Commentary: Advancing an implementation science agenda on mental health and psychosocial responses in war-affected settings: comment on trials of a psychosocial intervention for youth affected by the Syrian crisis - by Panter-Brick et al. (2018)

Pathways to resilience and pathways to flourishing: Examining the added-value of multisystem research and intervention in contexts of war and forced displacement

This paper examines the added-value that multisystem approaches bring to research and intervention in contexts of war and forced displacement. I highlight what is useful and truly innovative about systems-level work, aware that providing data-related evidence is only part of the story when connecting research to policy and practice. I discuss four types of added-value: these are conceptual, instrumental, capacity-building, and connectivity impacts that, respectively, aim to change current knowledge, improve implementation, build research skills, and strengthen network connectivity. Specifically, systems-based research can help transform the key frames of humanitarian work, fostering the more integrated and distributive models of professional assistance known as resilience and network humanitarianism. I argue that systems-level approaches on resilience and flourishing in war-affected and refugee populations help to articulate new mindsets, methodologies, partnerships, and ways of working relevant for humanitarian research, policy and practice. I focus attention on interdisciplinary, interventionist, prospective, transgenerational, and network-building initiatives. My specific examples cover the family context of mental health and trauma memory in Afghanistan, as well as program evaluation with Syrian refugees in Jordan, connecting stress biology to human experience, and social networks to psychological empowerment. The paper suggests future directions to support more effective and impactful systems-level work in protracted humanitarian crises.

Champion and audit and feedback strategy fidelity and their relationship to depression intervention fidelity: A mixed method study

Background

Globally, mental health disorders rank as the greatest cause of disability. Low and middle-income countries (LMICs) hold a disproportionate share of the mental health burden, especially as it pertains to depression. Depression is highly prevalent among those with non-communicable diseases (NCDs), creating a barrier to successful treatment. While some treatments have proven efficacy in LMIC settings, wide dissemination is challenged by multiple factors, leading researchers to call for implementation strategies to overcome barriers to care provision. However, implementation strategies are often not well defined or documented, challenging the interpretation of study results and the uptake and replication of strategies in practice settings. Assessing implementation strategy fidelity (ISF), or the extent to which a strategy was implemented as designed, overcomes these challenges. This study assessed fidelity of two implementation strategies (a 'basic' champion strategy and an 'enhanced' champion + audit and feedback strategy) to improve the integration of a depression intervention, measurement based care (MBC), at 10 NCD clinics in Malawi. The primary goal of this study was to assess the relationship between the implementation strategies and MBC fidelity using a mixed methods approach.

Methods

We developed a theory-informed mixed methods fidelity assessment that first combined an implementation strategy specification technique with a fidelity framework. We then created corresponding fidelity indicators to strategy components. Clinical process data and one-on-one in-depth interviews with 45 staff members at 6 clinics were utilized as data sources. Our final analysis used descriptive statistics, reflexive-thematic analysis (RTA), data merging, and triangulation to examine the relationship between ISF and MBC intervention fidelity.

Results

Our mixed methods analysis revealed how ISF may moderate the relationship between the strategies and MBC fidelity. Leadership engagement and implementation climate were critical for clinics to overcome implementation barriers and preserve implementation strategy and MBC fidelity. Descriptive statistics determined champion strategy fidelity to range from 61 to 93% across the 10 clinics. Fidelity to the audit and feedback strategy ranged from 82 to 91% across the 5 clinics assigned to that condition. MBC fidelity ranged from 54 to 95% across all clinics. Although correlations between ISF and MBC fidelity were not statistically significant due to the sample of 10 clinics, associations were in the expected direction and of moderate effect size. A coefficient for shared depression screening among clinicians had greater face validity compared to depression screening coverage and functioned as a proximal indicator of implementation strategy success.

Conclusion

Fidelity to the basic and enhanced strategies varied by site and were influenced by leadership engagement and implementation climate. Champion strategies may benefit from the addition of leadership strategies to help address implementation barriers outside the purview of champions. ISF may moderate the relationship between strategies and implementation outcomes.

Psychosocial concerns in a context of prolonged political oppression: Gaza mental health providers' perceptions

In this qualitative exploratory study, we investigated the perspectives of mental health providers in Gaza, Palestine, regarding the primary concerns of their clients who are exposed to low-intensity warfare and structural violence. We conducted qualitative interviews with 30 psychologists, social workers, psychiatric nurses, and psychiatrists providing services to communities in Gaza. Participants were asked to discuss their clients' most commonly occurring mental health problems, diagnoses, and psychosocial conditions. Thematic analysis identified one superordinate theme (Impact of the Blockade on Mental Health and Quality of Life) and four second-order themes (Concerns about Social Problems, General Concerns about Quality of Life, Concerns about the Mental Health of the Community, and Concerns Related to Children's Mental Health). Participants indicated that the social and political dimensions of mental health and the economic, educational, and health-related consequences of the ongoing blockade of Gaza were the main determinants of psychological burden among their clients. Findings demonstrated the importance of adopting an approach to mental health that includes understanding psychological indicators in a broader framework informed by human rights and social justice. Implications for research and clinical work are discussed, including the role of investments in social capital that may provide individuals with access to resources such as social support, which may in turn promote overall mental health.