Short- and longer-term impacts of Child Friendly Space Interventions in Rwamwanja Refugee Settlement, Uganda

Delivering therapy over telephone in a humanitarian setting: a pilot randomized controlled trial of common elements treatment approach (CETA) with Syrian refugee children in Lebanon

BACKGROUND

In recent years, the number of forcibly displaced persons has risen worldwide, with approximately 40% being children and adolescents. Most of them are hosted in low- and middle-income countries (LMICs). Many individuals meet the criteria for mental health issues, which can also be exacerbated by a number of risk factors, including low socioeconomic status, displacement, and stressors linked to conflicts in their country or region of origin. However, the vast majority never receive treatment for their psychological problems due to multiple reasons, including a shortage of mental health professionals in LIMCs, transportation challenges in accessing clinics, and clinic hours conflicting with family commitments. In the current study we investigated whether individual psychotherapy delivered by trained lay counsellors over telephone to Syrian refugee children living in Lebanon is effective and overcomes barriers to treatment access.

METHODS

After adaptation of Common Elements Treatment Approach (CETA) to remote delivery over telephone (t-CETA), preliminary effectiveness of the treatment modality was assessed with a pilot single blind randomised controlled trial including a total sample of 20 refugee children with diagnosed mental health problems. Data was analysed applying a Bayesian approach.

RESULTS

There was a significant session-by-session decrease in self-reported mental health symptoms over the course of treatment. Independent assessments showed that t-CETA resulted in a greater reduction of symptoms than standard in-person treatment as usual. There was no difference between groups for impairment. Importantly, the majority of children allocated to t-CETA completed treatment whilst no children in the treatment as usual condition were able to do so.

CONCLUSION

The study provides preliminary evidence that telephone-delivered psychotherapy in a humanitarian setting, delivered by lay counsellors under supervision, works and significantly increases access to treatment compared to traditional in-person treatment. However, findings remain to be replicated in larger trials.

TRIAL REGISTRATION

Clinical Trials. gov ID: NCT03887312; registered 22nd March 2019.

A pilot study of a brief and scalable psychosocial intervention for children and adolescents following disasters

OBJECTIVES

Following disaster exposure, a significant proportion of children/adolescents will develop levels of post-traumatic stress symptoms (PTSS) that do not meet diagnostic threshold for PTSD, but which cause ongoing distress. This paper describes the development and pilot testing of a brief, scalable, psychosocial intervention. SOLAR-Kids/Teens has been designed to be delivered by non-mental health professionals ('coaches') to children/adolescents experiencing moderate levels of PTSS following disasters.

METHODS

An international collaboration of experts developed The Skills fOr Life Adjustment and Resilience (SOLAR) for Kids and Teens programs. The programs were piloted-using a pre-post mixed methods design-with 10 children and adolescents (8-18 years), with the aims of examining the feasibility of the program's delivery model as well as the program's potential usefulness.

RESULTS

The pilot data indicated that after 1 day of training and with ongoing supervision, the SOLAR program was safe and feasible for coaches to deliver to children/adolescents experiencing PTSS. Coaches reported increased knowledge (p = .001), confidence (p = .001) and skills (p = .006). The programs were acceptable to coaches, children/adolescents and parents. Parents and children/adolescents reported reductions in trauma and anxiety symptoms from pre- to post-treatment, with moderate to large effect sizes.

CONCLUSIONS

The preliminary findings demonstrate that the SOLAR-Kids/Teens program is feasible, acceptable and safe to be delivered by trained non-mental health professionals to children and adolescents experiencing PTSS and anxiety following disaster exposure. Randomized controlled trials are required to evaluate the efficacy of the SOLAR-Kids/Teens programs.

Social work post-disaster response in Iran: A case study of the 2019 mass flooding in Poldokhtar, Lorestan

Flash-flooding affected Iran in March 2019 causing the displacement of thousands of people. Social workers established a Child Friendly Space (CFS) and applied comprehensive case management to provide psychosocial support for people who were affected by flooding (PWAF) (n = 565) in a community in Poldokhtar, covering a period of 3 months. Outreach services, involving community-volunteers, providing counseling, establishing CFS, training PWAF for reducing violence, and preventing child abuse were essential social work post-disaster interventions to support vulnerable populations. The article reflects upon the often-neglected role of social workers in post-disaster settings, and brings new material for discussion from the unexplored field of Iranian social workers.

