Delivering mental health and psychosocial support interventions to women and children in conflict settings: a systematic review

Prevalence of post-traumatic stress disorder and depressive symptoms among civilians residing in armed conflict-affected regions: a systematic review and meta-analysis

Background

Globally, populations afflicted by armed conflict are known to have high rates of mental health disorders.

Aims

This meta-analysis aims to estimate the prevalence of post-traumatic stress disorder (PTSD) and depressive symptoms among civilians residing in armed conflict-affected regions.

Methods

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A literature search employing MEDLINE(R), Embase Classic+Embase, APA PsycINFO, Ovid Healthstar, Journal@Ovid Full Text, Cochrane, PTSDpubs and CINAHL was conducted from inception until 19 March 2024 to identify relevant studies. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies, and a Comprehensive Meta-Analysis was used to conduct the statistical analysis.

Results

The search yielded 38 595 articles, of which 57 were considered eligible for inclusion. The included studies comprised data from 64 596 participants. We estimated a prevalence of 23.70% (95% CI 19.50% to 28.40%) for PTSD symptoms and 25.60% (95% CI 20.70% to 31.10%) for depressive features among war-afflicted civilians. The subgroup analysis based on time since the war and the country's economic status revealed the highest prevalence for both PTSD and depressive symptoms was present during the years of war and in low/middle-income countries.

Conclusions

The results of this study provide conclusive evidence of the detrimental impacts of armed conflict on mental health outcomes. Hence, it is crucial to emphasise the significance of both physical and mental health in the aftermath of war and take appropriate humanistic measures to overcome challenges in the management of psychiatric illnesses.

PROSPERO registration number

CRD42023416096.

The call for an "educational footprint" in conceptualizing mental health and psychosocial support: the case of Norwegian kindergarten teachers

This article presents an in-depth qualitative case study asking, "How do Norwegian kindergarten teachers conceptualize and negotiate the field of psychosocial support?" This article thoroughly explores how Norwegian kindergarten teachers perceive of the field Mental health and psychosocial support (MHPSS). Recognizing the global imperative to advance mental health and psychosocial support for children, the study highlights the crucial need for interprofessional grounded concepts and logics in developing MHPSS interventions. The study employs a grounded theory approach to actively develop concepts in the MHPSS field in Norway. The six selected Norwegian expert teachers can make up a so-called "unique case", representing a high-income country with a robust welfare system and child-centered pedagogy. Yet, they reveal challenges in embracing the concept of psychosocial support: The analysis shows that the teachers seem to neglect and even reject the concept of psychosocial support, while also expressing inferiority and lack of agency towards other professions. However, the teachers also express the desire for more knowledge, and with proudness they energetically engage in fostering children's agency and functioning by their everyday descriptions of «meeting with the child». The study calls for the kindergarten teachers' increased efforts to actively participate in MHPSS interventions, advocating for the further development of an «educational footprint» that can empower interprofessional work.

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.

Improving Retention in Mental Health and Psychosocial Support Interventions: An Analysis of Completion Rates across a Multi-Site Trial with Refugee, Migrant, and Host Communities in Latin America

Research on mental health and psychosocial support (MHPSS) interventions within refugee and migrant communities has increasingly focused on evaluating implementation, including identifying strategies to promote retention in services. This study examines the relationship between participant characteristics, study setting, and reasons for intervention noncompletion using data from the Entre Nosotras feasibility trial, a community-based MHPSS intervention targeting refugee, migrant, and host community women in Ecuador and Panama that aimed to promote psychosocial wellbeing. Among 225 enrolled women, approximately half completed the intervention, with varying completion rates and reasons for nonattendance across study sites. Participants who were older, had migrated for family reasons, had spent more time in the study community, and were living in Panamá (vs. Ecuador) were more likely to complete the intervention. The findings suggest the need to adapt MHPSS interventions to consider the duration of access to the target population and explore different delivery modalities including the role of technology and cellular devices as reliable or unreliable source for engaging with participants. Engaging younger, newly arrived women is crucial, as they showed lower completion rates. Strategies such as consulting scheduling preferences, providing on-site childcare, and integrating MHPSS interventions with other programs could enhance intervention attendance.

