Promoting children's learning and development in conflict-affected countries: Testing change process in the Democratic Republic of the Congo

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

BACKGROUND

Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.

OBJECTIVES

To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.

MAIN RESULTS

We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.

AUTHORS' CONCLUSIONS

To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

Addressing violence against children: A systematic review on interventions to accelerate the achievement of the UN sustainable development goal in Europe and Africa

BACKGROUND

Violence against children (VAC) is a global public health issue. In the context of limited resources, the United Nations Development Programme has coined the concept of a Sustainable Development Goals (SDG) accelerator for preventing and responding to VAC. An 'accelerator' is a provision that simultaneously leads to progress across multiple SDGs targets and goals.

OBJECTIVES

This systematic review synthesizes the literature on violence prevention evaluation studies using robust methods according to the SDG accelerator framework for children aged 0-18 in Western Europe and Central and West Africa. It also provides a lens for analyzing research inequities between the global North and South, examining the challenges and differences undermining knowledge production across regions, particularly in research output.

METHOD

We systematically searched 30 electronic databases and grey literature in English and French. The quality of included studies was assessed using the Cochrane Risk of Bias tool.

RESULTS

Nine evaluation studies related to four SDG goals and ten targets were included in the analysis. As a result, no intervention was identified as an accelerator for children in West and Central Africa. In contrast, three promising interventions were identified as accelerators in Western Europe. Two school-based interventions reduce bullying, depression, and substance abuse and improve psychological well-being; and one home-based intervention reduces child abuse, the severity of neglect, and mental health problems and improves school attendance. Moreover, this review also uncovered a lack of research from the Global South that points to serious disadvantages for authors and institutions and global violence prevention efforts, as it hinders the flow of knowledge and innovative practices.

CONCLUSIONS

The results highlight the need for future VAC prevention trials to integrate the SDG accelerators concept further. Additionally, more effort should be made to support scholars in the global South to address knowledge inequities and to enhance understanding of how accelerators work in different field settings and conditions. This effort will ensure that interventions accelerate SDG goals and impact the world's most vulnerable children.

School-based MHPSS interventions in humanitarian contexts: a realist review

OBJECTIVE

The aim of this review is to elucidate the characteristics of school-based mental health and psychosocial support (MHPSS) interventions in humanitarian contexts and the hypothesised mechanisms by which they influence well-being or learning outcomes.

METHODS

We conducted a realist review and searched PubMed, Embase, Global Health, CINAHL, PsychInfo, PILOTS and grey literature through January 2022. Eligible studies included children age 6-12 years, were conducted in humanitarian contexts in low-income or middle-income countries, and focused on universal MPHSS prevention in an educational setting, using any study design. Data were extracted and analysed using narrative synthesis and realist analysis techniques to create 'context-mechanism-outcome' configurations that were iteratively developed to modify, refine and substantiate programme theories.

RESULTS

Twenty-seven articles, representing 19 studies, were included in the review. We analysed data from 26 articles. Eleven evidenced-informed programme theories were developed at the levels of the child (n=4), teacher (n=3), caregiver (n=2), school environment (n=1) and school managers/administrators (n=1). At the child level, mechanisms related to strengthening coping skills, emotion regulation, interpersonal relationships led to improved psychosocial well-being or learning outcomes. At the teacher level, coping skills and the provision of support to students were linked to psychosocial well-being and learning outcomes. At the caregiver level, strengthening interpersonal bonds trigger improved psychosocial well-being, and at the school environment level, fostering feelings of security was linked to psychosocial well-being and learning outcomes. We did not find any evidence supporting the programme theory at the school managers/administrators level. We found limited evidence of positive impacts of the included interventions to support these programme theories.

CONCLUSIONS

These programme theories are a promising start towards ensuring school-based MHPSS interventions in humanitarian contexts better address the well-being and learning needs of children. Future research is needed to support these programme theories and enhance the evidence base.

