Intervention : Table of Contents

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Table of Contents

January-June 2020
Volume 18 | Issue 1
Page Nos. 1-95

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EDITORIAL

	Solidarity in the face of global fragility	p. 1
	Wendy Ager DOI:10.4103/INTV.INTV_8_20
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ARTICLES


	What works in psychosocial programming in humanitarian contexts in low- and middle-income countries: a systematic review of the evidence	p. 3
	Emily E Haroz, Amanda J Nguyen, Catherine I Lee, Wietse A Tol, Shoshanna L Fine, Paul Bolton DOI:10.4103/INTV.INTV_6_19 While there is growing evidence for the effectiveness of mental health interventions in low- and middle-income countries and humanitarian contexts, this is lacking for psychosocial programming. We aimed to summarise the evidence for psychosocial programming in these contexts through a systematic review (PROSPERO: CRD42017069066) of peer-reviewed and grey literature of programme evaluations. A total of n = 42,435 unique records were initially identified, with n = 211 records meeting full inclusion criteria. We identified 51 randomised controlled trials of 47 different interventions. The remaining studies used different evaluation methodology. Only three interventions had more than one experimental/quasi-experimental evaluation: Brief Intervention and Contact, Problem Management Plus and Child Friendly Spaces. While there are many studies of interventions, it was challenging to identify the same intervention across studies, leaving almost no interventions with more than one rigorous study supporting their use and many interventions that are poorly described. This makes it difficult to choose between them or even to implement them. Future research should focus on replication of well-described interventions in multiple different sites, to place future intervention selection on a more scientific basis. There is also a need to better understand the impact of psychosocial programmes in sectors other than health and protection, such as nutrition. These sectors may provide critical delivery mechanisms for psychosocial programming to broaden the reach of such interventions. Key implications for practice Efforts to build the evidence base for psychosocial programming in humanitarian settings are challenged by the breadth of programming delivered, populations served and outcomes targeted in this field, resulting in predominantly one-off studies of a wide range of interventions. To inform future intervention selection, research initiatives should focus on replication of well-described interventions in multiple contexts or stages of humanitarian response. Rigorous evaluation of community-focused psychosocial programmes is also needed.
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	Three models of scaling up mental healthcare post-disaster: common challenges	p. 18
	Boris Budosan, John Mahoney, Winnie Campos Dorego, Sabah Aziz, Kesavan Ratnasabapathipillai DOI:10.4103/INTV.INTV_11_19 There are number of challenges in strengthening mental healthcare services in underserved areas post-disaster. The objective of this paper is to identify common challenges by comparing and contrasting three models of scaling up mental healthcare services post-disaster. Primary and secondary data were collected before, during and after mental health programming in Sri Lanka, Haiti and the Philippines. A qualitative case study methodology including a set of narrative topics and programme indicators developed by the London School of Hygiene and Tropical Medicine was employed to document the services of the programmes. The authors added a set of outcome indicators to address the outcomes of programmes at community and individual level. We discuss challenges and conclude that sustainability of programme achievements, change of practices of trained non-specialised healthcare providers and their supervision and evidence of impact of clinical interventions are common challenges for scaling up mental health (MH) services post-disaster. We believe that more comparative evidence is needed on how MH services initiated by different actors’ post-disaster function in actual practice, especially in the longer term. Key implications for practice Mental health services can be significantly scaled up at community, primary and secondary healthcare level within a relatively short period of time post-disaster. Essential principles/components to be considered as key standards in MHPSS strategies post-disaster include regular consultations with local and national government and health authorities, a clear perspective on how to continue with longer term supervision after theoretical trainings, enough programme time allocated to clinical MH consultations (including follow-up) and focus on monitoring of improvement of clinical symptoms and functionality of clients. It would be useful for developers of MHPSS programming post-disaster to respect the key standards in designing an innovative service model with an optimal mix of community-based psychosocial, outpatient clinic and inpatient clinic-based interventions to improve wellbeing and resilience of clients at community level and access to PHC and SHC level including affordability of psychiatric medications.