'Madness' after the war in Bosnia and Herzegovina - challenging dominant understandings of distress

This article reports on the findings from a small-scale co-produced qualitative study on experiences of distress caused by the war in Bosnia and Herzegovina (BiH). Inspired by the emerging interdisciplinary field of Mad Studies, the study is novel and unique in two ways. First, it prioritises social understanding and interpretation of madness and distress. Second, an emphasis is placed on experiential knowledge. Beyond interviews with 20 people who experienced distress due to political conflict, this included contextualisation of the study in the knowledge generated through survivor research and within the field of Mad Studies. Study findings highlight the social causes and consequences of distress caused by conflict, such as war-related violence, gender-based violence, experiences of poverty and corruption. Participants stressed the importance of safety and support within their own home, mutual and supportive relationships with their families, friends, other people who experienced distress, the broader community and opportunities to do everyday activities they enjoy. In terms of professional support, the findings suggest that poverty alleviation and protection of people's right to self-determination through access to human rights advocacy and representation may be as relevant as non-coercive community-based services. This indicates that support for distress caused by political conflict need not be different from any other support for people who experience distress. Emphasis should be placed on survivor-run initiatives and non-coercive, community-based support which addresses social causes of distress and enables people to exercise self-determination.

Barriers and Facilitators to Implementing a Community-Based Psychosocial Support Intervention Conducted In-Person and Remotely: A Qualitative Study in Quibdó, Colombia

Community-based psychosocial support group (CB-PSS) interventions using task-shifting approaches are well suited to provide culturally appropriate services in low- and middle-income countries. However, contextual barriers and facilitators must be considered to tailor interventions effectively, particularly considering the challenges introduced by the COVID-19 pandemic. We explore the barriers, facilitators, and psychosocial changes associated with implementing a CB-PSS group intervention delivered by local lay providers to conflict-affected adults in Quibdó, Colombia, using both in-person and remote modalities. Data were analyzed from 25 individual interviews with participants and a focus group discussion involving staff members, including 7 community psychosocial agent facilitators and 2 mental health professional supervisors. The analysis used a thematic approach grounded in a descriptive phenomenology to explore the lived experiences of participants and staff members during implementation. Participant attendance in the in-person modality was compromised by factors such as competing work and family responsibilities and disruption caused by the COVID-19 pandemic. Participants in the remote modality faced challenges concerning unstable Internet connectivity, recurrent power outages caused by heavy rain, distractions, interruptions, and threats to confidentiality by family and coworkers. Despite these challenges, data revealed key contextual facilitators, including the community-based knowledge of facilitators and integration of traditional practices, such as the comadreo (informal talks and gatherings). Respondents shared that the CB-PSS groups promoted stronger community relationships and created opportunities for participants to exchange peer support, practice leadership skills, develop problem-solving skills based on peers' experiences, and enhance emotional regulation skills. Differences and similarities across in-person and remote modalities are discussed, as are key considerations for practitioners and policymakers.

The impact of mental health and psychosocial support programmes on children and young people's mental health in the context of humanitarian emergencies in low- and middle-income countries: A systematic review and meta-analysis

Humanitarian emergencies pose a significant global health challenge for children and young people's mental and psychological health. This systematic review investigates the effectiveness of mental health and psychosocial support (MHPSS) programmes delivered to children and young people affected by humanitarian emergencies in low- and middle-income countries (LMICs). Twelve electronic databases, key websites and citation checking were undertaken. Forty-three randomised controlled trials (RCTs) published in English between January 1980 and May 2023 were included in the review. Overall, the findings suggest that cognitive behavioural therapy may improve depression symptoms in children and young people affected by humanitarian emergencies. Narrative exposure therapy may reduce feelings of guilt. However, the impact of the other MHPSS modalities across outcomes is inconsistent. In some contexts, providing psychosocial programmes involving creative activities may increase the symptoms of depression in children and young people. These findings emphasise the need for the development of MHPSS programmes that can safely and effectively address the diverse needs of children and young people living in adversarial environments.

