees use coping strategies such as silence, stoicism, and suppression. Few studies were available regarding appropriate interventions for Sudanese refugees and it remains unclear which aspects of standard treatments used by western-trained mental health practitioners may be beneficial for members of this population.

Post-traumatic stress in asylum seekers and refugees from Chechnya, Afghanistan, and West Africa: gender differences in symptomatology and coping

BACKGROUND

Internationally, a high number of refugees are in need of help as a consequence of post-traumatic stress or acculturation problems.

AIMS

The present study investigated the gender-specific requirements for such interventions taking clinical symptoms as well as coping strategies into account.

METHODS

Five psychometric instruments assessing anxiety, depression, posttraumatic stress, somatic symptoms, and social adaptation were administered and semi-structured interviews with n = 150 asylum seekers and refugees from Chechnya, Afghanistan, and West Africa were conducted.

RESULTS

On the level of total test scores, women reported significantly more somatic symptoms than men but there were no further gender differences. On the item level of the questionnaires as well as with respect to the categories obtained from the interview data, marked gender differences were found. Women, as compared to men, reported more somatic symptoms, emotional outbursts, and loss of sexual interest, while men reported detachment. For women, typical coping strategies were concentrating on their children and various indoor activities, while men preferred looking for work and socializing.

CONCLUSION

Social psychiatric interventions should take gender-specific symptoms and coping strategies into account. For asylum seekers and refugees, same gender client-therapist dyads and groups are highly recommended.

Returning home: resettlement of formerly abducted children in Northern Uganda

This exploratory qualitative study considers the subjective resettlement experiences of children forced into armed conflict in Northern Uganda from the perspectives of 11 former child combatants and 11 adult community members. A thematic analysis was performed on the narrative data. The bioecological model was used to provide a conceptual framework for key themes. Major findings included the overarching impact of ongoing armed conflict on returnees' lives, the important role of the family in supporting children's resettlement, the harassment of former child soldiers by community members, and the community's inability to support systematically the returning children in tangible ways. This study recommends that humanitarian services at all levels strengthen the capacity of families to care for the material and psychoemotional needs of former child soldiers within their communities.

Paraprofessional counselling within asylum seekers' groups in the Netherlands: transferring an approach for a non-western context to a European setting

This article presents the application of a psychosocial care approach, which has been developed for and in a non-western context, within an asylum seekers' setting in the Netherlands. The project aimed to increase access to basic psychosocial care to a target population that experiences difficulties in entering mental healthcare services, by a group of trained peer asylum seekers and refugees. The development of an informal paraprofessional support system makes better use of existing resources, provides secondary benefits for the participants and helps to overcome the treatment gap between perceived needs and the formal mental healthcare system. The article describes the key components of such an approach, the Dutch context, the project implementation and finishes with a discussion on outcomes, strengths and weaknesses, risks and recommendations. In summary, we found this community approach to be applicable and relevant within an asylum seekers' centre, as it incorporates an additional easy-access level of psychosocial care and social agency, which seemed to empower participants and help prevent psychosocial problems from becoming more severe.

The ISTSS/Rand guidelines on mental health training of primary healthcare providers for trauma-exposed populations in conflict-affected countries

Mental health care for trauma-exposed populations in conflict-affected developing countries often is provided by primary healthcare providers (PHPs), including doctors, nurses, and lay health workers. The Task Force on International Trauma Training, through an initiative sponsored by the International Society for Traumatic Stress Studies and the RAND Corporation, has developed evidence- and consensus-based guidelines for the mental health training of PHPs in conflict-affected developing countries. This article presents the Guidelines, which provide a conceptual framework and specific principles for improving the quality of mental health training for PHPs working with trauma-exposed populations.