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	Peacework and mental health: from individual pathology to community responsibility	p. 28
	Maureen P Flaherty, Ellen Sikorski, Liliya Klos, Viktor Vus, Nina Hayduk DOI:10.4103/INTV.INTV_59_18 Using Canada and Ukraine as examples, this article asserts the importance of moving beyond addressing posttraumatic stress disorder as the major mental health focus in peacebuilding, to a more global whole health strategy as a way of building resilience in communities, preparing them better to deal with conflicts of different kinds, and generally providing habitus for people of all health and abilities to thrive. Authors who are academics, mental health service users and service providers examine current barriers to and movements toward mental health and wellness in their countries. Using a needs-based approach, authors assert the importance of using the social determinants of health, understanding engaged community membership requires good, supportive mental health. The social determinants of health provide the basis to move from a reactive medical model of health which seems prevelant globally to focus on proactive community, considering what it means to be a community member, including the importance of individual empowerment not only for their own community engagement but also for the actualization and development of their communities and the wider world. Key implications for practice It is important to move beyond treatment of posttraumatic stress disorder in response to trauma. Peacebuilding must include proactive mental health strategies. Global responsibility for individual health as described by the social determinants of health.
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	Evidence for suicide prevention strategies with populations in displacement: a systematic review	p. 37
	Emily E Haroz, Ellie Decker, Catherine Lee, Paul Bolton, Paul Spiegel, Peter Ventevogel DOI:10.4103/INTV.INTV_10_19 Little is known about effective strategies to reduce rates of suicide among refugees and other displaced populations. This review aims to synthesise and assess the evidence base for suicide prevention and response programmes in refugee settings. We conducted a systematic review from peer-reviewed literature databases (five databases) and grey literature sources of literature published prior to November 27, 2017. We identified eight records (six peer-reviewed articles and two grey literature reports) that met our inclusion criteria. None of the eight records provided conclusive evidence of effectiveness. Five records had an unclear level of evidence and three records were potentially promising or promising. Most of the studies reviewed utilised multiple synergistic strategies. The most rigorous study showed the effectiveness of Brief Intervention and Contact and Safety planning. There is limited evidence of the effectiveness of other suicide prevention strategies for these groups. Future studies should attempt to better understand the impact of suicide prevention strategies, and explicitly unpack the individual and synergistic effects of multiple-strategies on suicide-related outcomes. Evidence from this review supports the use of Brief Intervention and Contact type interventions, but more research is needed to replicate findings particularly among populations in displacement. Key implications for practice Despite lack of evidence for displaced populations, multitiered and public health approaches to suicide seem most promising. Simple scalable interventions based on brief caring contacts are feasible and effective. Strong evaluations of suicide prevention efforts are needed to better inform practice.
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	Contextualising therapeutic care for child survivors of sexual violence in situations of war: a reflection on theory, context and practice	p. 45
	Buuma M Maisha DOI:10.4103/INTV.INTV_50_18 In this article, the author sought to raise awareness of and discuss ways to effectively address contextual challenges faced by mental health workers who provide therapeutic services to child rape survivors in war-affected regions, in general, and in the cultural context of the eastern region of the Democratic Republic of Congo, in particular, where rape is considered a sexual taboo, causing or amplifying attachment issues for survivors. A qualitative analysis of current literature review and therapeutic practice has been conducted in this article. Two cases are presented to illustrate contextual challenges. The analysis of case one focuses on ethical dilemmas between asserting professional boundaries and addressing clients’ needs in situations wherein there are no alternative resources beyond the therapist’s scope of practice, whereas the analysis of case two focuses on relationship and attachment challenges for survivors because of the interpretation of rape as sexual taboo. It was observed that, given extraordinary contextual challenges, therapists who assist child survivors in war-affected zones interact with their clients beyond their offices. Connecting at an empathy level alone is not enough. It also takes the therapists’ ability to demonstrate compassion and creativity in their effort to facilitate the healing journey of their clients. Key implications for practice This article draws attention to wartime child rape and its context-specific consequences on the survivors' attachment security. Awareness is raised of the cultural context and ethical challenges surrounding the practice of therapeutic care for child survivors in war-affected regions. Observed limitations are reported to the Western model of therapeutic relationship and the requirement of compassion and solution-driven creativity by therapists beyond empathy for a more contextualised and effective support of their clients.
