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Falb K, Kullenberg S, T Yuan C, Blackwell A. Five recommendations to advance implementation science for humanitarian settings: the next frontier of humanitarian research. Confl Health 2024; 18:41. [PMID: 38807161 PMCID: PMC11134721 DOI: 10.1186/s13031-024-00597-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/19/2024] [Indexed: 05/30/2024] Open
Abstract
Challenges in delivering evidence-based programming in humanitarian crises require new strategies to enhance implementation science for better decision-making. A recent scoping review highlights the scarcity of peer-reviewed studies on implementation in conflict zones. In this commentary, we build on this scoping review and make five recommendations for advancing implementation science for humanitarian settings. These include (1) expanding existing frameworks and tailoring them to humanitarian dynamics, (2) utilizing hybrid study designs for effectiveness-implementation studies, (3) testing implementation strategies, (4) leveraging recent methodological advancements in social and data science, and (5) enhancing training and community engagement. These approaches aim to address gaps in understanding intervention effectiveness, scale, sustainability, and equity in humanitarian settings. Integrating implementation science into humanitarian research is essential for informed decision-making and improving outcomes for affected populations.
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Affiliation(s)
- Kathryn Falb
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sheree Kullenberg
- Airbel Impact Lab, International Rescue Committee, New York City, NY, USA
| | - Christina T Yuan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alexandra Blackwell
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK, 32 Wellington Square, OX1 2ER.
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Checchi F. Inferring the impact of humanitarian responses on population mortality: methodological problems and proposals. Confl Health 2023; 17:16. [PMID: 36998020 PMCID: PMC10061806 DOI: 10.1186/s13031-023-00516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/24/2023] [Indexed: 04/01/2023] Open
Abstract
Reducing excess population mortality caused by crises due to armed conflict and natural disasters is an existential aim of humanitarian assistance, but the extent to which these deaths are averted in different humanitarian responses is mostly unknown. This information gap arguably weakens governance and accountability. This paper considers methodological challenges involved in making inferences about humanitarian assistance's effect on excess mortality, and outlines proposed approaches. Three possible measurement questions, each of which contributes some inferential evidence, are presented: (1) whether mortality has remained within an acceptable range during the crisis (for which different direct estimation options are presented); (2) whether the humanitarian response is sufficiently appropriate and performant to avert excess mortality (a type of contribution analysis requiring in-depth audits of the design of humanitarian services and of their actual availability, coverage and quality); and (3) the actual extent to which humanitarian assistance has reduced excess deaths (potentially the most complex question to answer, requiring application of causal thinking and careful specification of the exposure, and for which either quasi-experimental statistical modelling approaches or a combination of verbal and social autopsy methods are proposed). The paper concludes by considering possible 'packages' of the above methods that could be implemented at different stages of a humanitarian response, and calls for investment in improved methods and actual measurement.
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Affiliation(s)
- Francesco Checchi
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
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Massazza A, May CR, Roberts B, Tol WA, Bogdanov S, Nadkarni A, Fuhr DC. Process evaluations of mental health and psychosocial support interventions for populations affected by humanitarian crises. Soc Sci Med 2022; 303:114994. [PMID: 35561423 DOI: 10.1016/j.socscimed.2022.114994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Randomised controlled trials (RCTs) have been increasingly used to test the effectiveness of mental health and psychosocial support(MHPSS) interventions for populations affected by humanitarian crises. Process evaluations are often integrated within RCTs of psychological interventions to investigate the implementation of the intervention, the impact of context, and possible mechanisms of action. We aimed to explore limitations and strengths of how process evaluations are currently conceptualised and implemented within MHPSS RCTs specifically. METHODS In April-June 2021 we conducted semi-structured interviews with 24 researchers involved in RCTs of MHPSS interventions in 23 different countries. Participants were selected based on systematic reviews of MHPSS interventions, funders' databases, and personal networks. Data were analysed using codebook thematic analysis. RESULTS The conduct of process evaluations was characterized by high heterogeneity in perceived function, implementation outcomes assessed, and methods used. While process evaluations were overwhelmingly considered as an important component of an RCT, there were different opinions on their perceived quality. This could be explained by the varying prioritization of effectiveness data over implementation data, confusion around the nature of process evaluations, and challenges in the collection and analysis of process data in humanitarian settings. Various practical recommendations were made by participants to improve future process evaluations in relation to: (i) study design (e.g., embedding process evaluations in study protocol and overall study objectives); (ii) methods (e.g., use of mixed methods); and (iii) increased financial and human resources dedicated to process evaluations. CONCLUSION The current state of process evaluations in MHPSS RCTs is heterogeneous. The quality of process evaluations should be improved to strengthen implementation science of the growing number of evidence-informed MHPSS interventions.