Accelerating progress towards the sustainable development goals for adolescents in Ghana: a cross-sectional study

Since the adoption of the sustainable development goals (SDGs) by the United Nations (UN), the search has been on to identify interventions that have effects on multiple SDG-targets simultaneously. Like other developing countries, Ghana has a youthful population and would require creative, urgent, youth-focused interventions to be able to attain the SDGs by 2030. This paper describes the application of the accelerator model on data from a sample of Ghanaian adolescents to identify potential accelerators towards selected SDG targets involving youth. The data for 944 adolescents, 10-19 years (mean age 12.31 ± 3.51 years), extracted from two cross-sectional surveys on children and adolescents aged 6-19 years in Kumasi, Ghana, were analysed in this paper. Variables considered suitable proxies for SDG targets and potential accelerators were identified from the study instruments. Consequently, four aligned SDG targets (good mental health, access to ICT, school completion and no open defaecation) and five accelerators (cognitive stimulation, no relative poverty, low student-teacher ratio, high caregiver education and safe water) were extracted. Associations between accelerators and SDG targets were assessed using multivariable logistic regression adjusting for sociodemographic covariates and multiple testing. Cumulative effects were tested by marginal effects modelling. The three hypothesised accelerators identified were cognitive stimulation, low student-teacher ratio, and no relative poverty. A combination of all three accelerators was associated with a higher likelihood of adolescents having access to Information and Communication Technology (ICT) by +73% (CI 0.72-0.74), no open defecation by +44% (CI 0.43-0.46), school completion by +27% (CI 0.26-0.27) and good mental health by +9% (CI 0.08-0.10). Three hypothesized accelerators showed association across all four SDG aligned targets. The accelerator model has been further validated in this dataset from Ghana. Robust interventions designed around these accelerators may represent an opportunity for achieving the SDGs in Ghana.

Gender-equitable caregiver attitudes and education and safety of adolescent girls in South Kivu, DRC: A secondary analysis from a randomized controlled trial

BACKGROUND

Adolescent girls face myriad threats to their well-being and safety as a result of gender-inequitable attitudes and norms, and these risks are often exacerbated during humanitarian emergencies. While humanitarian actors have begun to address caregivers' behaviors and gender attitudes as an approach to support and meet the needs of adolescent girls, best practices for working with caregivers to improve adolescent girls' well-being in these settings have yet to be identified.

METHODS AND FINDINGS

This study uses panel data from a program evaluation to analyze associations between changes in gender-equitable attitudes among caregivers and changes in schooling and violence victimization for girls ages 10 to 14 years old in the Democratic Republic of the Congo (DRC). Participants were recruited in May 2015 for baseline (May to July 2015) and endline (August to October 2016) data collection. Baseline and endline data for both caregivers and girls were available for 732 girls. The average ages of adolescents and caregivers were 12 and 40.7, respectively, and 92% of caregivers were female. The predictor of interest was the change in caregivers' gender-equitable attitudes between the 2 points in time, where attitudes were measured using 10 underlying survey questions. The primary outcomes of interest were dichotomous and included improvement in schooling participation and declines in physical, sexual, and emotional violence and feeling uncared for. Logistic regression was used to estimate the association between changes in caregivers' attitudes and 5 outcomes of interest and revealed that an increase in a caregiver's gender-equitable attitude score was associated with significantly greater odds of a girl experiencing an improvement in schooling participation (aOR = 1.08, CI [1.005, 1.154], p = 0.036) and of a girl experiencing a marginal decline in physical violence victimization (aOR = 1.07, CI [0.989, 1.158], p = 0.092). Analyses also revealed that older girls had lower odds of experiencing an improvement in schooling participation (aOR = 0.77, CI [0.686, 0.861], p < 0.001), physical violence (aOR = 0.86, CI [0.757, 0.984], p = 0.028), sexual violence (aOR = 0.86, CI [0.743, 1.003], p = 0.055), or emotional violence (aOR = 0.98, CI [0.849, 1.105], p = 0.005). Important limitations in this study include the self-reported nature of outcomes, use of single questionnaire items to construct the outcome variables, and potential self-selection bias.