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	Engaging men to promote resilient communities among Syrian refugees in Lebanon	p. 52
	Angela Veale, Fiona Shanahan, Alaa Hijazi, Zeina Osman DOI:10.4103/INTV.INTV_55_18 Engaging Men programmes seek to challenge the social norms, attitudes and practices that increase the risk of gender-based violence against girls and women while also harnessing positive male power to prevent violence and promote safety. This paper examines the impact of an Engaging Men intervention that engaged 1028 Syrian refugee and 440 Lebanese men in a 12-week training course structure. There were four core objectives: promoting peaceful interactions with others, reducing violence and gender-based violence, child protection and caregiving, and increasing community safety and harmony through a community project. Focus group discussions were conducted with 130 men, 28 wives, and 17 children of male participants, 10 family visits and 20 individual interviews by peer researchers.The findings were that programmes facilitated a safe emotional space for men to meet collectively to talk about their problems, to become more attuned and reflective about their relationships with their wives and children, which resulted in improved patterns of interaction and communication, increased openness and greater tolerance by men of changing gender roles in families as a result of displacement.The discussion calls for greater integration of psychosocial programming with other forms of programming from livelihoods to political advocacy and that programmes incorporate clear guidance on perpetrator accountability. Key implications for practice An intervention engaging with 1500 Syrian and Lebanese men reduced stress and improved family relations. Changes to gender-equitable attitudes were less clear. Interventions to engage refugee men should address refugee men's psychosocial needs in addition to viewing men's engagement as a means to protecting women and children. Findings highlight the importance of clearly defining the focus, aims and scope of interventions engaging with men, and that programmes incorporate clear guidance on perpetrator accountability.
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	Culturally adapted CBT (CA-CBT) for traumatised indigenous South Africans (Sepedi): a randomised pilot trial comparing CA-CBT to applied muscle relaxation	p. 61
	Baland Jalal, Qunessa Kruger, Devon E Hinton DOI:10.4103/INTV.INTV_68_18 In South Africa, there is a high rate of events such as criminal violence, stress and sexual assault, particularly in lower socio-economic status (SES) communities. Problems are particularly acute amongst indigenous groups. In spite of the great need for interventions for those having experienced these events, little information is available to guide treatment choices. The goal of this randomised controlled trial was to test the efficacy and feasibility of culturally adapted CBT (CA-CBT) compared to applied muscle relaxation (AMR) for traumatised South Africans belonging to the Sepedi cultural group. Twenty patients with post-traumatic stress disorder (PTSD) completed the study. In the completer analysis, we found that CA-CBT offered substantial benefits over AMR, as seen in large effect sizes for PTSD (d = 2.11) as well as anxiety symptoms (d = 2.41), depressive symptoms (d = 2.25), and culturally salient somatic symptoms and syndromes (d = 1.41). The intent-to-treat analysis showed smaller but still large effect sizes for all measures: PTSD (d = 1.27), associated anxiety symptoms (d = 1.38), depressive symptoms (d = 1.30), and culturally salient somatic symptoms and syndromes (d = .99). Our study suggests that CBT can be successfully adapted for South African indigenous groups. Key implications for practice This study shows the efficacy and acceptability of CBT in a randomised controlled pilot trial of an understudied group in great need of treatment compared to an active treatment condition (applied muscle relaxation (AMR)). This is the first study to show efficacy of CBT for PTSD in any South African indigenous group and suggests that CBT may be successfully adapted for that group, with large effect sizes compared to AMR. CA-CBT, which emphasises the treatment of somatic sensations, yoga-like stretching and meditation techniques to promote emotional and psychological flexibility, may be effective in treating indigenous South Africans.
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FIELD REPORTS


