Assessing the feasibility of providing a parenting intervention for war-affected families in northern Uganda

Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective

We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of zr = 0.24 (95%CI 0.20, 0.29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.

The Relationship Between Family Cohesion and Depression Among School-Going Children With Elevated Symptoms of Behavioral Challenges in Southern Uganda

PURPOSE

Depression is among the leading causes of disability and contributes significantly to the overall disease burden affecting children. Family cohesion has been identified as a protective factor against depression. Examining this relationship is necessary in sub-Saharan Africa, specifically in Uganda-a country characterized by a high prevalence of HIV/AIDS, and high rates of chronic poverty, all of which stress family functioning and elevate child behavioral challenges. This study examined the relationship between family cohesion and depression among school-going children with elevated symptoms of behavioral challenges in southern Uganda.

METHODS

At baseline, 2089 children were enrolled in the National Institutes of Health-funded Strengthening Mental Health and Research Training Africa study in Southwestern Uganda. This article analyzed data from 626 children aged 8-13 years with elevated behavioral challenges. We conducted multilevel mixed-effects Poisson regression to determine the association between family cohesion and depression. We controlled for sociodemographic and household characteristics.

RESULTS

The mean age was 10.3 years. The overall mean depression score was 3.2 (standard deviation = 2.7, range = 0-15). Family cohesion (β = -0.03, 95% confidence interval [CI]: -0.04, -0.02, p < .001) and owning essential items by the child (β = -0.13, 95% CI: -0.23, -0.04, p = .005) were protective against depression among children. Additionally, we observed being a single orphan (β = -0.44, 95% CI: -0.03, -0.86, p = .036) and having both parents (β = -0.43, 95% CI: -0.06, -0.81, p = .023) were associated with depression among children.

DISCUSSION

Findings from this study reveal that family cohesion was protective against depression. Therefore, it is vital to strengthen family support systems by developing programs aimed at strengthening family relationships as a catalyst for addressing depression among children.

Training of interventionists and cultural adaptation procedures: A systematic review of culturally adapted evidence-based parenting programs in Africa

There has been an increase in the implementation of evidence-based parenting programs from high-income countries to several African countries. In this review, we systematically evaluated intervention studies of culturally adapted parenting programs in nine African countries with the objective of examining the quality of training for interventionists and cultural adaptation procedures. A total of 18 studies, obtained from an electronic search of 6 databases, met the inclusion criteria and were evaluated following PRISMA guidelines. The Ecological Validity Model was adopted to organize data on cultural adaptation procedures. Sixteen of the 18 studies reported information regarding the clinical training of interventionists and the cultural adaptations undertaken. Live and interactive workshops were the most common format used to train interventionists in the focal intervention. Overall, cultural adaptations in most studies included translation of intervention protocols into the local language. However, studies varied in the way cultural adaptation procedures were reported with some studies failing to report on cultural adaptation procedures. Concurring with previous literature, attending to issues of culture, power, privilege, access, sustainability, and other relevant concepts to increase the cultural relevance is highly encouraged in parent intervention studies in Africa. This review provides a baseline upon which future training and adaptation procedures can be built.

Contextualizing Potential Factors Impacting on Behaviors of Primary School Adolescents in Northern Uganda

Our study contextualized empirical factors influencing adolescent behaviors. An assessment using focus group discussion (FGD) was done with randomly selected adolescents in primary schools in Northern Uganda to explore the influence of child poverty and parenting among other factors on adolescents' behaviors. A semi-structured interview guide and in-depth interviews were also conducted for parents/guardians and teachers, respectively. Adolescents expressed desirable developmental outcomes contrary to teachers' concerns regarding achieving them. Parenting and places of residence had a significant positive impact on adolescent behaviors, with the village residence having a much earlier influence compared to parenting. Our findings revealed a scanty understanding of child poverty, parenting, and adolescent development among parents/guardians. Any action-oriented toward awareness would promote adolescent behavioral development.

A Systematic Review of Evidence-Based Family Interventions for Trauma-Affected Refugees

Family connections are crucial for trauma-affected refugees from collectivistic cultures. Evidence-based family interventions are consistently promoted to support a host of mental and relational health needs of families exposed to traumatic stressors; however, there is still limited research focused on cultural adaptation and the testing of the effectiveness of these interventions on some of the most disenfranchised populations in the aftermath of forced displacement. This systematic review was conducted to examine the reach of existing evidence-based family interventions implemented with newly resettled refugees globally. Studies included in this review include those testing the effectiveness of a systemic treatment with pre and post intervention evaluation, studies with or without control groups, and studies that include at least one family member in addition to the target participants. Twelve studies met the inclusion criteria. Barriers to conducting randomized control trials with displaced refugee populations are discussed. Recommendations are made for future studies to include a focus on scientifically rigorous multi-method designs, specific cultural adaptation frameworks, and the integration of relational aspects rather than focusing only on individual adjustment. Global displacement continues to rise; therefore, it is imperative that the mental health and wellbeing of displaced populations be treated with a comprehensive, multi-level framework.

