Towards an integrated model for supervision for mental health and psychosocial support in humanitarian emergencies: A qualitative study

Implementing the 'Integrated Model for Supervision' for mental health and psychosocial support programming within humanitarian emergencies: A mixed-methods evaluation across six humanitarian contexts

BACKGROUND

The 'Integrated Model for Supervision' (IMS) offers important guidance for how to provide supportive supervision within mental health and psychosocial support (MHPSS) programming in humanitarian emergencies. The current study sought to (i) describe how the IMS was implemented following IMS training; (ii) assess whether delivery of the IMS training is associated with changes in a selection of theoretically supported quantitative outcomes; and (iii) elicit feedback on the IMS and its implementation process.

METHODS

Data was collected from a participant pool of n = 119 individuals from six different humanitarian organisations that had previously participated in an IMS training. For the first and third objectives, interviews at 6- and 12-months post-training were conducted and thematically analysed. For the second objective, timepoint comparison analytical techniques were used across five distinct timepoints.

RESULTS

Quantitative findings showed significant increases in participant self-efficacy, supervision knowledge, and supervision confidence, alongside some evidence of reductions in participant burnout. Qualitatively, participants underscored the IMS's efficacy in creating supportive supervision structures within their organisations, identified barriers and facilitators to implementation and proposed strategies for sustainability. Additionally, they highlighted positive impacts of implementing the IMS on staff, organisational culture, and service quality.

DISCUSSION/CONCLUSION

This study supports the effectiveness and acceptability of the IMS in enhancing the capacity of organisations to provide supportive supervision in humanitarian contexts, as key to promote the wellbeing of humanitarian MHPSS workers and the quality of the services they deliver. Challenges remain, however, to ensure sustainable implementation of the IMS, which guide ongoing efforts towards its improvement.

Facilitators and barriers to participation and scale-up of a non-specialist delivered psychological intervention for adolescents in low-resourced settings: a process evaluation

Globally, the number of refugees and displaced individuals has surpassed 100 million for the first time in history. Refugees are more likely than non-refugee populations to experience psychological distress and develop mental disorders. Early Adolescent Skills for Emotion (EASE), developed by the World Health Organization, is a potentially scalable task-sharing intervention targeting symptoms of internalizing disorders such as depression and anxiety for 10-15 years old and their caregiver. Prior to this study a randomized controlled trial in Amman, Jordan was conducted showing effectiveness of EASE reducing caregiver distress and inconsistent disciplinary parenting as well as reducing internalizing problems in adolescence. This study aims to explore individual and contextual barriers and facilitators for scaling the EASE intervention for Syrian refugees in Jordan. Ten semi-structured interviews and four focus group discussions were conducted between October 2020 and February 2023 with five key mental health and psychosocial support (MHPSS) informants, eight EASE providers, 11 adolescents, and 12 caregivers. Purposeful quota sampling technique was used to recruit participants with attention to sex and age and number of interviews and focus group discussions determined through empirical saturation. Inductive and deductive codes were utilized in a six-step thematic analysis. Participants reported a beneficial impact of EASE sessions in terms of reducing experienced anxiety levels, improved communication between adolescents and caregivers, reduced feelings of anger and jealousy, and improved familial relationships. Individual participation was hampered by transportation issues, scheduling conflicts, gender-mixed groups, and competing responsibilities. Scale-up facilitators included; increased mental health awareness, perceived low cost of EASE, feasibility of delivery by non-specialists, and an intervention engaging both adolescents and caregivers. Barriers included location, online sessions, sustainability, general implementation issues caused by individual barriers, and some concerns about non-specialists. Results add nuances not detected in the previous randomized control trial in Jordan and provide important context for understanding effectiveness results. Future research should investigate the cost-effectiveness of EASE along with stepped-care implementation models to provide EASE within existing health systems.

