The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones

Fostering Prosociality in Refugee Children: An Intervention With Rohingya Children

Prosocial behavior is a distinguishing characteristic of human nature. Although prosocial behaviors emerge early in development, contextual factors play an important role in how these behaviors are manifested over development. A large body of research focuses on the trajectory of prosocial development across diverse cultures and investigating contexts that foster it. Against this backdrop of developmental research endeavoring to understand and enhance the cooperative side of humanity, is the catastrophic impact of profoundly negative forces on social-emotional development for children forced to flee from violent conflict. Close to half a million Rohingya children, whose families were forced to flee genocide in Myanmar, now live in the largest refugee camp in the world. To examine the resilience of human prosociality in the face of extreme adversity, we documented initial levels of prosociality in Rohingya refugee children living in a mega-camp (Cox's Bazar, Bangladesh) and the extent to which those levels were improved following a multifaceted intervention designed to foster prosociality. The research was a partnership between Rohingya community members with lived experience, humanitarian practitioners, and developmental researchers. A sample of 152 Rohingya children (5-12 years) participated in pre- and postintervention assessments of prosocial behaviors and related cognitive-affective processes. The 10-day collaboration-based intervention was implemented between November 2021 and January 2022 by Rohingya researchers. Birthplace was used as a proxy measure of trauma level. Children born in Myanmar (N = 88) directly experienced relatively higher levels of trauma (genocide, forced migration) than children who were born in the camp after their families fled from Myanmar (N = 64). Children were individually tested pre- and postintervention with a task battery, including a helping (Origami) and two sharing tasks (Dictator Game [DG], Forced Choice sharing) measuring prosocial behavior. Assessments of related cognitive-affective processes included measures of empathic responding and emotion perspective-taking in story tasks (Imagine, Judgment) and executive function (EF) skills (Younger: Hearts & Flowers; Older: Dimensional Change Card Sorting). Small group intervention sessions conducted over 10 days targeted these prosocial behaviors and cognitive-affective processes and were based on collaborative activities, emotion perspective taking and EF skills training with the same partner throughout the intervention phase. We used latent change modeling to examine initial levels (preintervention) and intervention-related changes in these measures from pre- to postintervention. Prosocial responding was found across all measures (preintervention) and improvements (pre- to postintervention change) were apparent across most measures. Age and birthplace variables were significant predictors of initial levels and intervention-related change. Initial levels: Regarding age, older children (9-12 years) showed higher levels than younger children (5-8 years) of sharing in the Forced Choice task but lower levels in the DG. Older children also showed higher levels of empathic responding when asked to report how they would feel and respond to another person's misfortune in the Imagine task. Regarding birthplace, prior to the intervention camp-born children showed higher levels than Myanmar-born children of helping in the Origami task and reported more behavioral responses indicating how they would respond to misfortune in the Imagine task. In contrast, Myanmar-born children had higher levels of sharing in the DG and consistently chose equality over inequality in the Forced Choice sharing task, even when their partner would receive more, indicating a pattern of generosity in these children. Myanmar-born children had lower levels than camp-born children on EF measures. Intervention-related change: Regarding age, older but not younger children were more likely to increase choices for equality over inequality on the Forced Choice sharing task following the intervention. Regarding birthplace and helping, camp-born children increased behaviors that helped their partner make origami shapes themselves ("how-to" helping), whereas Myanmar-born children increased behavior that took over folding for their partner ("do-for" helping). For sharing tasks, Myanmar-born but not camp-born children increased sharing in the DG and showed an increased pattern of generosity in Forced Choice sharing task. In the Imagine story task, children born in Myanmar were more likely than those born in camp to increase empathic responding (i.e., imagining how they would feel). Children born in Myanmar showed less improvement on EF measures than children born in the camp. Taken together, these findings provide evidence that in a context of extreme adversity, Rohingya children exhibited prosociality and benefitted from a multifaceted intervention. Our research adds credence to the view that human prosociality is a fundamental characteristic of humanity that not only survives but can be enhanced in even the most adverse of childhood environments. Our multifaceted intervention, which was implemented within a collaborative social context and targeted prosocial behaviors and related cognitive-affective processes, was designed to be easily implemented within existing psychosocial support programs in refugee contexts. As the numbers of children affected by violent conflict and forced migration rise alarmingly worldwide, there is a critical need to expand research partnerships that aim to improve developmental outcomes for these millions of children.