CONCLUSIONS

Results suggest that supporting caregivers to increase gender equitable attitudes may be associated with benefits in dual outcomes of education and safety for adolescent girls in eastern DRC. Further research is needed to better understand how to induce a shift in these attitudes in multisectoral programming.

TRIAL REGISTRATION

NCT02384642.

Children's learning and development in conflict- and crisis-affected countries: Building a science for action

This paper critically reviews the opportunities and challenges in designing and conducting actionable research on the learning and development of children in conflict- and crisis-affected countries. We approached our review through two perspectives championed by Edward Zigler: (a) child development and social policy and (b) developmental psychopathology in context. The aim of the work was to answer the following questions: What works to enhance children's learning and development in such contexts? By what mechanisms? For whom? Under what conditions? How do experiences and conditions of crisis affect the basic processes of children's typical development? The review is based on a research-practice partnership started in the Democratic Republic of the Congo in 2010 and expanded to research in Niger and Lebanon in 2016. The focus of the research is on the impact of Healing Classrooms (a set of classroom practices) and Healing Classrooms Plus (an additional set of targeted social and emotional learning activities), developed by the International Rescue Committee, on children's academic outcomes and social and emotional learning. We sought to extract lessons from this decade of research for building a global developmental science for action. Special attention is paid to the importance of research-practice partnerships, conceptual frameworks, measurement and methodology. We conclude by highlighting several essential features of a global developmental science for action.

Youth in Northern Ireland: Linking Violence Exposure, Emotional Insecurity, and the Political Macrosystem

Growing up in the aftermath of armed conflict puts youth at a higher risk for psychopathology—particularly in societies like Northern Ireland which continue to be characterized by intergroup tension and cyclical violence. This risk may be heightened during adolescence, when youth are beginning to explore their identities and are becoming more aware of intergroup dynamics in both their immediate communities and the broader society. It is also during this stage when youth increasingly witness or engage in antisocial behavior and sectarian activities. A series of studies in Belfast conducted by Cummings et al. (2014, Child Dev Perspect, 12(1), 16–38; 2019, J Clin Child Adolesc Psychol, 48(2), 296–305) showed that adolescents’ exposure to sectarian violence resulted in heightened emotional insecurity about the community and subsequent adjustment problems. Though the impact of direct exposure to violence is well documented, few studies have accounted for the influence of sectarianism that occurs outside of one's immediate environment. These influences may include the general climate surrounding events that are not experienced firsthand but are nonetheless salient, such as the overarching levels of tension between groups or societal discourse that is threatening to one's identity. These higher‐level influences, often referred to collectively as the macrosystem, are a necessary component to consider for adequately assessing one's socio‐developmental environment. Yet, measurement at this level of the social ecology has proven elusive in past work. The current study advances research in this area by using newspaper coding as a method of measuring the political macrosystem in Northern Ireland and assessing whether a tense or threatening climate serves as an added risk factor for youth living in Belfast.

In the current study, we measured sectarian violence at the level of the macrosystem by systematically collecting and coding newspaper articles from Northern Ireland that were published between 2006 and 2011 (N = 2,797). Each article was coded according to its level of overall political tension between Catholics and Protestants, threat to Catholics, and threat to Protestants. When aggregated, these assessments reflected the overarching trends in Catholic–Protestant relations during this period. In order to assess the association between these sociopolitical trends and the direct experiences of adolescents, the newspaper coding was linked with five waves of survey data from families (N = 999) in socioeconomically disadvantaged areas of Belfast. Using a series of multilevel moderation analyses, we then tested whether intergroup tension and ingroup threat moderated the relation between adolescents’ direct exposure to violence and their emotional insecurity. These analyses were followed by a thematic analysis of the coded newspaper articles in order to provide further context to the findings.