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Affiliation(s)
- Alessandro Massazza
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Carl R May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; NIHR North Thames Applied Research Collaborative, London, UK
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Wietse A Tol
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sergiy Bogdanov
- Centre for Mental Health and Psychosocial Support, National University of Kyiv-Mohyla Academy, Kyiv, Ukraine
| | - Abhijit Nadkarni
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniela C Fuhr
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Advancing and translating knowledge: a systematic inquiry into the 2010-2020 mental health and psychosocial support intervention research evidence base. Glob Ment Health (Camb) 2022; 9:133-145. [PMID: 36618729 PMCID: PMC9806978 DOI: 10.1017/gmh.2022.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Emily Mendenhall
- Edmund A Walsh School of Foreign Service, Georgetown University, Washington, D.C., USA.
| | - Timothy Newfield
- Department of History, Georgetown University, Washington, D.C., USA
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Brathwaite R, Rocha TBM, Kieling C, Gautam K, Koirala S, Mondelli V, Kohrt B, Fisher HL. Predicting the risk of depression among adolescents in Nepal using a model developed in Brazil: the IDEA Project. Eur Child Adolesc Psychiatry 2021; 30:213-223. [PMID: 32162056 PMCID: PMC7486232 DOI: 10.1007/s00787-020-01505-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/29/2020] [Indexed: 12/11/2022]
Abstract
The burden of adolescent depression is high in low- and middle-income countries (LMICs), yet research into prevention is lacking. Development and validation of models to predict individualized risk of depression among adolescents in LMICs is rare but crucial to ensure appropriate targeting of preventive interventions. We assessed the ability of a model developed in Brazil, a middle-income country, to predict depression in an existing culturally different adolescent cohort from Nepal, a low-income country with a large youth population with high rates of depression. Data were utilized from the longitudinal study of 258 former child soldiers matched with 258 war-affected civilian adolescents in Nepal. Prediction modelling techniques were employed to predict individualized risk of depression at age 18 or older in the Nepali cohort using a penalized logistic regression model. Following a priori exclusions for prior depression and age, 55 child soldiers and 71 war-affected civilians were included in the final analysis. The model was well calibrated, had good overall performance, and achieved good discrimination between depressed and non-depressed individuals with an area under the curve (AUC) of 0.73 (bootstrap-corrected 95% confidence interval 0.62-0.83). The Brazilian model comprising seven matching sociodemographic predictors, was able to stratify individualized risk of depression in a Nepali adolescent cohort. Further testing of the model's performance in larger socio-culturally diverse samples in other geographical regions should be attempted to test the model's wider generalizability.
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Affiliation(s)
- Rachel Brathwaite
- Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
| | - Thiago Botter-Maio Rocha
- Department of Psychiatry, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil ,Child and Adolescent Psychiatry Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Christian Kieling
- Department of Psychiatry, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil ,Child and Adolescent Psychiatry Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Kamal Gautam
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal
| | - Suraj Koirala
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal
| | - Valeria Mondelli
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Brandon Kohrt
- Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal ,Division of Global Mental Health, George Washington University, Washington, DC USA
| | - Helen L. Fisher
- Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF UK
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Kohrt BA, Carruth L. Syndemic effects in complex humanitarian emergencies: A framework for understanding political violence and improving multi-morbidity health outcomes. Soc Sci Med 2020; 295:113378. [PMID: 33051023 PMCID: PMC7501533 DOI: 10.1016/j.socscimed.2020.113378] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022]
Abstract
A hallmark of complex humanitarian emergencies is the collective exposure, often over extended periods of time, to political violence in the forms of war, terrorism, political intimidation, repression, unlawful detention, and forced displacement. Populations in complex humanitarian emergencies have higher risks of multiple co-morbidities: mental disorders, infectious diseases, malnutrition, and chronic non-communicable diseases. However, there is wide variation in the health impacts both across and within humanitarian emergencies. Syndemic theory is an approach to conceptualizing disease and social determinants to understand differential patterns of multi-morbidity, elucidate underlying mechanisms, and better design interventions. Syndemic theory, if applied to complex humanitarian emergencies, has the potential to uncover origins of localized patterns of multi-morbidity resulting from political violence and historical inequities. In this paper, we present two case studies based on mixed-methods research to illustrate how syndemic models can be applied in complex humanitarian emergencies. First, in a Nepal case study, we explore different patterns of posttraumatic stress disorder (PTSD) and depression co-morbidity among female former child soldiers returning home after war. Despite comparable exposure to war-related traumas, girl soldiers in high-caste Hindu communities had 63% co-morbidity of PTSD and depression, whereas girl soldiers in communities with mixed castes and religions, had 8% PTSD prevalence, but no cases of PTSD and depression co-morbidity. In the second case study, we explore the high rates of type 2 diabetes during a spike in political violence and population displacement. Despite low rates of obesity and other common risk factors, Somalis in Ethiopia experienced rising cases of and poor outcomes from type-2 diabetes. Political violence shapes healthcare resources, diets, and potentially, this epidemiological anomaly. Based on these case studies we propose a humanitarian syndemic research agenda for observational and intervention studies, with the central focus being that public health efforts need to target violence prevention at family, community, national, and global levels. Violence is a key feature of syndemic interactions in many contexts. In complex humanitarian emergencies, political violence exacerbates multi-morbidity. A syndemic approach could integrate fragmented and siloed health responses in complex humanitarian emergencies. A syndemic approach demands mitigating the roots of political violence and resulting multi-morbidities.