Expanding the Traumatic Stress Framework to Incorporate a Socioecological Family Systems Perspective

Over the past few decades, there has been a growing interest among systemic researchers and clinicians to address issues related to psychological traumatic stress. Yet, research in this area has largely focused on intrapersonal and physiological processes in conceptualizing traumatic stress and its various outcomes. Despite the usefulness of intrapersonally focused models of traumatic stress, this approach has its limitations. Emerging evidence indicates that both proximal contexts, such as family, and distal socioecological contexts, such as political and environmental systems, can have a profound effect on traumatic stress risk, presentation, and recovery. In the present article, we review and synthesize emerging research on traumatic stress and integrate findings from intrapersonally and systemically focused models of traumatic stress. We propose and present evidence for what we term the dynamic socioecological framework of traumatic stress, a heuristic framework for conceptualizing the interactions between different forms of traumatic stress. This framework puts forward the dimensions of traumatic stress typology, severity, and timing, underscoring how traumatic stress risk, presentation, and recovery are highly dependent upon the systems in which people are embedded. We conclude with a discussion of the research and clinical implications of this conceptual framework.

Bridging the Gap between the Pressing Need for Family Skills Programmes in Humanitarian Settings and Implementation

A supportive environment with nurturing caregivers is essential for the healthy development of children. For children who have been exposed to extreme stress, such as humanitarian contexts, the need for strong, healthy, nurturing caregiver relationships may assume even greater importance. Much research has been building to position family skills interventions as a key tool in encouraging safe and supporting relationships between caregivers and children, thus preventing many problem behaviours and poor mental health. While there is substantial evidence of the effectiveness of family skills interventions in high-income and stable contexts, evidence of interventions that have been tested in humanitarian and challenging settings, such as contexts of refugee and displacement, are far fewer. Despite the role that family skills interventions can play in protecting children from current and future challenges, there is a significant lack of such interventions being utilised in humanitarian settings. We put forward seven likely reasons for this lack of uptake. Furthermore, the Strong Families programme, a UNODC family skills intervention, is presented as an example of an intervention that aims to bridge this gap of interventions that meet the need for humanitarian and contexts of extreme stress. More research is needed to unpack the content, delivery mechanisms and reach of family skills programmes to further aid programme developers in investing in efforts that might provide significant sustained impact for families in humanitarian contexts.

Systemic interventions for traumatic event exposure: A 2010-2019 decade review

Trauma exposure is a pervasive issue worldwide. People exposed to traumatic events may develop PTSD, depression, anxiety, and other mental health symptoms. Family and intimate partner relationship problems also are frequently associated with trauma exposure. The purpose of this study was to conduct a systematic research synthesis of the empirical evidence on systemic interventions for traumatic event exposure from 2010 to 2019. A search of peer-reviewed research resulted in 31 articles that met inclusion criteria and were included in this review. Systemic interventions were grouped by modality (e.g., parent-child, couple, group). The collective evidence was strongest for systemic youth-caregiver interventions, group, and couple treatment categories for traumatic event exposure. Youth-centered interventions that included various combinations of family member participation can be considered probably efficacious. Overall, results indicated that systemic interventions for traumatic event exposure were successful in reducing posttraumatic stress symptoms including PTSD, depression, and anxiety, and improving relational outcomes.

Participants' experiences of engagement in community-centred mental health and psychosocial support programmes in conflict-affected communities within sub-Saharan Africa: a qualitative systematic review

BACKGROUND

Sub-Saharan Africa (SSA) experienced a burden of organised violence within 18 low-income and middle-income countries and hosted over 33 million displaced persons in 2019. Community-centred mental health and psychosocial support (cc-MHPSS) programmes may provide insights to address the psychosocial well-being of conflict-affected individuals, though literature is mixed on community impact. This review aimed to synthesise qualitative evidence to understand the kind of experiences conflict-affected participants have and how these experiences occur during cc-MHPSS programme engagement in SSA.

METHODS

We searched Global Health, MEDLINE, Psychological Information Database, Embase Classic+Embase, Social Policy and Practice, Web of Science, Africa-Wide Information, PubMed and Global Index Medicus databases. Eligible publications qualitatively reported on conflict-affected participants' experiences of engagement in cc-MHPSS programmes. Data were extracted to summarise publication characteristics. The results were synthesised using a thematic synthesis analysis.