Support interventions to promote health and wellbeing among women with health-related consequences following traumatic experiences linked to armed conflicts and forced migration: a scoping review

BACKGROUND

Women exposed to armed conflicts and forced migration face significant health-related risks and consequences. Consequently, there is a need to identify and develop effective interventions that provide tailored support for them. The aim of this scoping review was to examine research evaluating support interventions promoting the health and well-being among women with traumatic experiences linked to armed conflict and/or forced migration.

METHODS

A scoping review of empirical studies evaluating non-pharmacologic/non-surgical interventions promoting health and well-being among adult women with traumatic experiences linked to armed, torture, and/or forced migration, identified through systematic searches in February 2022 within five databases (AMED, CINAHL, Cochrane Library, PsycINFO, and PubMed). Methodological characteristics and results were extracted and analyzed with narrative analysis using tabulations, descriptive statistics, text-based summaries, and thematization.

RESULTS

Assessment of 16 748 records resulted in 13 included reports. The methodological approaches were quantitative (n = 9), qualitative (n = 2), and mixed methods (n = 2), with most reports being feasibility/pilot studies (n = 5) and/or randomized controlled trials (n = 4). The most common recruitment strategy was non-probability sampling (n = 8). Most interventions were conducted in North America (n = 4), Asia (n = 3) or Middle East (n = 3). Thirteen intra-intervention techniques and five categories of components utilized within the interventions were identified, the most common being skill building (n = 12). Ten developed the interventions through theoretical frameworks or manuals/therapy, while five developed interventions through public or stakeholder involvement. Eleven studies evaluated outcomes related to psychological health, disorders, or distress. A large proportion of the investigated outcomes showed post-exposure improvements and improvements when compared with controls. Qualitative findings highlighted improved mental and physical health, empowerment and stigma reduction, and enhanced knowledge.

CONCLUSION

Few studies have developed and evaluated tailored support interventions for this population, containing a range of components and intra-intervention techniques. No clear focus was identified regarding outcome measures, and most studies used non-probability sampling. Few developed interventions through public contribution in collaboration with women. While limited studies show promising effects on women's mental health, more empirical intervention research that closely corresponds to women's needs are needed.

Piloting a mental health intervention for young adults in poverty enrolled in post-secondary education in post-conflict regions in Colombia: a study protocol

Background

Colombia has endured more than five decades of internal armed conflict, which led to substantial costs for human capital and mental health. There is currently little evidence about the impact of incorporating a mental health intervention within an existing public cash transfer program to address poverty, and this project aims to develop and pilot a mental health support intervention embedded within the human capital program to achieve better outcomes among beneficiaries, especially those displaced by conflict and the most socioeconomically vulnerable.

Methods

The study will consist of three phases: semi-structured one-to-one interviews, co-design and adaptations of the proposed intervention with participants and pilot of the digital intervention based on cognitive behavioral therapy and transdiagnostic techniques to determine its feasibility, acceptability, efficacy, and usefulness in 'real settings'. Results will inform if the intervention improves clinical, educational and employment prospects among those who use it.

Results

Knowledge will be generated on whether the mental health intervention could potentially improve young people's mental health and human capital in conflict-affected areas? We will evaluate of the impact of potential mental health improvements on human capital outcomes, including educational and employment outcomes.

Conclusion

Findings will help to make conclusions about the feasibility and acceptability of the intervention, and it will assess its effectiveness to improve the mental health and human capital outcomes of beneficiaries. This will enable the identification of strategies to address mental health problems among socioeconomically vulnerable young people that can be adapted to different contexts in in low and middle-income countries.

The impacts of the Syrian conflict on child and adolescent health: a scoping review

BACKGROUND

The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population.

METHODS

A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence.

RESULTS

A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health.