Interventions to enhance psychological resilience in forcibly displaced children: a systematic review

BACKGROUND

Children represent nearly 40% of forcibly displaced populations and are subject to stressors that affect well-being. Little is known about the effects of interventions to enhance psychological resilience in these children, outside clinical settings.

METHODS

We conducted a systematic review, following Cochrane methods. Eligible studies tested resilience-enhancing interventions outside clinical settings in forcibly displaced children/adolescents. We included longitudinal quantitative studies with comparator conditions irrespective of geographical scope or language. We searched articles published between January 2010 and April 2020 in PubMed, Embase, Cochrane Library, Web of Science, PsycINFO and the WHO's Global Index Medicus. To standardise effect sizes across the different reported outcomes, we transformed reported mean differences to standardised mean differences using Hedge's g statistic with associated 95% CI. We pooled data for meta-analysis where appropriate. We used Cochrane tools to assess study risk of bias and used Grading of Recommendations Assessment, Development and Evaluation to determine evidence quality for meta-analysed outcomes.

RESULTS

Searches yielded 4829 results. Twenty-three studies met inclusion criteria. Studies reported 18 outcomes measured by 48 different scales; only 1 study explicitly measured resilience. Eight studies were randomised controlled trials; the rest were non-randomised pre-post studies. Interventions were diverse and typically implemented in group settings. Studies reported significant improvement in outcomes pertinent to behavioural problems, coping mechanisms and general well-being but not to caregiver support or psychiatric symptoms. In meta-analysis, resilience was improved (g_av=0.194, 95% CI 0.018 to 0.369), but anxiety symptoms and quality of life were not (g_av=-0.326, 95% CI -0.782 to 0.131 and g_av=0.325, 95% CI -0.027 to 0.678, respectively). Risk of bias varied. Quality of evidence for most graded outcomes was very low.

CONCLUSIONS

The multiplicity of study designs, intervention types, outcomes and measures incumbered quantifying intervention effectiveness. Future resilience research in this population should use rigorous methods and follow reporting guidelines.

PROSPERO REGISTRATION NUMBER

CRD42020177069.

The effectiveness of therapeutic interventions on psychological distress in refugee children: A systematic review

OBJECTIVE

To systematically review existing research exploring the effectiveness of psychological interventions in reducing symptoms of distress amongst refugee and asylum-seeker children.

METHOD

Six databases were searched to identify English studies presenting original empirical quantitative data (published before September 2022) testing the efficacy of psychological interventions for children from refugee and asylum-seeking backgrounds. Quality of studies were assessed through the Appraisal Tool for Cross-Sectional Studies as well as the Cochrane Risk of Bias Tool. Relevant data were extracted to facilitate a narrative synthesis.

RESULTS

Seventy-one eligible articles were identified (n > 10,000). A number of cognitive-behavioral, psychosocial, and trauma-focused interventions that catered specifically to children and their families were identified. A synthesis of these results suggest that interventions may assist in the reduction of various psychopathologies, although the effects were mixed across intervention types.

CONCLUSIONS

While the review yielded promising findings, most findings were derived from small pilot and empirical studies, leading to difficulties with drawing conclusions. There remains a need for studies using more rigorous research methodologies to expand and ratify this valuable knowledge base.

CLINICAL SIGNIFICANCE

 Forced displacement is at an all-time high. Many children are being forced to seek asylum and refuge, and they become vulnerable to the development of poor mental health, with limited understanding surrounding how to appropriately intervene. This review aims to equip clinicians with increased knowledge and confidence in working therapeutically alongside clients from refugee or asylum-seeking background, with the goal of fostering positive mental health and wellbeing.

Improving adolescent mental health and protection in humanitarian settings: longitudinal findings from a multi-arm randomized controlled trial of child-friendly spaces among South Sudanese refugees in Uganda

BACKGROUND

The effects of conflict and displacement on adolescent mental health and protection are profound and can have lasting consequences. We aimed to investigate the effectiveness of two group-based psychosocial interventions on mental health and protection of South Sudanese refugee adolescents.

METHODS

A randomized controlled trial was done in four villages within the Omugo extension of Rhino Camp refugee settlement in the West Nile region of Uganda. Male and female adolescents (aged 9-14 years) were randomly assigned to attend 12 weeks of either a Standard psychosocial intervention delivered in a child-friendly space (CFS) or a more structured sequential delivery of psychosocial sessions guided by a newly developed Toolkit for Child-Friendly Spaces in Humanitarian Settings. The primary outcomes were psychological distress and resilience 12 months after baseline assessment. The trial is registered with ClinicalTrials.gov, NCT03897894.