The results indicated that adolescents’ response to direct exposure to sectarian violence varied based on the political climate at the time of their interview. Overall, the adolescents’ emotional insecurity about the community increased with exposure to sectarian violence. During periods when the sociopolitical climate was characterized by high levels of intergroup political tension, this relation was slightly weaker—regardless of the adolescents’ ingroup (i.e., Protestant vs. Catholic). During periods when the sociopolitical climate was coded as threatening, this relation was weaker for Catholic adolescents. That is, high levels of macro‐level threat—particularly events coded as threatening for Protestants—seemed to be a protective factor for Catholic adolescents. Group differences were also found based on the adolescents’ cumulative amount of exposure to sectarian violence. As threat in the macrosystem increased, Catholic adolescents who were directly exposed to higher than average levels of sectarian violence became more emotionally secure, while Catholics with little to no exposure to violence became more insecure. Contrastingly, Protestant adolescents directly exposed to higher than average levels of sectarian violence were more insecure than Protestants with little to no violence exposure.

A thematic analysis of the newspaper articles revealed the categories of events that were viewed by coders as politically tense and threatening. Five primary themes emerged: ineffective policing and justice, family and community unrest, memories of violence, destabilized leadership, and organized paramilitary activity. Many of the articles coded as most threatening reported on a spike in attacks organized by dissident republican groups—that is, members of the Catholic community with, particularly hardline views. This may be pertinent to the finding that associations between sectarian violence exposure and emotional insecurity were exacerbated during this time for Protestants but not for Catholics. Findings from the thematic analysis provide a deeper examination of the context of events taking place during the study period, as well as their potential bearing on interpretation of the macro‐level effects.

In conclusion, these findings illustrate how one's response to the immediate environment can vary based on shifts in the political macrosystem. The current study thus contributes conceptually, empirically, and methodologically to the understanding of process relations between multiple levels of the social ecology and adolescent functioning. These results may further inform the design of future interventions and policies meant to lessen the impact of political violence. The methods used here may also be useful for the study of other contexts in which macrosystem effects are likely to have a salient impact on individual wellbeing.

Improving lives by accelerating progress towards the UN Sustainable Development Goals for adolescents living with HIV: a prospective cohort study

Background

Low-income and middle-income countries (LMICs) face major challenges in achieving the UN's Sustainable Development Goals (SDGs) for vulnerable adolescents. We aimed to test the UN Development Programme's proposed approach of development accelerators—provisions that lead to progress across multiple SDGs—and synergies between accelerators on achieving SDG-aligned targets in a highly vulnerable group of adolescents in South Africa.

Methods

We did standardised interviews and extracted longitudinal data from clinical records at baseline (2014–15) and 18-month follow-up (2016–17) for adolescents aged 10–19 years living with HIV in the Eastern Cape province of South Africa. We used standardised tools to measure 11 SDG-aligned targets—antiretroviral therapy adherence, good mental health, no substance use, HIV care retention, school enrolment, school progression, no sexual abuse, no high-risk sex, no violence perpetration, no community violence, and no emotional or physical abuse. We also assessed receipt at both baseline and follow-up of six hypothesised development accelerators—government cash transfers to households, safe schools (ie, without teacher or student violence), free schools, parenting support, free school meals, and support groups. Associations of all provisions with SDG-aligned targets were assessed jointly in a multivariate path model, controlling for baseline outcomes and sociodemographic and HIV-related covariates, and adjusted for multiple outcome testing. Cumulative effects were tested by marginal effects modelling.