RESULTS

The search yielded 953 records, of which 20 publications were included in the review. Included publications were located in Rwanda (n=8), the Democratic Republic of the Congo (n=3), Mozambique (n=3), Sierra Leone (n=1), Ghana (n=1), Uganda (n=1), Zimbabwe (n=1) and South Sudan (n=1); one publication included three countries (Sierra Leone, Liberia and Uganda). Findings include the themes of (1) the experience of change in time and space, and (2) the sharing and silence of participants' experiences. Findings demonstrate that elements transferred by participants from a cc-MHPSS programme to a natural community, and vice versa, contribute to participants' healing. Elements' transfer, or non-transfer, was often related to participants' disclosure, or non-disclosure, of experiences.

DISCUSSION

Findings suggest that there are elements from a cc-MHPSS programme and a wider community which aid participant engagement and work therapeutically. More rigorous research is needed concerning how participants experience change during cc-MHPSS programme engagement in proximity to their relationship with the wider community.

PROSPERO REGISTRATION NUMBER

CRD42020197300.

Expanding our international reach: Trends in the development of systemic family therapy training and implementation in Africa

Family therapy is growing around the world including in many parts of Africa. Although the African continent has many mental and family health needs that family therapists are well-suited to treat, barriers to the widespread application of family therapy on the African continent remain. In this article, we review the current state of systemic family therapy (SFT) in Africa. Drawing from existing literature, we discuss past, current, and future trends, including challenges related to the training and implementation of SFT in Africa. We devote sections of this article to discussing the historical and cultural context, including the fit for family therapy, along with ongoing initiatives in various African countries, using examples from three African countries. We emphasize and discuss the influence of Western models of family therapy in informing family therapy research, training, and implementation in Africa and discuss implications for the African context.

The impact of alcohol misuse on fathering in Northern Uganda: An ethnographic study of fathers

The Acholi people of northern Uganda experienced decades of conflict. Alcohol misuse is high among northern Ugandan men. This is common in displaced or post-war communities. Because parents are often the most significant and proximal influence in a child's development, it is important to understand the relationships between parental behavioral health and parenting. The purpose of this ethnographic study was to understand the impact of alcohol misuse on fathering, from fathers' perspectives. We collected qualitative data from several sources, including in-depth interviews with 19 fathers. Informants identified three ways in which a father can "overdrink": drinking to drunkenness, spending too much money on alcohol, or spending too much time drinking alcohol. Fathers described the specific ways in which overdrinking impacted each of the three primary roles of a father, which were identified as providing, educating, and creating a stable home. Of the negative effects of overdrinking, a compromised ability to provide for basic needs was described as the most salient. The findings suggest that support for families in this region should include support for father's substance misuse, as a father's overdrinking is widely understood to be problematic for the entire family.

Strong families: a new family skills training programme for challenged and humanitarian settings: a single-arm intervention tested in Afghanistan

BACKGROUND

Children living in challenged humanitarian settings (including those in rural/underserved areas, the displaced, refugees, in conflict/post conflict situations) are at greater risk of mental health difficulties or behavioural problems, with caregivers acting as their main protective factors. While many family skills programmes exist, very few were developed for, or piloted in, low resource settings (settings with limited infrastructure, typical of humanitarian settings). We therefore designed a brief and light programme; the Strong Families (SF) programme, consisting of 5 h contact time over 3 weeks. We conducted a pilot study with the aim to test the feasibility of implementation, and a preliminary look at the effectiveness of SF, in improving child behaviour and family functioning in families living in Afghanistan.

METHODS

We recruited female caregivers and children aged 8-12 years through schools and drug treatment centres in Afghanistan and enrolled them in the SF programme. Demographic data, emotional and behavioural difficulties of children and parental skills and family adjustment measures were collected from caregivers before, 2 and 6 weeks after the intervention. Outcome was assessed through the SDQ (Strengths and Difficulties Questionnaire), assessing children's behavioural, emotional, and social issues, and PAFAS (Parenting and Family Adjustment Scales), measuring parenting practices and family functioning.

RESULTS

We enrolled 72 families in the programme with a 93.1% retention rate (n = 67) for data collection 6 weeks post intervention. Mean age of caregivers was 36.1 years, they had 3.8 children on average and 91.7% of them had experienced war/armed conflict in their past. The average total difficulty score of the SDQ (ranging from 0 to 40, with scores above 16 being indicative of high problems) of the 72 children reduced significantly, from 17.8 at pre-test to 12.9 at post-test and 10.6 at second follow-up, with no difference in gender and most noticeably amongst those with the highest scores at baseline. Likewise, PAFAS scores decreased significantly after the programme, again with caregivers with the highest scores at baseline improving most.

