A process study of early achievements and challenges in countries engaged with the WHO Special Initiative for Mental Health.

BACKGROUND: There is increasing awareness of the importance of the transformation of mental health systems. Launched in 2019, the WHO Special Initiative for Mental Health seeks to accelerate access to quality and affordable care for mental health conditions as an integral component of Universal Health Coverage. Nine countries are currently engaged with the initiative. METHODS: This study reviewed processes of implementation-and progress achieved-across all settings by late 2022. It involved review of 158 documents provided by WHO relating to Special Initiative activities and 42 interviews with country-level stakeholders, WHO Regional and HQ personnel engaged with the initiative, and core donors. Documents were thematically coded using a template based upon the WHO framework of health system building blocks. Responses to structured interviews were coded based on an emergent thematic framework. RESULTS: Documentation reported similar achievements across all domains; however challenges were reported most frequently in relation to service delivery, leadership and governance, and workforce. Issues of financing were notable in being twice as likely to be reported as a challenge than a success. Interviews indicated four major areas of perceived achievement: establishing a platform and profile to address mental health issues; convening a multi-stakeholder, participatory engagement process; new, appropriate services being developed; and key developments in law, policy, or governance around mental health. The planning process followed for the initiative, senior country-level buy-in and the quality of key personnel were the factors considered most influential in driving progress. Ambivalent political commitment and competing priorities were the most frequently cited challenges across all interviewees. CONCLUSIONS: The role of the Special Initiative in raising the profile of mental health on national agendas through a participatory and inclusive process has been widely valued, and there are indications of the beginnings of transformational shifts in mental health services. To secure these benefits, findings suggest three strategic priorities: increasing political prioritisation and funding for systems-level change; clearly articulating sustainable, transformed models of care; and promoting feasible and contextualised measures to support accountability and course correction. All are of potential relevance in informing global strategies for mental health systems transformation in other settings.

Genetic architecture and socio-environmental risk factors for major depressive disorder in Nepal.

BACKGROUND: Major depressive disorder (MDD) is the leading cause of disability globally, with moderate heritability and well-established socio-environmental risk factors. Genetic studies have been mostly restricted to European settings, with polygenic scores (PGS) demonstrating low portability across diverse global populations. METHODS: This study examines genetic architecture, polygenic prediction, and socio-environmental correlates of MDD in a family-based sample of 10 032 individuals from Nepal with array genotyping data. We used genome-based restricted maximum likelihood to estimate heritability, applied S-LDXR to estimate the cross-ancestry genetic correlation between Nepalese and European samples, and modeled PGS trained on a GWAS meta-analysis of European and East Asian ancestry samples. RESULTS: We estimated the narrow-sense heritability of lifetime MDD in Nepal to be 0.26 (95% CI 0.18-0.34, p = 8.5 × 10-6). Our analysis was underpowered to estimate the cross-ancestry genetic correlation (rg = 0.26, 95% CI -0.29 to 0.81). MDD risk was associated with higher age (beta = 0.071, 95% CI 0.06-0.08), female sex (beta = 0.160, 95% CI 0.15-0.17), and childhood exposure to potentially traumatic events (beta = 0.050, 95% CI 0.03-0.07), while neither the depression PGS (beta = 0.004, 95% CI -0.004 to 0.01) or its interaction with childhood trauma (beta = 0.007, 95% CI -0.01 to 0.03) were strongly associated with MDD. CONCLUSIONS: Estimates of lifetime MDD heritability in this Nepalese sample were similar to previous European ancestry samples, but PGS trained on European data did not predict MDD in this sample. This may be due to differences in ancestry-linked causal variants, differences in depression phenotyping between the training and target data, or setting-specific environmental factors that modulate genetic effects. Additional research among under-represented global populations will ensure equitable translation of genomic findings.

Erratum: Improving psychosocial well-being and parenting practices among refugees in Uganda: Results of the journey of life effectiveness trial - CORRIGENDUM.

[This corrects the article DOI: 10.1017/gmh.2024.38.].

Improving psychosocial well-being and parenting practices among refugees in Uganda: Results of the journey of life effectiveness trial.