RESULTS

Between May 28, 2019, and February 20, 2020, 1,280 eligible adolescents were recruited. With 70.2% retention at follow-up, 214 assigned to the Standard, 211 assigned to the Toolkit, and 370 assigned to the waitlist control were included in the intention-to-treat and as-treated analysis. Both the Toolkit and Standard approaches were more effective in reducing psychological distress and perceived protection risks reported by adolescents compared to no intervention. Differential intervention impacts are indicated in subgroup analyses.

CONCLUSIONS

The trial found that both psychosocial interventions when implemented in a CFS are well suited as a first-line mental health and violence prevention intervention for adolescent populations exposed to conflict and forced displacement. Where feasible, CFS should be implemented as a primary response strategy soon after displacement to improve psychological health and reduce the risk environment for adolescents.

The Effectiveness of Women and Girls Safe Spaces: A Systematic Review of Evidence to Address Violence Against Women and Girls in Humanitarian Contexts

One in three women and girls will experience violence in their lifetime. In conflict and postconflict settings, the incidence of violence against women and girls (VAWG) is exacerbated, resulting in increased negative social, economic, health, and psychosocial effects. In an attempt to prevent and respond to the occurrence of VAWG in humanitarian settings, Women and Girls Safe Spaces (WGSS) have been promoted as a promising intervention. The authors conducted a systematic review to examine the current quantitative evidence available on the impact and effectiveness of WGSS programs. The authors reviewed relevant peer-reviewed and gray literature using predefined search terms for potential inclusion. Seven records met inclusion criteria. Records included evaluations of WGSS programs implemented in the Democratic Republic of the Congo, Ethiopia, Uganda, Tanzania, Kenya, Bangladesh, and Pakistan. While none of the studies reported reductions in exposure to or incidence of VAWG among program participants, three evaluations demonstrated moderate improvements in psychosocial well-being, social support, and attitudes toward rites of passage. Additionally, only three of the seven evaluations employed rigorous methodologies. This study illustrates the paucity of existing quantitative evidence around the impact of WGSS and the need for further research examining the potential benefits of this widely implemented intervention for women and girls. A stronger evidence base has the potential to inform policy and program development and to help governments, organizations, and communities better allocate limited resources in response to VAWG.

Advancing and translating knowledge: a systematic inquiry into the 2010-2020 mental health and psychosocial support intervention research evidence base

Background and study objectives

MHPSS is increasingly seen as a critical component to effective and responsible humanitarian programming. This review examines the extent to which MHPSS research generated since 2010 has contributed to the public health evidence base and how this has influenced and impacted programming and policy in humanitarian settings.

Methods

This mixed-method study included a scoping literature review (n = 50) and a consultation process with qualitative key informant interviews (n = 19) and online survey responses (n = 52) to identify the facilitating and inhibiting factors for the two areas of inquiry and to understand the broader context in which knowledge is generated and taken up. The interviews were thematically analysed and the survey responses were descriptively analysed.

Results

The review identified a rapidly growing evidence base that has evaluated a range of MHPSS interventions. However, few studies examined long-term impacts of interventions, there was limited direct evidence on outcomes for children and adolescents and whole family approaches, and there were minimal replications of the same approach that could test efficacy across settings and population groups. A general shift was identified in the consultation process away from a focus on disorder towards the more positive aspects of wellbeing. However, there remained a mismatch in many studies included in the literature review, whereby the interventions were broad, community-based but the outcome measures used still focused on changes in symptoms of mental disorders.

Conclusion

The evidence base for MHPSS has grown significantly over the last 10 years. However, several knowledge gaps remain, as does the divide between research and practice. Moving forward, MHPSS intervention research needs to be more responsive to the needs on the ground.

Empowering refugee families in transit: the development of a culturally competent and compassionate training and support package

Background

Refugee parents who fled conflicts suffered violence and traumas and face huge challenges in supporting the health and welfare of their children while in transit.

Aims

To describe the development of a culturally competent and compassionate training and support package (TSP) for nurses, social and health care workers and volunteers, with a focus on parenting needs among unsettled refugees fleeing conflict.