CONCLUSIONS

The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

How positive deviants helped in fighting the early phase of COVID-19 pandemic? A qualitative study exploring the roles of frontline health workers in Nepal

Positive deviance is an approach wherein learnings from persons who fare better than their peers under similar circumstances are used to enable behavioral and social change. Such behaviors and solutions are likely affordable, acceptable, sustainable, and fit into the socio-cultural milieu. Despite the wide use of positive deviance in many public health programs and research, it has yet to be used to study frontline workers in the context of COVID-19. Therefore, this study aimed to explore the positive deviance traits among frontline health workers during the early days of the COVID-19 pandemic in Nepal. This qualitative study followed a grounded theory approach. The data was collected through in-depth interviews among the 17 identified participants representing different cadres of the health workforce, types of health facilities, and regions across Nepal purposively. The findings are structured around four major themes: challenges, finding solutions and innovations, positive lessons, and motivations. The personal challenges included fear and anxiety about the uncertainties. The professional challenges included stigma, infection control, and changing work style with the use of personal protective equipment. Despite the challenges, they managed available resources and innovated low-cost, technological, and practice-based solutions. They were able to reflect upon the positive lessons learned, such as self-sustainability, teamwork, and policy direction and research, and self-reflection of personal growth and patient care. The intrinsic motivation included their inherent value system, and the extrinsic motivation included appreciation and acknowledgment, family and social support, psychosocial support from peers, and support from higher authorities. This study provides insights into how the positive deviance approach can help identify the solution amid the most challenging circumstances, such as the COVID-19 pandemic in low-resource settings. However, more extensive studies are warranted to explore deeper into positive deviance and its long-term effects in bringing positive outcomes during the pandemic.

The mental health consequences on children of the war in Ukraine: A commentary

The news from Ukraine is currently full of heart-wrenching stories accompanied by graphic images of civilian casualties and massacres that are telecast world-wide on a daily basis. It is hard to fathom the magnitude of the devastation and disruption to regular lives and everyday routines that war brings with it, the witnessing of countless deaths, the associated trauma of living in perpetual fear, and the daily experience of many families and orphans who are crowded into basement bomb shelters now for months on end. These issues make us contemplate the mental health consequences, among other lasting effects, of this costly war in Ukraine, and wars in other countries not so widely featured in Western news. Despite people of all ages being affected by war, children are especially vulnerable. This commentary outlines some of the epidemiology of the consequences of war, the mental health sequelae specifically, and the complexity of providing culturally and contextually relevant interventions that meet the needs of children.

Psychosocial health and quality of life among North African women

Studies on relationships between psychosocial factors and health among North African (NA) women are scarce. This research investigated the self-perceived psychosocial well-being of NA women by a structured questionnaire and anthropometric survey examining the possible explanatory variables of their mental health in comparison to a sample of NA migrants. The association of endogenous stress, psychological well-being, discomfort, and quality of life with migrant/non-migrant status, demographic characteristics, and adiposity indices was examined. Moreover, the internal consistency of the questionnaire was tested using Cronbach's alpha. A sample of 228 women living in Tunis and Casablanca participated in a survey in Tunisia and Morocco. According to multiple regression models, migrant/non-migrant status was the best explanatory variable of well-being and quality of life, marital status, educational level and the number of children were explanatory variables of discomfort and endogenous stress. Among anthropometric variables, central adiposity was a significant explanatory variable of well-being. The comparison with women who migrated mainly from Morocco and Tunisia to Italy (NA migrants) exhibited higher weight status and central adiposity in NA migrants. The perceived stress and discomfort were the same in the two groups; the migrants, despite reporting lower psychological well-being, presented a higher quality of life than residents. Our findings emphasise the potential to promote monitoring of the psychosocial health of NA women, planning effective interventions.

Nagorno-Karabakh conflict: Mental health repercussions and challenges in Azerbaijan

The Armenia-Azerbaijan Nagorno-Karabakh conflict has made many Azerbaijanis internally displaced (IDP), missing, wounded, disabled, or killed. The war and its aftermath have drastically impacted the mental health of these populations, leading to depression, anxiety, and stress-related psychosomatic illnesses such as dissociative disorder. However, their access to medical and psychological services is limited. Intervention in terms of policy making, healthcare services, information systems, and social support is required to promoting social integration and facilitate accessibility to mental healthcare. National and international organisations, foreign aids, and media support can contribute to this end. The psychological effects of the war on children, healthcare shortage associated with COVID-19, accommodation and welfare problems, limited access to vaccination, technology, and educational opportunities, dangerous explosive remnants, as well as isolation and marginalisation of the IDPs can all be challenges facing the mental health of these populations. Organising programs such as support groups to share wartime experience, resilience promotion, psychosocial support for healthcare providers, religious identification, integral COVID-19 management, beside accommodation and education support are recommended to enhance the condition of these Azerbaijani populations.