CONCLUSIONS

The implementation of a brief family skills programme was seemingly effective and feasible in a resource-limited setting and positively improved child mental health and parenting practices and family adjustment skills. These results suggest the value of such a programme and call for further validation through other methods of impact assessment and outcome evaluation.

TRIAL REGISTRATION

ISRCTN76509384. Retrospectively registered on March 9, 2020.

Bioecological Implications of Narrative Exposure Therapy in Low-Resource Settings: Individual, Family, Community, and Socio-Political Contexts

Traumatic stress can have detrimental effects on individuals, families, and communities. Narrative Exposure Therapy (NET) is an evidence-based intervention for decreasing individuals' posttraumatic stress disorder (PTSD) symptoms and has been tested in some of the most challenging contexts, such as in post-conflict refugee camps. Although the focus of NET is on reducing individual PTSD symptoms, the impact of NET can be seen beyond the individual level. The purpose of this manuscript was to examine some of the ecological implications of using NET with trauma-affected populations in low-resource settings. We highlight select implications of NET that extend beyond the individual to systemic effects at the family, community, and sociopolitical levels using several case examples. Finally, we outline limitations and future directions for improving the delivery of NET in settings with limited resources.

Behavioral Observations in Northern UGANDA: Development of a Coding System to Assess Mother-Child Interactions in a Post-war Society

There is growing interest in causes and consequences of disruptions in parent-child relationships in post-war environments. Recent studies mainly relied on self-reports to gain information about family dynamics following war exposure. Considering the limitations of self-report measures, we see the need for an in-depth examination of post-conflict parenting based on observational and quantitative data. The aim of the present study was the development of a coding system for a culturally bound description of parent-child interactions in northern Uganda, where virtually the entire population has been severely affected by 20 years of civil war. Interactions of 101 mothers and their 6- to 12-year-old children were observed during a structured interaction task (problem solving discussion). Foundation for the development of the coding system was the Family and Peer Process Code (FPP code). The cultural adaptation of the FPP code was based on in-depth qualitative analyses of the problem solving task, including a combination of inductive and deductive latent content analyses of textual data and videotapes, member checking and consultations of experts in the field of behavioral observations. The final coding system consists of 35 exhaustive and mutually exclusive content codes including codes for verbal, vocal, and compliance behavior as well as 14 affect codes. Findings indicate that the assessment of behavioral observations in post-conflict settings provides unique insights into culture- and context-specific interaction patterns and may be critical for the development and evaluation of parenting interventions.

Caregiving for children through conflict and displacement: a pilot study testing the feasibility of delivering and evaluating a light touch parenting intervention for caregivers in the West Bank

A child's adjustment to wartime stress is reliant not only on individual responses and qualities, but very significantly on the availability of support that they may receive from their parent or caregivers and quality of relationships. Strengthening parental support has the potential to be valuable. A pilot two-arm randomised controlled trial investigated the feasibility of delivering and evaluating the "Caring for Children Through Conflict and Displacement" intervention with caregivers in the West Bank. Feasibility to recruit and train non-specialist staff on-the-ground to screen families for eligibility, collect outcome data, deliver the intervention and to recruit and retain families in the study were examined. Research staff and intervention facilitators were successfully appointed in the field, screened participants and delivered the intervention to 120 caregivers, collecting outcome measures pre-and post-delivery. All families completed the outcome measures, with very little missing data. This indicated that the intervention can be delivered feasibly and evaluated with families in this humanitarian context. Preliminary outcome data showed promise that the intervention may have the potential to both improve family functioning and reduce children's problem behaviour. Implications of family-focused initiatives, particularly within a conflict/post-conflict context for the prevention of several negative health and social outcomes directions, are discussed.

Adapting and Pilot Testing a Parenting Intervention for Homeless Families in Transitional Housing

Intervention adaptation is a promising approach for extending the reach of evidence-based interventions to underserved families. One highly relevant population in need of services are homeless families. In particular, homeless families with children constitute more than one third of the total homeless population in the United States and face several unique challenges to parenting. The purpose of this study was to adapt and pilot test a parenting intervention for homeless families in transitional housing. An established adaptation model was used to guide this process. The systematic adaptation efforts included: (a) examining the theory of change in the original intervention, (b) identifying population differences relevant to homeless families in transitional housing, (c) adapting the content of the intervention, and (d) adapting the evaluation strategy. Next, a pilot test of the adapted intervention was conducted to examine implementation feasibility and acceptability. Feasibility data indicate an intervention spanning several weeks may be difficult to implement in the context of transitional housing. Yet, acceptability of the adapted intervention among participants was consistently high. The findings of this pilot work suggest several implications for informing continued parenting intervention research and practice with homeless families in transitional housing.