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Affiliation(s)
- Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, Department of Global Health, Milken School of Public Health, George Washington University, USA.
| | - Lauren Carruth
- School of International Service, American University, Washington, DC, 20016, USA.
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Interpersonal violence and suicidality among former child soldiers and war-exposed civilian children in Nepal. Glob Ment Health (Camb) 2018; 5:e9. [PMID: 29507745 PMCID: PMC5827420 DOI: 10.1017/gmh.2017.31] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 10/20/2017] [Accepted: 10/25/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Suicide risk reduction is crucial for 15-29-year-old youth, who account for 46% of suicide deaths in low- and middle-income countries. Suicide predictors in high-resource settings, specifically depression, do not adequately predict suicidality in these settings. We explored if interpersonal violence (IPV) was associated with suicidality, independent of depression, in Nepal. METHODS A longitudinal cohort of child soldiers and matched civilian children, enrolled in 2007 after the People's War in Nepal, were re-interviewed in 2012. The Depression Self-Rating Scale and Composite International Diagnostic Interview assessed depression and suicidality, respectively. Non-verbal response cards were used to capture experiences of sexual and physical IPV. RESULTS One of five participants (19%) reported any lifetime suicidal ideation, which was associated with sexual IPV, female gender, former child soldier status and lack of support from teachers. Among young men, the relationship between sexual IPV and suicidality was explained by depression, and teacher support reduced suicidality. Among young women, sexual IPV was associated with suicidality, independent of depression; child soldier status increased suicidality, and teacher support decreased suicidality. Suicide plans were associated with sexual IPV but not with depression. One of 11 female former child soldiers (9%) had attempted suicide. CONCLUSION Sexual IPV is associated with suicidal ideation and plans among conflict-affected young women, independent of depression. Reducing suicide risk among women should include screening, care, and prevention programs for sexual IPV. Programs involving teachers may be particularly impactful for reducing suicidality among IPV survivors.
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Kohrt BA, Bourey C. Culture and Comorbidity: Intimate Partner Violence as a Common Risk Factor for Maternal Mental Illness and Reproductive Health Problems among Former Child Soldiers in Nepal. Med Anthropol Q 2016; 30:515-535. [PMID: 27558762 PMCID: PMC5177473 DOI: 10.1111/maq.12336] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 07/13/2016] [Accepted: 08/17/2016] [Indexed: 12/11/2022]
Abstract
Our objective was to elucidate how culture influences internal (psychological), external (social), institutional (structural), and health care (medical) processes, which, taken together, create differential risk of comorbidity across contexts. To develop a conceptual model, we conducted qualitative research with 13 female child soldiers in Nepal. Participants gave open-ended responses to intimate partner violence (IPV) vignettes (marital rape, emotional abuse, violence during pregnancy). Twelve participants (92%) endorsed personal responses (remaining silent, enduring violence, forgiving the husband). Twelve participants endorsed communication with one's husband. Only four participants (31%) sought family support, and three contacted police. Ultimately, 12 participants left the relationship, but the majority (nine) only left after the final IPV experience, which was preceded by prolonged psychological suffering and pregnancy endangerment. In conclusion, comorbidity risks are increased in cultural context that rely on individual or couples-only behavior, lack external social engagement, have weak law and justice institutions, and have limited health services.