Caregivers play a critical role in mediating the impacts of forced displacement on children; however, humanitarian programming remains hampered by a lack of evidence-based programming. We present findings from an evaluation of a group-based curriculum delivered over the course of 12 sessions, journey of life (JoL). A waitlist-control quasi-experimental design was implemented in the Kiryandongo refugee settlement (intervention n = 631, control n = 676). Caregiver mental distress, measured using the Kessler-6, was the primary outcome. Secondary outcomes included (a) functioning, (b) social support and (c) caregiving attitudes and behaviors. Propensity score matching (PSM) and Cohen's d estimates were used to examine the intervention effects. According to our primary PSM analysis, JoL led to significant improvements in mental distress (coef.: 2.33; p < 0.001), social support (coef.: 1.45; p < 0.001), functioning (coef.: 2.64; p < 0.001), parental warmth/affection (coef.: 2.48; p < 0.001), parental undifferentiated rejection (coef.: 0.49; p < 0.001) and attitudes around violence against children (VAC) (coef.: 1.98; p < 0.001). Evidence from Cohen's d analysis underscored the value of the intervention's effect on parental warmth/affection (0.74), mental distress (0.70) and VAC attitudes (0.68). This trial adds to the evidence on holistic parenting programming to improve the mental health and parenting outcomes among refugee caregivers.

In-Person Social Interactions and Anxiety During the COVID-19 Pandemic: Exploring the Role of Household Size and Virtual Social Contact Among Midlife and Older Black South African Adults.

OBJECTIVES: The current study investigates how physical distancing during the coronavirus disease 2019 (COVID-19) pandemic was associated with increased anxiety among a cohort of midlife older Black South African adults and the extent to which household size and virtual social contact modify this association for men and women. METHODS: We analyze data from a phone survey conducted from July 2021 to March 2022 as part of Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (n = 2,080). We employ logistic regression to estimate the association between changes in in-person social interactions and anxiety symptoms and examine whether the association is modified by household size and changes in virtual social contact. We perform analyses separately for women and men. RESULTS: Declines in in-person social interactions were associated with increased anxiety for women and men (odds ratios [OR] = 2.52, p < .001). For women only, declines were greater for those living in larger households (OR = 1.11, p = .032). Declines were buffered by increased virtual social contact for both women (OR = 0.55, p = .025) and men (OR = 0.45, p = .019). DISCUSSION: Although the anxiety symptoms of women and men were similarly affected by declines in in-person social interaction, the modifying influence of household size is unique to women, likely due to gender-specific social roles. For women, living in larger households may mean greater caregiving burden, exacerbating the detrimental association between physical distancing and anxiety. On the other hand, both women and men may have used virtual means to connect with friends and family living outside their homes, buffering against increased anxiety.

Alcohol use and internal migration in Nepal: a cross-sectional study.

BACKGROUND: Alcohol use is a leading cause of disease. Although low- and middle-income countries (LMICs) have lower per capita alcohol consumption, the alcohol-attributable disease burden is high in these settings with consumption increasing. LMICs are also experiencing unprecedented levels of internal migration, potentially increasing mental stress, changing social restrictions on drinking, and increasing alcohol availability. We assessed the relationship between internal migration, opportunity to drink, and the transition from first use to regular alcohol use and alcohol use disorders (AUD) in Nepal, a low-income, South Asian country. METHODS: A representative sample of 7435 individuals, aged 15-59 from Nepal were interviewed in 2016-2018 (93% response rate) with clinically validated measures of alcohol use and disorders and life history calendar measures of lifetime migration experiences. Discrete-time hazard models assessed associations between migration and alcohol use outcomes. RESULTS: Net of individual sociodemographic characteristics, internal migration was associated with increased odds of opportunity to drink (OR 1.32, 95% CI 1.14 to 1.53), onset of regular alcohol use given lifetime use (OR 1.29, 95% CI 1.13 to 1.48) and AUD given lifetime use (OR 1.24, 95% CI 0.99 to 1.57). The statistically significant association between internal migration and opportunity to drink was specific to females, whereas the associations between migration and regular use and disorder were statistically significant for males. CONCLUSIONS: Despite high rates of internal migration worldwide, most research studying migration and alcohol use focuses on international migrants. Findings suggest that internal migrants are at increased risk to transition into alcohol use and disorders. Support services for internal migrants could prevent problematic alcohol use among this underserved population.

