Mediators of focused psychosocial support interventions for children in low-resource humanitarian settings: analysis from an Individual Participant Dataset with 3,143 participants

BACKGROUND

Research on psychosocial interventions has been focused on the effectiveness of psychosocial interventions on mental health outcomes, without exploring how interventions achieve beneficial effects. Identifying the potential pathways through which interventions work would potentially allow further strengthening of interventions by emphasizing specific components connected with such pathways.

METHODS

We conducted a preplanned mediation analysis using individual participant data from a dataset of 11 randomized controlled trials (RCTs) which compared focused psychosocial support interventions versus control conditions for children living in low- and middle-income countries (LMICs) affected by humanitarian crises. Based on an ecological resilience framework, we hypothesized that (a) coping, (b) hope, (c) social support, and (d) functional impairment mediate the relationship between intervention and outcome PTSD symptoms. A systematic search on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed, PyscARTICLES, Web of Science, and the main local LMICs databases was conducted up to August 2018. The hypotheses were tested by using individual participant data obtained from study authors of all the studies included in the systematic review.

RESULTS

We included 3,143 children from 11 studies (100% of data from included studies), of which 1,877 from six studies contributed to the mediation analysis. Functional impairment was the strongest mediator for focused psychosocial interventions on PTSD (mediation coefficient -0.087, standard error 0.040). The estimated proportion of effect mediated by functional impairment, and adjusted for confounders, was 31%.

CONCLUSIONS

Findings did not support the proposed mediation hypotheses for coping, hope, and social support. The mediation through functional impairment may represent unmeasured proxy measures or point to a broader mechanism that impacts self-efficacy and agency.

Future orientation of youth with a history of war trauma: a qualitative study in the African context

Adolescence is an important developmental period for social relationships, identity formation and future planning. Traumatic experiences, such as war and persecution, may interfere with optimal development, including the future orientation of adolescents. The present study examines how young adult war survivors construct, make sense of, and narrate their future goals, plans, and expectations. The participants were 13 Liberian 25-35-year old male and female refugees living in Ghana. This qualitative study is based on semi-structured interviews with prompting questions. By applying a phenomenological approach the interview transcripts were categorized into themes and subthemes about future orientations. Results revealed three main themes, two of them desired a positive future orientation, indicating optimism and determination to improve one's own life and to contribute to a flourishing nation and to peacebuilding. The third theme illustrated a failure to reconstruct war-shattered lives and involved pessimistic views of the future. The results are discussed in relation to peacebuilding and the developmental challenges of young adults as war survivors.

The Role of Culture, Violence, and Personal Factors Affecting Dream Content

The impact of culture, violent environment, gender, and age on dream content was studied among 205 children in three groups: a Palestinian group living in a violent environment (n = 80), and Palestinian (n = 45) and Finnish (n = 80) groups living in peaceful areas. They were matched for age (7-12) and gender. The method used was a 7-day dream diary in which the participants recorded the dreams they recalled every morning. Results showed that living in a violent environment affected dream content more than did culture and personal factors. The results confirmed our hypothesis that a violent and dangerous environment was associated with mundane, intensive, and vivid dreams incorporating persecution and aggression themes. As an indication of individualistic versus collective dream characteristics, results showed that the dreams of the Palestinian children from Gaza incorporated more "external scenes" of anxiety, whereas the Finnish children's dreams had more "inner anxiety scenes."

Birth experience of women conceiving with assisted reproduction: a prospective multicenter study

OBJECTIVE

To determine how infertility and subsequent assisted reproductive treatment (ART) affect a woman's childbirth experience.

DESIGN

Prospective multicenter case-control study.

SETTING

We recruited women pregnant with a singleton fetus after either ART (n = 324) or spontaneous conception (n = 304) from five infertility clinics and one university maternity clinic in Finland.

METHODS

We studied their childbirth experience with the Delivery Satisfaction Scale. We compared how psychosocial and obstetric factors affected satisfaction and dissatisfaction with childbirth between and within the ART and the control group. Logistic regression was then used to analyse the most important contributors to the experienced dissatisfaction.