Data-driven supervision to optimize the effectiveness of proactive case detection for mental health care among children: a proof-of-concept study

This proof-of-concept study evaluated an optimization strategy for the Community Case Detection Tool (CCDT) aimed at improving community-level mental health detection and help-seeking among children aged 6-18 years. The optimization strategy, CCDT+, combined data-driven supervision with motivational interviewing techniques and behavioural nudges for community gatekeepers using the CCDT. This mixed-methods study was conducted from January to May 2023 in Palorinya refugee settlement in Uganda. We evaluated (1) the added value of the CCDT+ in improving the accuracy of detection and mental health service utilization compared to standard CCDT, and (2) implementation outcomes of the CCDT+. Of the 1026 children detected, 801 (78%) sought help, with 656 needing mental health care (PPV = 0.82; 95% CI: 0.79, 0.84). The CCDT+ significantly increased detection accuracy, with 2.34 times higher odds compared to standard CCDT (95% CI: 1.41, 3.83). Additionally, areas using the CCDT+ had a 2.05-fold increase in mental health service utilization (95% CI: 1.09, 3.83). The CCDT+ shows promise as an embedded quality-optimization process for the detection of mental health problems among children and enhance help-seeking, potentially leading to more efficient use of mental health care resources.

Practical challenges for mental health services among Rohingya refugee in Bangladesh

Rohingya Muslims have been forcefully displaced from their mother land, Rakhaine State, Myanmar to Bangladesh, a country with about 170 million population with a treatment gap of more than 90% for standard mental health care. Due to the experienced trauma and displacement, high prevalence of depression, anxiety and post-traumatic tress disorders has been identified among Rohingya refugees in addition to the enduring mental health burden of Bangladesh. Very little has been known regarding the practical challenges of mental health services among Rohingya refugees in Bangladesh. In this commentary, we aimed to highlight the practical challenges for mental health services in Rohingya camps in Bangladesh along with our speculative ways forward based on available evidence, work experience, and informal communications. We highlighted the available mental health services, several major challenges including awareness, perception and belief towards mental health, language and cultural barriers, dearth of skilled service providers, inadequate services for severe mental illness, dearth of mental health services for children, inadequate provision of supervision and 'Care for Caregivers' program, and privacy and confidentiality of the clients. Although significant improvements have been made in the mental health field in the emergency crisis sector in Cox's Bazar over the past years, concentrated efforts are urgently required to actualize proposed solutions in this paper.

Psychosocial impacts of Baby Friendly Spaces for Rohingya refugee mothers in Bangladesh: A pragmatic cluster-randomized controlled trial

Background

This study evaluated the effectiveness of Baby Friendly Spaces (BFS), a psychosocial support program for Rohingya refugee mothers of malnourished young children in Bangladesh. Because BFS was already being implemented, we examined the benefit of enhancing implementation supports.

Methods

In matched pairs, 10 sites were randomized to provide BFS treatment as usual (BFS-TAU) or to receive enhanced implementation support (BFS-IE). 600 mothers were enrolled and reported on maternal distress, functional impairment, subjective well-being and coping at baseline and 8-week follow-up. Data were analyzed using multilevel linear regression models to account for clustering; sensitivity analyses adjusted for the small number of clusters.

Results

Significant within-group improvements in BFSIE were observed for distres (-.48, p = .014), functional impairment (-.30, p = .002) and subjective well-being (.92, p = .011); improvements in BFS-TAU were smaller and not statistically significant. Between-group comparisons favored BFS-IE for distress (β = -.30, p = .058) and well-being (β = .58, p = .038). Sensitivity adjustments produced p-values above .05 for all between-group comparisons.

Discussion

Feasible adjustments to implementation can improve program delivery to increase impact on maternal distress and well-being. Although results should be interpreted with caution, study design limitations are common in pragmatic, field-based research.