Findings

1063 (90%) of 1176 eligible adolescents were interviewed. Three provisions were shown to be development accelerators. Parenting support was associated with good mental health (odds ratio 2·13, 95% CI 1·43–3·15, p<0·0001), no high-risk sex (2·44, 1·45–5·03, p=0·005), no violence perpetration (2·59, 1·63–4·59, p<0·0001), no community violence (2·43, 1·65–3·86, p<0·0001), and no emotional or physical abuse (2·38, 1·65–3·76; p<0·0001). Cash transfers were associated with HIV care retention (1·87, 1·15–3·02, p=0·010), school progression (2·05, 1·33–3·24, p=0·003), and no emotional or physical abuse (1·76, 1·12–3·02, p=0·025). Safe schools were associated with good mental health (1·74, 1·30–2·34, p<0·0001), school progression (1·57, 1·17–2·13, p=0·004), no violence perpetration (2·02, 1·45–2·91, p<0·0001), no community violence (1·81, 1·30–2·55, p<0·0001), and no emotional or physical abuse (2·20, 1·58–3·17, p<0·0001). For five of 11 SDG-aligned targets, a combination of two or more accelerators showed cumulative positive associations, suggesting accelerator synergies of combination provisions. For example, the fitted probability of adolescents reporting no emotional or physical abuse (SDG 16.2) with no safe schools, cash transfers, or parenting support was 0·25 (0·16–0·34). With cash transfer alone it was 0·37 (0·33–0·42), with safe school alone 0·42 (0·30–0·55), and with parenting support alone 0·44 (0·30–0·59). With all three development accelerators combined, the probability of adolescents reporting no emotional or physical abuse was 0·76 (0·67–0·84). After correcting for multiple tests, four of the SDG-aligned targets (antiretroviral therapy adherence, no substance use, school enrolment, and no sexual abuse) were not associated with any hypothesised accelerators.

Interpretation

The findings suggest the UN's accelerator approach for this high-risk adolescent population has policy and potential financing usefulness. Services that simultaneously promote several SDG targets, or combine to support particular targets, might be important to meet not only health-related targets, but also to ensure that adolescents in LMICs thrive within a new development framework.

Funding

Nuffield Foundation, UK Research and Innovation Global Challenges Research Fund, UKAID, Janssen Pharmaceutica, International AIDS Society, John Fell Fund, European Research Council, Economic and Social Research Council, Philip Leverhulme Trust, and UNICEF.

Interventions integrating health and academic education in schools to prevent substance misuse and violence: a systematic review

Background

Schools struggle to timetable health education. Interventions integrating academic and health education to reduce substance use and violence offer promise. No current systematic reviews examine such interventions.

Objectives

To review evidence to explore the following questions: (1) what types of interventions integrating health and academic education in schools serving those aged 4–18 years have been evaluated? (2) What theories of change inform these interventions? (3) What factors facilitate or limit the successful implementation and receipt of such interventions, and what are the implications for the delivery of such implementations in the UK? (4) How effective are such interventions in reducing smoking and violence and the use of alcohol and drugs, and at increasing attainment? Does this vary by students’ sociodemographic characteristics? (5) What factors appear to influence the effectiveness of such interventions?

Data sources

In total, 19 databases were searched from 18 November to 22 December 2015, updating searches for outcome evaluations for violence on 28 February 2018 and for substance use on 14 May 2018. References were extracted from included studies and authors contacted.

Review methods

Included studies reported on theories of change, and process or outcome evaluations of interventions that integrated academic and health education to reduce substance use and/or violence. References were screened on the title/abstract and then on the full report. Data extraction and appraisal used Cochrane, Evidence for Policy and Practice Information Centre and other established tools. Theories of change and process data were qualitatively synthesised. Outcome evaluations were synthesised narratively and meta-analytically.

Results

In total, 78,451 unique references were originally identified and 62 reports included. Search updates on 28 February and 14 May 2018 retrieved a further 2355 and 1945 references, respectively, resulting in the inclusion of six additional reports. Thirty-nine reports described theories, 16 reports (15 studies) evaluated process and 41 reports (16 studies) evaluated outcomes. Multicomponent interventions are theorised to erode ‘boundaries’ (strengthen relationships) between academic and health education, teachers and students, behaviour in classrooms and in the wider school, and schools and families. Teachers, pro-social peers and parents are theorised to act as role models and reinforcers of healthy behaviours learnt in lessons. There was clear evidence that interventions are facilitated by supportive senior management and alignment with the schools’ ethos, collaborative and supportive teaching environments, and positive pre-existing student, teacher and parent attitudes towards interventions. The barriers were overburdened teachers who had little time to both learn and implement integrated curricula. The strongest evidence for effectiveness was found for the reduction of substance use in school key stages (KSs) 2 and 3. For example, a meta-analysis for substance use at KS3 reported a mean difference of –0.09 (95% confidence interval –0.17 to –0.01). A meta-analysis for effectiveness in reducing violence victimisation in KS2 found no effect. There was mixed evidence for effects on academic outcomes, with meta-analysis precluded by methodological heterogeneity.