RESULTS

Dissatisfaction with childbirth was as common in the ART group (11%) as in the control (10%) group. In the ART group, the women's education level, cesarean section (CS) and their partner's absence from the delivery were associated with dissatisfaction. In the control group, significant factors for dissatisfaction were nulliparity, severe pregnancy-related anxiety, emergency CS, recalled intense pain and the partner's absence from the delivery. According to adjusted logistic regression analysis of the whole sample, the independent risk factors were elective CS [odds ratio (OR) 5.7; 95% confidence interval (CI) 2.2-14.1] and emergency CS (OR 2.9; 95% CI 1.3-6.5), recalled intense pain (OR 6.8; 95% CI 3.3-16.2) and the partner's absence from the delivery (OR 2.7; 95% CI 1.1-7.3).

CONCLUSION

ART is not a risk factor for dissatisfaction with childbirth by itself. However, the contributors to an unsatisfactory childbirth differ partly between women conceiving with ART and those conceiving spontaneously.

TENTS guidelines: development of post-disaster psychosocial care guidelines through a Delphi process

BACKGROUND

How best to plan and provide psychosocial care following disasters remains keenly debated.

AIMS

To develop evidence-informed post-disaster psychosocial management guidelines.

METHOD

A three-round web-based Delphi process was conducted. One hundred and six experts rated the importance of statements generated from existing evidence using a one to nine scale. Participants reassessed their original scores in the light of others' responses in the subsequent rounds.

RESULTS

A total of 80 (72%) of 111 statements achieved consensus for inclusion. The statement 'all responses should provide access to pharmacological assessment and management' did not achieve consensus. The final guidelines recommend that every area has a multi-agency psychosocial care planning group, that responses provide general support, access to social, physical and psychological support and that specific mental health interventions are only provided if indicated by a comprehensive assessment. Trauma-focused cognitive-behavioural therapy (CBT) is recommended for acute stress disorder or acute post-traumatic stress disorder, with other treatments with an evidence base for chronic post-traumatic stress disorder being made available if trauma-focused CBT is not tolerated.

CONCLUSIONS

The Delphi process allowed a consensus to be achieved in an area where there are limitations to the current evidence.

Health as human security in the occupied Palestinian territory

We describe the threats to survival, development, and wellbeing in the occupied Palestinian territory using human security as a framework. Palestinian security has deteriorated rapidly since 2000. More than 6000 Palestinians have been killed by the Israeli military, with more than 1300 killed in the Gaza Strip during 22 days of aerial and ground attacks ending in January, 2009. Israeli destruction and control of infrastructure has severely restricted fuel supplies and access to water and sanitation. Palestinians are tortured in prisons and humiliated at Israeli checkpoints. The separation wall and the checkpoints prevent access to work, family, sites of worship, and health-care facilities. Poverty rates have risen sharply, and almost half of Palestinians are dependent on food aid. Social cohesion, which has kept Palestinian society intact, including the health-care system, is now strained. More than US$9 billion in international aid have not promoted development because Palestinians do not have basic security. International efforts focused on prevention of modifiable causes of insecurity, reinvigoration of international norms, support of Palestinian social resilience and institutions that protect them from threats, and a political solution are needed to improve human security in the occupied Palestinian territory.

Children's Mental Health in Times of Economic Recession: Replication and Extension of the Family Economic Stress Model in Finland

This study evaluated the applicability of the family economic stress model (FESM) in understanding the influences of economic hardship on child mental health during a nationwide economic recession in Finland. The information was gathered from 527 triads of 12-year-olds and their mothers and fathers from a population sample. The structural equation models showed that the FESM fit the data well, indicating its generalizability in Finnish society. The results confirmed that a reduction in disposable family income constitutes a risk for child mental health through increased economic pressure and negative changes in parental mental health, marital interaction, and parenting quality. Controlling the children's prerecession mental health substantiated that economic hardship can lead to deterioration in children's mental health. Alternative models based on fully recursive analyses revealed reciprocal influences between parents and their children over time: Children's prerecession mental health problems predicted compromised parenting, which in turn contributed to children's internalizing and externalizing symptoms during the recession.