Evaluating the feasibility of a group psychosocial intervention for migrant and host community women in Ecuador and Panamá: protocol for a multi-site feasibility cluster trial

BACKGROUND

Community- and strengths-based psychosocial interventions are central to mental health and psychosocial support guidelines, but rigorous evidence regarding the effectiveness of these interventions is limited. The complexity and variability that is inherent to many community-based psychosocial interventions requires innovative strategies in order to facilitate the comparability and synthesis across research studies without compromising the fit and appropriateness of interventions to specific study populations and context. Entre Nosotras is a community-based psychosocial intervention developed for migrant and host community women that is designed to be flexible enough to enable integration of external intervention components and adaptable to diverse study contexts and populations. This protocol describes a study that aims to evaluate the appropriateness, acceptability, and feasibility of integrating a standardized stress management intervention into Entre Nosotras.

METHODS

This study will evaluate the appropriateness, acceptability, feasibility, and safety of intervention and research procedures for a cluster randomized comparative effectiveness trial conducted in Ecuador and Panamá with migrant and host community women. In this feasibility trial, we will allocate communities nested within the three study sites to the integrated Entre Nosotras + stress management intervention versus Entre Nosotras alone through stratified randomization. Migrant and host community women residing in these study communities who report low to moderate levels of distress will be allocated to the intervention condition that their community is assigned (n = 220 total). We will collect quantitative measures of psychosocial wellbeing, psychological distress, coping, social support, and functioning from study participants. We will collect quantitative measures of fidelity and facilitator competencies through observation and facilitator self-assessment. Data on appropriateness, acceptability, feasibility, and safety will be gathered from participants and facilitators through quantitative assessments at 0, 5, and 10 weeks post-enrollment and qualitative interviews conducted with all facilitators and a subset of 70 study participants during the post-intervention follow-up period.

DISCUSSION

Results from this feasibility trial will determine whether a multi-site cluster randomized comparative effectiveness trial of an adaptable community-based psychosocial intervention for migrant and host community women is relevant, acceptable, and feasible.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05130944 . Registered November 23, 2021-retrospectively registered.

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.

Compounding inequalities: Adolescent psychosocial wellbeing and resilience among refugee and host communities in Jordan during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic and associated risk-mitigation strategies have altered the social contexts in which adolescents in low- and middle-income countries live. Little is known, however, about the impacts of the pandemic on displaced populations, and how those impacts differ by gender and life stage. We investigate the extent to which the pandemic has compounded pre-existing social inequalities among adolescents in Jordan, and the role support structures play in promoting resilience.

METHODS

Our analysis leverages longitudinal quantitative survey data and in-depth qualitative interviews, collected before and after the onset of COVID-19, with over 3,000 Syrian refugees, stateless Palestinians and vulnerable Jordanians, living in camps, host communities and informal tented settlements. We utilize mixed-methods analysis combining multivariate regression with deductive qualitative tools to evaluate pandemic impacts and associated policy responses on adolescent wellbeing and mental health, at three and nine months after the pandemic onset. We also explore the role of support systems at individual, household, community, and policy levels.

FINDINGS

We find the pandemic has resulted in severe economic and service disruptions with far-reaching and heterogenous effects on adolescent wellbeing. Nine months into the pandemic, 19.3% of adolescents in the sample presented with symptoms of moderate-to severe depression, with small signs of improvement (3.2 percentage points [pp], p<0.001). Two thirds of adolescents reported household stress had increased during the pandemic, especially for Syrian adolescents in host communities (10.7pp higher than any other group, p<0.001). Social connectedness was particularly low for girls, who were 13.4 percentage points (p<0.001) more likely than boys to have had no interaction with friends in the past 7 days. Adolescent programming shows signs of being protective, particularly for girls, who were 8.8 percentage points (p<0.01) more likely to have a trusted friend than their peers who were not participating in programming.