Implementing supportive supervision in acute humanitarian emergencies: Lessons learned from Afghanistan and Ukraine

Mental Health and Psychosocial Support (MHPSS) practitioners working in humanitarian contexts are at significant risk of mental health conditions, ultimately hindering the quality and sustainability of their work. Supportive supervision has shown to be effective in improving the wellbeing of MHPSS staff and volunteers and enhancing the effectiveness of MHPSS service delivery. Despite these proven benefits, there is a lack of standardised guidelines to inform supportive supervision within humanitarian contexts. To address this gap, the Trinity Centre for Global Health and the International Federation of the Red Cross Red Crescent Societies' Reference Centre for Psychocosial Support co-developed the 'Integrated Model for Supervision' (IMS) Handbook and supporting tools and led IMS trainings with four humanitarian organisations in Ukraine, Afghanistan, Jordan, and Nigeria from June-August 2021. The subsequent acute humanitarian emergencies that occurred in Afghanistan and Ukraine provided the opportunity to (i) examine the implementation of the IMS in the acute stages of two humanitarian crises and (ii) identify the challenges and lessons learned from this process. This study employed a case study design using semi-structured qualitative interviews with five MHPSS personnel (female: 4; male: 1) who had received training in the IMS and were directly involved in the implementation of supportive supervision using IMS guidelines in either Ukraine or Afghanistan. Results showed that participants identified the key steps needed for the implementation of supportive supervision and reported two significant barriers to implementation including the stress of a humanitarian crisis leading to competing responsibilities and priorities, staff shortages and time constraints as well as the challenge of creating a new supervision structure when none had existed previously. Overall, participants felt that the IMS resulted in improved knowledge, confidence, perceived support, team cohesion, staff wellbeing and was a helpful blueprint to guide the implementation of supportive supervision in humanitarian contexts.

Testing the effectiveness and acceptability of online supportive supervision for mental health practitioners in humanitarian settings: a study protocol for the caring for carers project

BACKGROUND

Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project.

METHOD

A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress (Professional Quality of Life Scale), perceived injustice, clinical self-efficacy (Counseling Activity Self-Efficacy Scale), service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention.

DISCUSSION

There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.

Gender considerations for supportive supervision in humanitarian contexts: A qualitative study

Supportive supervision has been shown to improve mental health outcomes and job retention for mental health and psychosocial support (MHPSS) workers in humanitarian contexts. However, the impact of gender on supervision practices has been poorly evaluated and documented in international guidelines to date. To address this gap, qualitative interviews were conducted with 12 MHPSS staff working in diverse humanitarian contexts to identify key gender considerations in supportive supervision. Results show that gender in supervision is influenced by the context of MHPSS work; with culture, religion and gender roles identified as key elements. Participants discuss recruitment mechanisms, highlighting the unequal gender distribution and inequitable opportunities within MHPSS programming. The importance of addressing power dynamics impacted by gender and of ensuring the safety of women within supervision is also highlighted. Finally, participants discuss the gender differences across the various supervisory formats. Altogether, results indicate that gender has the potential to influence supportive supervision within MHPSS, and it is recommended that international guidelines account for nuances of gender in supportive supervision within humanitarian contexts.

What matters in mental health care? A co-design approach to developing clinical supervision tools for practitioner competency development

Background

Specialised mental health (MH) care providers are often absent or scarcely available in low resource and humanitarian settings (LRHS), making MH training and supervision for general health care workers (using task-sharing approaches) essential to scaling up services and reducing the treatment gap for severe and common MH conditions. Yet, the diversity of settings, population types, and professional skills in crisis contexts complicate these efforts. A standardised, field tested instrument for clinical supervision would be a significant step towards attaining quality standards in MH care worldwide.

Methods

A competency-based clinical supervision tool was designed by Médecins Sans Frontières (MSF) for use in LRHS. A systematic literature review informed its design and assured its focus on key clinical competencies. An initial pool of behavioural indicators was identified through a rational theoretical scale construction approach, tested through waves of simulation and reviewed by 12 MH supervisors in seven projects where MSF provides care for severe and common MH conditions.