Limitations

Study quality was variable. Integration was sometimes not emphasised in theories of change.

Conclusions

These interventions are undertheorised but involve multiple forms of boundary erosion. There is clear evidence of characteristics affecting implementation. Interventions are likely to have the greatest impact on substance use. These programmes may be effective in reducing substance use but do not appear to reduce violence and findings on educational impacts are mixed.

Future work

Future evaluations should assess interventions with clearer theories of change and examine academic outcomes alongside violence and substance use outcomes.

Study registration

This study is registered as PROSPERO CRD42015026464.

Funding

The National Institute for Health Research Public Health Research programme.

Assessment of progress in education for children and youth with disabilities in Afghanistan: A multilevel analysis of repeated cross-sectional surveys

Recent study shows that 617 million children and adolescents-or six out of 10 globally- are not acquiring minimum levels in literacy and mathematics, indicating the magnitude of the learning acquisition problem. For children with disabilities in context of conflict, the situation is arguably even worse: the literature shows that they face difficulties to access the education system due to multiple barriers, and when they do access, they are not learning. Our paper examines if an active education policy promoting inclusion since 2005 in Afghanistan, a protracted crisis context, has been effective. Using two cross sectional household surveys carried out eight years apart (2005-2013), our study shows that access to school and literacy did not improve between 2005 and 2013 for children and youth with disabilities. Both access and literacy outcomes were worse for girls with disabilities, those with a mental, learning or associated disability and those living in household where the head was uneducated. Finally, odds of being mentally distressed significantly declined between 2005 and 2013 indicating that schools might play a protective role for children with disabilities in Afghanistan. Our findings suggest that a multilevel multi-pronged adaptation of the existing system to improve the learning experience and promote children's resilience, particularly for children with disabilities, in conflict context such as Afghanistan, is required.

Risk or resource: Does school climate moderate the influence of community violence on children's social-emotional development in the Democratic Republic of Congo?

Exposure to community violence is thought to create risk for the social and emotional development of children, including those children living in low-income, conflict-affected countries. In the absence of other types of community resources, schools may be one of the few community resources that can help buffer children from the negative effects of community violence exposure. We sampled 8,300 students ranging in age from 6-18 years in 123 schools from the eastern Democratic Republic of Congo to examine whether and how two distinct dimensions of positive school climate can protect two key features of children's social-emotional development in the presence of community violence. Multi-level models tested the hypothesis that students' perceptions of a positive school climate moderated the relation between community violence and self-reported mental health problems and peer victimization. Findings support the hypothesis. Specifically, a positive school climate protected against mental health problems and peer victimization in the presence of high community violence. Students who experienced high community violence and a negative school climate generally demonstrated the worst development. We find complex interactions between the dimensions of school climate and exposure to violence on student social-emotional development that highlight the salience of children's contexts for developmental studies in low-income countries. We use dynamic developmental systems theory and differential impact to discuss the dual potential of schools as a buffer against the effects of violence or as a source of compounded risk.

A systematic review and synthesis of theories of change of school-based interventions integrating health and academic education as a novel means of preventing violence and substance use among students

BACKGROUND

Schools can play an important role in promoting health. However, many education policies and institutions are increasingly emphasising academic attainment targets, which appear to be diminishing the time available for health education lessons. Interventions that integrate both health and academic learning may present an ideal solution, simultaneously addressing health education and academic development. The theories of change underlying these interventions are therefore of interest, but are poorly studied.

METHODS

A systematic review of evaluations of interventions that integrate academic and health education for reduced substance use and/or violence was carried out. As part of this, reports describing theory were assessed for quality and data extracted. Theoretical data were synthesised within and across individual interventions using reciprocal translation and meta-ethnographic line of argument synthesis to produce an overall theory of change for interventions that integrate health and academic education to prevent substance use and violence.