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Kohrt BA, Yang M, Rai S, Bhardwaj A, Tol WA, Jordans MJD. Recruitment of child soldiers in Nepal: Mental health status and risk factors for voluntary participation of youth in armed groups. PEACE AND CONFLICT : JOURNAL OF PEACE PSYCHOLOGY : THE JOURNAL OF THE DIVISION OF PEACE PSYCHOLOGY OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION 2016; 22:208-216. [PMID: 27524877 PMCID: PMC4980080 DOI: 10.1037/pac0000170] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Preventing involuntary conscription and voluntary recruitment of youth into armed groups are global human rights priorities. Pathways for self-reported voluntary recruitment and the impact of voluntary recruitment on mental health have received limited attention. The objective of this study was to identify risk factors for voluntarily joining armed groups, as well as the association of conscription status and mental health. In Nepal, interviews were conducted with 258 former child soldiers who participated in a communist (Maoist) revolution. Eighty percent of child soldiers joined 'voluntarily'. Girls were 2.07 times as likely to join voluntarily (95% CI, 1.03-4.16, p=0.04). Among girls, 51% reported joining voluntarily because of personal connections to people who were members of the armed group, compared to 22% of boys. Other reasons included escaping difficult life situations (36%), inability to achieve other goals in life (28%), and an appealing philosophy of the armed group (32%). Poor economic conditions were more frequently endorsed among boys (22%) than girls (10%). Voluntary conscription was associated with decreased risk for PTSD among boys but not for girls. Interventions to prevent voluntary association with armed groups could benefit from attending to difficulties in daily life, identifying non-violent paths to achieve life goals, and challenging the political philosophy of armed groups. Among boys, addressing economic risk factors may prevent recruitment, and prevention efforts for girls will need to address personal connections to armed groups, as it has important implications for preventing recruitment through new methods, such as social media.
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Affiliation(s)
- Brandon A Kohrt
- Duke Global Health Institute & Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
| | - Minyoung Yang
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Sauharda Rai
- Duke Global Health Institute & Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
| | - Anvita Bhardwaj
- Division of Nutritional Sciences, Cornell University, Ithaca, USA
| | - Wietse A Tol
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Mark J D Jordans
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK
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Kohrt BA, Worthman CM, Adhikari RP, Luitel NP, Arevalo JMG, Ma J, McCreath H, Seeman TE, Crimmins EM, Cole SW. Psychological resilience and the gene regulatory impact of posttraumatic stress in Nepali child soldiers. Proc Natl Acad Sci U S A 2016; 113:8156-61. [PMID: 27402736 PMCID: PMC4961140 DOI: 10.1073/pnas.1601301113] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Adverse social conditions in early life have been linked to increased expression of proinflammatory genes and reduced expression of antiviral genes in circulating immune cells-the conserved transcriptional response to adversity (CTRA). However, it remains unclear whether such effects are specific to the Western, educated, industrialized, rich, and democratic (WEIRD) cultural environments in which previous research has been conducted. To assess the roles of early adversity and individual psychological resilience in immune system gene regulation within a non-WEIRD population, we evaluated CTRA gene-expression profiles in 254 former child soldiers and matched noncombatant civilians 5 y after the People's War in Nepal. CTRA gene expression was up-regulated in former child soldiers. These effects were linked to the degree of experienced trauma and associated distress-that is, posttraumatic stress disorder (PTSD) severity-more than to child soldier status per se. Self-perceived psychological resilience was associated with marked buffering of CTRA activation such that PTSD-affected former child soldiers with high levels of personal resilience showed molecular profiles comparable to those of PTSD-free civilians. These results suggest that CTRA responses to early life adversity are not restricted to WEIRD cultural contexts and they underscore the key role of resilience in determining the molecular impact of adverse environments.
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Affiliation(s)
- Brandon A Kohrt
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27708; Duke Global Health Institute, Duke University, Durham, NC 27710; Transcultural Psychosocial Organization Nepal, Kathmandu 44616, Nepal;
| | | | - Ramesh P Adhikari
- Transcultural Psychosocial Organization Nepal, Kathmandu 44616, Nepal
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization Nepal, Kathmandu 44616, Nepal
| | - Jesusa M G Arevalo
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
| | - Jeffrey Ma
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
| | - Heather McCreath
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
| | - Teresa E Seeman
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Epidemiology, University of California, Los Angeles School of Public Health, Los Angeles, CA 90095
| | - Eileen M Crimmins
- Davis School of Gerontology, University of Southern California, Los Angeles, CA 90089
| | - Steven W Cole
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095; Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles School of Medicine, Los Angeles, CA 90095
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