Mapping the factors behind ongoing war stress in Ukraine-based young civilian adults

While the literature on well-being and stress following natural disasters is well-developed, it is less so when it comes to ongoing war experiences. Between September and October of 2022, 223 Ukraine-based civilian adults (156 women and 67 men) completed a survey measuring symptoms of post-traumatic stress disorder (PTSD), peritraumatic experiences, paranoia, quality of life, death anxiety, anxiety about weapons of mass destruction and depression (i.e. assumed 'war consequence' factors), as well as perceived social support, resilience, loneliness and expected military support from the West (i.e. assumed 'buffer' factors). Our exploratory structural equation model (SEM) suggests that Perceived Social Support predicted fewer PTSD Symptoms and more Peritraumatic Experiences. The regression modelling, however, shows that Perceived Social Support was also positively correlated with Peritraumatic Experiences. Highlighting the need for a civilian war stress buffer disruption theory, we argue that when composed of one's circle of family and friends, social support could likely mean greater exposure to war stressors through the mutual sharing of ongoing war experiences with no end in sight. Such a possible war stress sharing deterioration effect would imply that Perceived Social Support may compound peritraumatic distress if the support in question is offered by those facing the same grim reality.

Battling on two fronts: The mental wellbeing of war zone medics

The essential roles and responsibilities of healthcare professionals commissioned on the frontlines of active war zone/s are indispensible, wherein they are explicitly exposed to detrimental conditions due to conflicting situations. With compromised healthcare infrastructure in active war zones, the role of healthcare workers becomes fundamental in delivering urgent medical care while facing significant risks. Beyond instantaneous availability of medication, healthcare workers manoeuvre through the psychological trauma of war, addressing prevalent ordeal and inadequate mental health support. They appear as supporters for peace, documenting rampant atrocities and contribute actively to post-war revival by rebuilding healthcare infrastructure, providing psychosocial support and participation in public health initiatives. This viewpoint highlights the comprehensive impact of conflicting situations on healthcare infrastructure, thus underscoring the necessity for cooperation required for safeguarding of mental wellbeing of healthcare professionals required at the intersection of health and war.

Post-traumatic stress disorder and associated factors among high school students who experienced war in Woldia town

Background

The experience of war in recent time is very common around the world, and the impact is profound on the mental health of the victims, especially among the young population. The most implicated mental health problem is post-traumatic stress disorder, which comes after an exposure to trauma as a severe and long-term result of the traumatic event. Studies in developed countries revealed this finding, but there is insufficient information in developing countries, where much of war and conflict exist and young population live including Ethiopia. Therefore, this study aims to assess the prevalence and associated factors of post-traumatic stress disorder among high school students who experienced war.

Objective

We assessed the prevalence and factors associated with post-traumatic stress disorder among high school students who experienced war.

Methods

A multi-centered school base cross-sectional study was conducted from May 23 to June 08, 2022. Data were collected from high school students in Woldia town. Bivariable and multivariable logistic regression was used to identify the independent factors associated with post-traumatic stress disorder.

Results

A total of 338 of the 410 students participated in this study (94.5% response rate). The prevalence of post-traumatic stress disorder was 39.2%. In the multivariable analysis, poor social support (AOR = 3.40, 95% CI: 1.45, 7.95), depression (AOR = 3.24, 95% CI: 1.69,6.21), high level of perceived stress (AOR = 2.98, 95% CI: 1.61, 5.50), being in war fighting situation (AOR = 2.85, 95% CI: 1.40, 5.78), and witnessing the murder of family members or friends (AOR = 3.05, 95% CI: 1.47, 6.32) were factors significantly associated with post-traumatic stress disorder at a p-value <0.05.

Conclusions and recommendations

In this study, around two in five of high school students had post-traumatic stress disorder. Independent factors of PTSD were depression, high stress levels, poor social support, witnessing the murder of family members/friends, and being in war fighting situation. We recommend that the Ministry of Education and the Ministry of Health collaborate to integrate mental health services into schools. This focuses on the early detection of students at risk of PTSD, such as those with depression, high perceived stress levels, and exposure to murder or war, and provides necessary social support to prevent PTSD.

The 12 dimensions of health impacts of war (the 12-D framework): a novel framework to conceptualise impacts of war on social and environmental determinants of health and public health

Global rates of armed conflicts have shown an alarming increase since 2008. These conflicts have devastating and long-term cumulative impacts on health. The overriding aim in these conflicts is to achieve military or political goals by harming human life, which is the antithesis of the moral underpinnings of the health professions. However, the profession has rarely taken on a global advocacy role to prevent and eliminate conflicts and wars. To assume such a role, the health profession needs to be aware of the extensive and multiple impacts that wars have on population health. To facilitate this discourse, the author proposes a novel framework called 'The Twelve Dimensions of Health Impacts of War' (or the 12-D framework). The framework is based on the concepts of social and environmental determinants of population health. It has 12 interconnected 'dimensions' beginning with the letter D, capturing the adverse impacts on health (n=5), its social (n=4) and environmental determinants (n=3). For health, the indices are Deaths, Disabilities, Diseases, Dependency and Deformities. For social determinants of health, there are Disparities in socioeconomic status, Displacements of populations, Disruptions to the social fabric and Development reversals. For environmental determinants, there is Destruction of infrastructure, Devastation of the environment and Depletion of natural resources. A relatively simple framework could help researchers and lay public to understand the magnitude and quantify the widespread health, social and environmental impacts of war, comprehensively. Further validation and development of this framework are necessary to establish it as a universal metric for quantifying the horrific impacts of war on the planet and garner support for initiatives to promote global peace.