Results

Qualitative analysis yielded two sets of competency grids based on a supervisee's professional background: one for 'psychological/counselling' and another for 'psychiatric/mhGAP' practitioners. Each grid features 22-26 competencies, plus optional items for specific interventions. While the structure and content were assessed as logical by supervisors, there were concerns regarding the adequacy of the tool to field reality.

Conclusions

Humanitarian settings have specific needs that require careful consideration when developing capacity-building strategies. Clinical supervision of key competencies through a standardised instrument represents an important step towards ensuring progress of clinical skills among MH practitioners.

Addressing the mental health needs and burdens of children fleeing war: a field update from ongoing mental health and psychosocial support efforts at the Ukrainian border

Background: The ongoing horrors of the war in Ukraine have led to enormous consequences: loss of life, severe injuries, and mass movements of civilians. Exposure to war, living in conflict zones, and forced displacement increase the risk of experiencing a broad spectrum of direct and indirect burdens towards physical and mental health, in particular among children. Objective: This letter to the editor aims to provide multiple clinical and 'mental health and psychosocial support' (MHPSS) systems' perspectives by experts working in ongoing aid efforts to bridge and disseminate their current observations towards child and adolescent mental health services involved in the mental health response to the current war in Ukraine. Results and Discussion: The diverse perspectives from three mental health professionals involved in the MHPSS response highlight the different burdens and needs of children being confronted with situations of an existential nature. Children live through transformed social situations, deteriorated life conditions, general uncertainty, and encounter numerous losses. As such, war is the ultimate non-normative and existential stressor. The four perspectives highlight the need to: (1) adjust help toward the needs of the beneficiary, (2) understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters, (3) recognise losses and embrace finding ways to facilitate grief, and (4) continue to address these needs in a coordinated way that follows inter-agency guidelines. Conclusion: Better understanding the needs of refugee children underlines the importance of investing in their future by providing resources for humanitarian aid and psychosocial interventions during sustained emergencies. The perspectives presented in this letter emphasise that psychosocial care is deeply rooted in intersubjective help-encounters and, therefore, a professionalisation of interventions should co-occur with their humanisation and be adapted to subjective needs, varying sociocultural backgrounds, and the individuals themselves with the goal of reducing suffering and fostering well-being.

HIGHLIGHTS

The three expert humanitarian aid perspectives highlight the need to: adjust help toward the needs of the beneficiary,understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters,recognise losses and embrace finding ways to facilitate grief, andcontinue to address these needs in a coordinated way that follows inter-agency guidelines.

Identifying best practice for the supervision of mental health and psychosocial support in humanitarian emergencies: a Delphi study

BACKGROUND

Supportive supervision has been shown to improve worker resilience and wellbeing, which are particularly important in the context of humanitarian emergency settings. Despite its noted importance however, supervision remains an under-prioritised area in mental health and psychosocial support (MHPSS).

METHOD

The present study used a Delphi consensus-building methodology to examine levels of agreement among a diverse sample of MHPSS stakeholders (n = 48) on key ideas and concepts relating to supervision in humanitarian settings.

RESULTS

The majority of statements presented showed a high degree of consensus, with some receiving almost universal agreement, such as the importance of using active listening skills in the supervisory context and the need for supervisors to have access to their own supervisory support. However, disagreement on several points remained. For example, participants disagreed about whether the qualities required to be an effective supervisor can be taught, or whether they are more innate and should be screened for when recruiting supervisors. Gender differences in responses were also analysed, with potential associations between gender and level of agreement emerging in relation to statements about power dynamics, remote supervision, and intervention quality enhancement.

CONCLUSIONS

The findings of the present study are discussed in terms of their implications for a forthcoming set of guidelines for supervision of MHPSS in humanitarian settings: The Integrated Model for Supervision (IMS).