Methods

The multi-method approach included: a scoping review covering parenting needs of refugees fleeing conflict zones; collection of stories from refugee parents, healthcare workers and volunteers via a mobile application; discussions between team members; a piloted and evaluated curriculum.

Results

High levels of family distress and deterioration of parental identity were identified. Informed by these results, the curriculum is articulated along 20 bite-sized learning units, covering four age stages of childhood as well as targeting adults’ well-being. Pilot training was evaluated positively, confirming feasibility and usefulness of the TSP.

Conclusions

Unsettled refugee parents fleeing conflicts face psycho-social and practical difficulties negatively affecting their parenting skills. The care workforce should be trained in order to provide culturally competent and compassionate support to help these families. Open access digital platforms are promising as autodidactic and self-help tools among hard-to-reach populations.

Educational, psychosocial, and protection outcomes of child- and youth-focused programming with Somali refugees in Dollo Ado, Ethiopia

Child- and youth-friendly spaces have become a common feature of emergency humanitarian provision. This study reports on the outcomes of child and youth learning centres (CYLCs) in Ethiopia's Buramino Camp established for those fleeing conflict in Somalia. Eighty-five youths completed baseline assessments shortly after arrival and follow-up assessments three to six months later. Caregivers of 106 younger children completed similar appraisals. 693 children attending the CYLCs completed pre- and post-educational assessments, which indicated major gains-significant at p<0.0001-in both literacy (younger children, t=9.06; youth, t=13.87) and numeracy (younger children, t=13.94; youths, t=17.10). Children's CYLC attendance increased reports of met needs among caregivers (t=2.53, p<0.05) and youths (t=2.57, p<0.05), and, among caregivers but not youths, significantly moderated protection concerns (t=2.39, p<0.05, and t=-1.90, p=0.06, respectively). There was general improvement in psychosocial well-being over time for all children; CYLC attendance predicted greater reductions in reported difficulties only among younger children (t=2.51, p<0.05).

Improving mental health and psychosocial wellbeing in humanitarian settings: reflections on research funded through R2HC

Major knowledge gaps remain concerning the most effective ways to address mental health and psychosocial needs of populations affected by humanitarian crises. The Research for Health in Humanitarian Crisis (R2HC) program aims to strengthen humanitarian health practice and policy through research. As a significant portion of R2HC's research has focused on mental health and psychosocial support interventions, the program has been interested in strengthening a community of practice in this field. Following a meeting between grantees, we set out to provide an overview of the R2HC portfolio, and draw lessons learned. In this paper, we discuss the mental health and psychosocial support-focused research projects funded by R2HC; review the implications of initial findings from this research portfolio; and highlight four remaining knowledge gaps in this field. Between 2014 and 2019, R2HC funded 18 academic-practitioner partnerships focused on mental health and psychosocial support, comprising 38% of the overall portfolio (18 of 48 projects) at a value of approximately 7.2 million GBP. All projects have focused on evaluating the impact of interventions. In line with consensus-based recommendations to consider a wide range of mental health and psychosocial needs in humanitarian settings, research projects have evaluated diverse interventions. Findings so far have both challenged and confirmed widely-held assumptions about the effectiveness of mental health and psychosocial interventions in humanitarian settings. They point to the importance of building effective, sustained, and diverse partnerships between scholars, humanitarian practitioners, and funders, to ensure long-term program improvements and appropriate evidence-informed decision making. Further research needs to fill knowledge gaps regarding how to: scale-up interventions that have been found to be effective (e.g., questions related to integration across sectors, adaptation of interventions across different contexts, and optimal care systems); address neglected mental health conditions and populations (e.g., elderly, people with disabilities, sexual minorities, people with severe, pre-existing mental disorders); build on available local resources and supports (e.g., how to build on traditional, religious healing and community-wide social support practices); and ensure equity, quality, fidelity, and sustainability for interventions in real-world contexts (e.g., answering questions about how interventions from controlled studies can be transferred to more representative humanitarian contexts).

Editorial: Navigating the science-practice gap in child maltreatment

This issue of the Journal provides an extraordinarily rich array of timely and important investigations on topics ranging from psychotic symptoms in adolescents to several types of neurodevelopmental disorders to brain structure in young children with sleep disturbances. Papers feature longitudinal studies, a meta-analysis, and intervention research, including follow-up of a randomized clinical trial. Remarkably, these studies involve tens of thousands of children and adolescents residing on four continents. The longitudinal studies are especially noteworthy for their large cohorts and systematic assessments.