Testing the Social Interaction Learning Model's Applicability to Adolescent Substance Misuse in an Australian Context

BACKGROUND

Parents and peers both influence the development of adolescent substance misuse, and the Social Interaction Learning (SIL) model provides a theoretical explanation of the paths through which this occurs.

OBJECTIVE

The SIL model has primarily been tested with conduct outcomes and in US samples. This study adds to the literature by testing the SIL model with four substance use outcomes in a sample of Australian youth.

METHOD

We used structural equation modeling to test the fit of the SIL model to a longitudinal sample (n = 907) of students recruited in grade 5 in Victoria, Australia participating in the International Youth Development Study, who were resurveyed in grades 6 and 10.

RESULTS

The model fit was good (χ2(95) = 248.52, p < .001; RMSEA = .04 [90% CI: .036 - .049]; CFI = .94; SRMR = .04). Path estimates from parenting to antisocial behavior and from antisocial behavior to antisocial peers were significant. In turn, having antisocial peers was significantly related to alcohol use, binge drinking, tobacco use, and marijuana use. From parenting, only the direct path to marijuana use was significant, but indirect effects were significant.

CONCLUSIONS

The SIL model illustrates that parenting plays an early role in the formation of adolescent peer relations that influence substance misuse and identifies etiological pathways that can guide the targets of prevention. The SIL pathways appear robust to the Australian social and policy context.

Feasibility of Implementation of a Parenting Intervention with Karen Refugees Resettled from Burma

Parents and children exposed to war and relocation have high rates of negative relational and mental health outcomes. This study tested the feasibility of implementing an adapted evidence-based parenting intervention for contexts of trauma and relocation stress. Eleven Karen refugee caregivers from Burma participated in the intervention. Participants and a focal child completed ethnographic interviews as well as structured assessments at baseline and follow-up. Caregivers reported changes in their teaching, directions, emotional regulation, discipline, and child compliance. Children reported changes in these areas and in positive parent involvement. Caregivers reported higher mental health distress immediately after the intervention, potentially due to increased awareness. Researchers made personalized referrals for counseling services as needed. Children reported a decrease in mental health symptoms.

Preparing the Field for Feasibility Testing of a Parenting Intervention for War-Affected Mothers in Northern Uganda

In this article, we discuss the successful implementation of an adapted evidence-based parenting intervention for families affected by two decades of war in Northern Uganda. The adaptation and adoption of such interventions to support mental health and family functioning is widely endorsed by prevention scientists and considered a priority in global mental health. The preparation and early adoption phases of engaging with a highly vulnerable community affected by war trauma are documented in this paper along with a discussion of the steps taken to adapt a parenting intervention for cultural and contextual fit. This study is a component of an overall program of research aimed at reducing the long-term negative effects of war on parenting practices and childhood outcomes, which have considerable implications for preventing mental, neurological, and substance-use disorders. The processes described here cover a 4-year period culminating in the implementation of the nine-session Enhancing Family Connection intervention piloted with a group of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility results promising for further testing the intervention.

Parental care protects traumatized Sri Lankan children from internalizing behavior problems

BACKGROUND

Research in war-torn regions has mainly focused on the impact of traumatic experiences on individual mental health and has found high prevalence rates of psychiatric disorders in affected adults and children. However, little is known about the possible protective factors occurring in children's environments in the aftermath of mass trauma. Therefore, we conducted a cross-sectional study with families in Northern Sri Lanka, a region that had been shattered by a long-lasting civil war and devastated by the Asian tsunami in 2004.

METHODS

Schoolchildren aged 7 to 11 (N = 359) were interviewed on the basis of standardized measures to assess children's exposure to traumatic events, mental health symptoms, and parenting behavior as perceived by children. All interviews were carried out by local senior counselors.

RESULTS

Linear regression analyses identified exposure to mass trauma and family violence as significant risk factors of child mental health whereas parental care emerged as a significant factor associated with fewer behavior problems. In addition, parental care significantly moderated the relationship between mass trauma and internalizing behavior problems.

CONCLUSIONS

Family characteristics seem to be strongly associated with children's mental health even in regions severely affected by mass trauma. This finding is particularly relevant for the development of targeted psychosocial interventions for children and families living in war torn areas.