	Use of store-and-forward tele-mental health for displaced Syrians	p. 66
	Nadim Almoshmosh, Hussam Jefee-Bahloul, Waseem Abdallah, Andres Barkil-Oteo DOI:10.4103/INTV.INTV_53_19 The Syrian conflict has resulted in the worst humanitarian crisis of the 21^st century with millions of people displaced inside Syria or in neighbouring countries. Severe shortages of mental health professionals in the area have created many challenges in addressing the mental health needs of this vulnerable population. In response, the Syrian Tele-Mental Health (STMH) Network was established in June 2014 following evidence gathered through a pilot survey. Using a ‘store-and-forward’ type of telemedicine, the STMH network was able to provide psychiatric consultations to 19 primary care centres serving 123 Syrian patients over a period of three years. In this article, we report and comment on the data obtained during this period including the strengths, limitations and challenges of such an approach.
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	Psychological first aid through the ‘SIX Cs model’ − an intervention with migrants on the move	p. 71
	Einav Levy, Moshe Farchi, Yori Gidron, Eitan Shahar DOI:10.4103/INTV.INTV_51_18 Thousands of migrants passed through the Balkans whilst migrating from the Middle East to Europe between 2015 and 2016. Humanitarian actions were conducted throughout this route as agencies and governments provided support. The Camp of Preševo, on the Southern border of Serbia, was established by the local authorities as a registration camp to monitor the migration and deliver aid. Part of this aid was psychosocial. Past studies show a relatively high prevalence of stress symptoms among forced migrants, presumably due to exposure to war-related atrocities and experience of forced migration. NATAN, an Israeli non-governmental organisation, is a volunteer-based organisation that delivered psychosocial support to the migrants using the ‘SIX Cs model’. This model focuses on cognitive and behavioural components and is based on the neuropsychology of resilience. It has advantages that were relevant to the context of the camp, namely culturally adaptive, easy to administer, short and adjustable to varied contexts. Moreover, the model gives tools, which could be used later by the migrants in the absence of a therapist. This report describes the SIX Cs model and the implementation of its intervention in the Preševo camp.
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	Baby friendly spaces: an intervention for pregnant and lactating women and their infants in Cameroon	p. 78
	Elisabetta Dozio, Karine Le Roch, Cécile Bizouerne DOI:10.4103/INTV.INTV_61_18 In complex humanitarian emergencies, infants and young children are exposed to a higher risk of malnutrition, morbidity, delayed development and mortality. As shown by earlier research, maternal mental health and capacity for nurturing are of fundamental importance in child health and development. Since 2006, the international nongovernmental organisation, Action Contre la Faim, has been implementing a holistic approach to interventions for pregnant and lactating women and their young children to prevent child mortality and developmental delay in contexts affected by war and natural disasters. The experience presented here of ‘Baby Friendly Spaces’ refers to a programme in Cameroon, implemented with Central African refugees. The activities comprised in this model are focused on maternal mental health, parental skills, early child stimulation and infant and young child feeding practices. Results show a positive and significant (p < 0.01) impact on maternal wellbeing, breastfeeding practices and mother–child relationships. These findings reinforce previous evidence highlighting the necessity of implementing programmes, within complex humanitarian contexts, to reinforce the mother’s psychological wellbeing and increase capacity to provide nurturing care to guarantee the child’s health status and development.
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	Psychoeducation for children in a psychiatric ward in the immediate aftermath of the 2011 earthquake and tsunami in Japan	p. 85
	Naru Fukuchi DOI:10.4103/INTV.INTV_39_19 On 11 March 2011, Japan was struck by a massive earthquake and tsunami. There were a number of hospitals in the disaster-affected area, including some with psychiatric and children’s wards. Since all utilities were completely cut off for several days, children in the hospital had no access to information about the disaster. Therefore, they lacked a sense of the gravity of the situation and did not show any signs of panic. However, as several psychiatric hospitals located in the coastal area were severely devastated by the tsunami and therefore were unable to continue providing medical services, inpatients of these hospitals had to be accommodated in other hospitals that had children’s wards. The workers on these wards had to respond to minimise the negative psychological impact of this situation on the children in their care. On 18 March 2011, one week after the disaster, brief psychoeducation presentations were conducted with PowerPoint slides, teaching the children how to cope with the stress they were experiencing, using an original rating scale: a mood thermometer. Observations suggest that brief psychoeducation in the immediate phase after a disaster may effectively reduce the psychological trauma that children might otherwise experience.
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COMMENTARY


	How can the COVID-19 response advance global mental health?	p. 92
	Steven Weine, Mary Bunn DOI:10.4103/INTV.INTV_9_20
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BOOK REVIEW


	Diversity Competence: Cultures don’t meet, people do by Edwin Hoffman and Arjan Verdooren. Bussum: Uitgeverij Coutinho. 2018 (352 pages) ISBN: 978-90-4690598-2	p. 94
	Ton Haans DOI:10.4103/INTV.INTV_1_20
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