RESULTS

Forty-eight reports provided theoretical descriptions of 18 interventions. An overarching theory that emerged was that eroding 'boundaries' at multiple and mutually reinforcing levels-by integrating academic and health education, by transforming relationships between teachers and students, by generalising learning from classrooms to the wider school environment and by ensuring consistent messages from schools and families-is intended to lead to the development of a community of engaged students oriented towards pro-social behaviour and away from substance use, violence and other risk behaviours.

CONCLUSIONS

Eroding 'boundaries' between health and academic education, teachers and students, classrooms and the wider school and schools and families were seen to be the most critical to establishing new frameworks of family, classroom or school organisation that are conducive to promoting both academic and social-emotional outcomes. Whether such interventions are feasible to implement and effective in reducing risk behaviours will be examined in other reports arising from the review.

A multiple-group confirmatory factor analysis of teacher perceptions of social and emotional learning in rural Malawi

BACKGROUND

Social and emotional learning (SEL) positively impacts children's school achievement and adult productivity. Successful implementation of SEL relies on teachers' pedagogical beliefs and practices.

AIMS

We examined whether the Teachers' SEL Belief Scale designed in the United States is adoptable in low-income countries such as Malawi in response to a growing interest in teacher practices in SEL but a lack of research instruments in these countries.

SAMPLES

The data used in this study were from 432 teachers working in 34 randomly selected primary schools in Zomba, a rural district in Malawi.

METHODS

We used multiple-group confirmatory factory analysis to investigate the factor structure and the invariance of the adapted scale across teachers with different characteristics such as gender and training experience in SEL. When invariant, we compared group mean differences among teachers in our sample by gender and training experience.

RESULTS

We found that the Teachers' SEL Belief Scale measured a similar construct of pedagogical perceptions of SEL among the sampled teachers, and it functioned equivalently across teachers with different genders and training experiences. Female teachers had lower perceived institutional support for SEL instruction compared to male teachers. Untrained teachers had lower levels of pedagogical comfort as well as perceived support for SEL compared to trained teachers.

CONCLUSIONS

Our findings validate the adaptability of the Teachers' SEL Belief Scale in low-income contexts such as Malawi. We did not find evidence of systematic bias relative to group membership. In addition, significantly lower pedagogical comfort and institutional support among female and untrained teachers suggest areas for policy intervention to improve teacher performance in SEL in Malawi.

Integration of academic and health education for the prevention of physical aggression and violence in young people: systematic review, narrative synthesis and intervention components analysis

OBJECTIVES

To systematically review evidence on the effectiveness of interventions including integration of academic and health education for reducing physical aggression and violence, and describe the content of these interventions.

DATA SOURCES

Between November and December 2015, we searched 19 databases and 32 websites and consulted key experts in the field. We updated our search in February 2018.

ELIGIBILITY CRITERIA

We included randomised trials of school-based interventions integrating academic and health education in students aged 4-18 and not targeted at health-related subpopulations (eg, learning or developmental difficulties). We included evaluations reporting a measure of interpersonal violence or aggression.

DATA EXTRACTION AND ANALYSIS

Data were extracted independently in duplicate, interventions were analysed to understand similarities and differences and outcomes were narratively synthesised by key stage (KS).

RESULTS

We included 13 evaluations of 10 interventions reported in 20 papers. Interventions included either full or partial integration, incorporated a variety of domains beyond the classroom, and used literature, local development or linking of study skills and health promoting skills. Evidence was concentrated in KS2, with few evaluations in KS3 or KS4, and evaluations had few consistent effects; evaluations in KS3 and KS4 did not suggest effectiveness.

DISCUSSION

Integration of academic and health education may be a promising approach, but more evidence is needed. Future research should consider the 'lifecourse' aspects of these interventions; that is, do they have a longitudinal effect? Evaluations did not shed light on the value of different approaches to integration.