Feasibility, acceptability and preliminary effectiveness of a community-based group psychosocial support model for conflict survivors in Colombia: An assessment of in-person and remote intervention modalities during the COVID-19 pandemic

Background

Community-based psychosocial support (CB-PSS) interventions utilizing task sharing and varied (in-person, remote) modalities are essential strategies to meet mental health needs, including during the COVID-19 pandemic. However, knowledge gaps remain regarding feasibility and effectiveness.

Methods

This study assesses feasibility, acceptability and preliminary effectiveness of a CB-PSS intervention for conflict-affected adults in Colombia through parallel randomized controlled trials, one delivered in-person (n = 165) and the other remotely (n = 103), implemented during the COVID-19 pandemic and national protests. Interventions were facilitated by nonspecialist community members and consisted of eight problem-solving and expressive group sessions.

Findings

Attendance was moderate and fidelity was high in both modalities. Participants in both modalities reported high levels of satisfaction, with in-person participants reporting increased comfort expressing emotions and more positive experiences with research protocols. Symptoms of depression, anxiety and posttraumatic stress disorder improved among in-person participants, but there were no significant changes for remote participants in comparison to waitlist controls.

Implications

This CB-PSS intervention appears feasible and acceptable in both in-person and remote modalities and associated with reduction in some forms of distress when conducted in-person but not when conducted remotely. Methodological limitations and potential explanations and areas for future research are discussed, drawing from related studies.

Clinical characteristics of psychotic disorders in patients with childhood trauma

Childhood trauma is an important predictor of psychotic disorders, with special emphasis on physical and sexual abuse. It influences the clinical picture and course of psychotic disorders. This study was conducted in the Department of Psychiatry of the University Clinical Hospital Mostar. The sample consisted of 135 participants, aged 18 to 65 years. The screening instrument to examine cognitive status was the short version of MMSE-2. Patients' background information was collected using a sociodemographic questionnaire constructed for this study. To determine childhood trauma, the Child Abuse Experience Inventory was used to examine physical, sexual, and emotional abuse, neglect and domestic violence. The positive and negative syndrome scale scale was used to evaluate the clinical profile of psychoticism, the SSI questionnaire was used to evaluate the severity of suicidality, and the functionality of the participants was evaluated using the WHODAS 2.0. Results indicate that a significant number of participants with psychotic disorders experienced childhood trauma, an important determinant of their illness. Participants who had witnessed abuse had more severe clinical presentations (earlier onset and longer duration of illness) and more pronounced psychotic symptomatology and a lower degree of functionality. Decreased functionality is associated with witnessing abuse and physical abuse. During the civil war, a significant percentage of the participants were in childhood and adolescent development (26.7%) and exposed to frequent emotional abuse and domestic violence. As 1 traumatic event in childhood makes a person more susceptible to more traumatic experiences during life. Childhood trauma is a serious and pervasive problem that has a significant impact on the development, course, and severity of the clinical presentation of psychotic disorders. Accordingly, it is necessary to provide continuous education to mental health workers, primarily psychiatrists, regarding childhood trauma so that treatment may be approached more systematically and a plan of therapeutic interventions may be more adequately designed, which would necessarily include psychosocial support in addition to pharmacotherapy.

Communicating effectively with inclusion health populations: 2022 ICCH symposium

OBJECTIVE

To describe communication strategies for clinical practice that allow practitioners to work more effectively with marginalised population groups and to discuss how to incorporate these into medical practice.

METHODS

Active practitioners working in inclusion health and people with lived experience of homelessness and the asylum-seeking process shared their perspectives in the symposium at the 2022 International Conference on Communication in Healthcare (ICCH) and a subsequent conference on empathy in healthcare. The views of attendees were sought.

SYMPOSIUM DISCUSSION

We describe the perspectives shared at the symposia under two main themes: communication needs in people experiencing homelessness and migrant populations, and trauma-informed practice.

CONCLUSIONS

People experiencing homelessness have more communication challenges compared to the general adult population. Migrant, refugee, and asylum-seeking populations also face the complexity of negotiating unfamiliar healthcare, legal and social systems with the added burden of language barriers. Trauma-informed practice provides a useful framework that can improve communication with these groups.