CONCLUSIONS

Pre-existing social inequalities among refugee adolescents affected by forced displacement have been compounded during the COVID-19 pandemic, with related disruptions to services and social networks. To achieve Sustainable Development Goal targets to support healthy and empowered development in adolescence and early adulthood requires interventions that target the urgent needs of the most vulnerable adolescents while addressing population-level root causes and determinants of psychosocial wellbeing and resilience for all adolescent girls and boys.

Leveraging Systems Science to Promote the Implementation and Sustainability of Mental Health and Psychosocial Interventions in Low- and Middle-Income Countries

ABSTRACT

Advancements in global mental health implementation research have revealed promising strategies for improving access to evidence-based mental health care. These advancements have not translated, however, into a reduced prevalence of mental disorders. In this review we examine the relationships between determinants (i.e., barriers and facilitators) and outcomes of mental health services in low- and middle-income countries to identify opportunities for improving the population-level impact and sustainability of innovations in global mental health. We identified three key implementation and services outcomes that influenced the prevalence of mental disorders in the 56 included review articles: supply (access, implementation), demand (help seeking, utilization), and quality (effectiveness, quality of care) of mental health services. Determinants of these outcomes revealed seven themes: community stakeholder engagement; cultural relevance; stigma; human resource capacity; organization of services; governance, policy, and financing; and sociopolitical and community context. We developed a causal loop diagram to illustrate the relationships among these determinants and outcomes. The causal loop diagram revealed the central role of community stakeholder engagement in bridging implementation and patient outcomes, the importance of addressing stigma and social determinants of mental health, and the need to complement supply-side implementation strategies with approaches to equilibrate demand and improve the quality of services. Applying systems science methodologies to global mental health research presents an opportunity to examine the complex relationships among community and health system factors that influence implementation of evidence-based interventions in order to identify sustainable approaches to improve the population-level impact of mental health services in low- and middle-income countries.

Delivering nutrition interventions to women and children in conflict settings: a systematic review

Background

Low/middle-income countries (LMICs) face triple burden of malnutrition associated with infectious diseases, and non-communicable diseases. This review aims to synthesise the available data on the delivery, coverage, and effectiveness of the nutrition programmes for conflict affected women and children living in LMICs.

Methods

We searched MEDLINE, Embase, CINAHL, and PsycINFO databases and grey literature using terms related to conflict, population, and nutrition. We searched studies on women and children receiving nutrition-specific interventions during or within five years of a conflict in LMICs. We extracted information on population, intervention, and delivery characteristics, as well as delivery barriers and facilitators. Data on intervention coverage and effectiveness were tabulated, but no meta-analysis was conducted.

Results

Ninety-one pubblications met our inclusion criteria. Nearly half of the publications (n=43) included population of sub-Saharan Africa (n=31) followed by Middle East and North African region. Most publications (n=58) reported on interventions targeting children under 5 years of age, and pregnant and lactating women (n=27). General food distribution (n=34), micronutrient supplementation (n=27) and nutrition assessment (n=26) were the most frequently reported interventions, with most reporting on intervention delivery to refugee populations in camp settings (n=63) and using community-based approaches. Only eight studies reported on coverage and effectiveness of intervention. Key delivery facilitators included community advocacy and social mobilisation, effective monitoring and the integration of nutrition, and other sectoral interventions and services, and barriers included insufficient resources, nutritional commodity shortages, security concerns, poor reporting, limited cooperation, and difficulty accessing and following-up of beneficiaries.

Discussion

Despite the focus on nutrition in conflict settings, our review highlights important information gaps. Moreover, there is very little information on coverage or effectiveness of nutrition interventions; more rigorous evaluation of effectiveness and delivery approaches is needed, including outside of camps and for preventive as well as curative nutrition interventions.

PROSPERO registration number

CRD42019125221.

Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.