Refugee caregivers: Associations between psychosocial wellbeing and parenting in Uganda.

Caregivers in humanitarian settings experience compounding stressors that may challenge their ability to provide quality parenting to children in their care. In recognition of this precarity, our analysis examines the linkage between psychosocial wellbeing and parenting behaviours among caregivers in Kiryandongo Settlement, Uganda. Using baseline data from an evaluation of a psychosocial intervention designed to support caregiver wellbeing and engage caregivers to support children in their communities, multi-variable ordinary least square regressions were used to estimate how various measures of psychosocial wellbeing (i.e. psychological distress, social support, and functioning) and parenting attitudes (related to violence against children) are associated with parental warmth and rejection. Profound livelihood challenges were found, as nearly half of the sample (48.20%) indicated cash from INGOs as their income source and/or reported never attending school (46.71%). Increased social support (coef. 0.11; 95% CIs: 0.08-0.15) and positive attitudes (coef. 0.21; 95% CIs: 0.14-0.29) were significantly associated with more desirable parental warmth/affection. Similarly, positive attitudes (coef. 0.16; 95% CIs 0.11-0.20), reduced distress (coef. 0.11; 95% CIs: 0.08-0.14) and increased functioning (coef. 0.03; 95% CIs: 0.01-0.04) were significantly associated with more desirable scores of parental undifferentiated rejection. While further research is needed to examine underlining mechanisms and causal pathways, our findings both link individual wellbeing characteristics with parenting behaviours and suggest further exploration into whether and how broader elements of the ecosystem may influence parenting outcomes.

Ensuring equity in mental health and psychosocial support during the COVID-19 pandemic and beyond.

Populations affected by armed conflict and other humanitarian crises are at elevated risk for mental health problems. While the COVID-19 pandemic has had broadly deleterious effects on livelihoods, economic well-being, and population health worldwide, vulnerable groups have been disproportionately impacted by the pandemic. Providing mental health and psychosocial support (MHPSS) services during these times to vulnerable groups, especially in low- and middle-income countries and humanitarian settings, is essential. In an effort to comply with the public health response to the pandemic and mitigate COVID-19 transmission, significant implementation adaptations were made to service delivery during the pandemic. This short report describes several strategies to ensure that equity was central to these adaptations and public health responses, and provides recommendations for ensuring continuity of this progress post-pandemic. Examples and key lessons learned are given related to strategies to increase access to MHPSS services, improve meaningful stakeholder engagement, develop and support community networks, and implement community-based psychosocial support groups. They come from diverse settings of Bangladesh, Colombia, Ecuador, and Lebanon. The COVID-19 pandemic has highlighted the importance of preventing and treating MHPSS issues. It also has created opportunities for innovative programming to address overlooked problems, improve the quality of services provided, and increase focus on equity. It is vital that we use the momentum and attention generated around MHPSS services during the COVID-19 pandemic to continue to build and improve existing MHPSS services in more equitable ways for vulnerable populations.

We need to build the evidence: A systematic review of psychological first aid on mental health and well-being.

Ensuring effective mental health and psychosocial support is crucial following exposure to a potentially traumatic event and can have long-term consequences for individuals, families, and communities. Psychological first aid (PFA) has become a widespread intervention of choice following exposure to conflict or disaster; however, its impact is unknown. This systematic review assessed PFA efficacy in improving the mental health and psychosocial well-being of individuals exposed to potentially traumatic events. We searched PubMed, PsycINFO, PTSDpubs, and EMBASE for peer reviewed studies evaluating programmatic outcomes of PFA, or an adapted intervention, published in English before March 9, 2021. Studies evaluating training outcomes or program feasibility were excluded. The primary outcomes were reported measures of participant mental health and psychosocial well-being, with narrative results presented for each. The Cochrane Risk of Bias tool was applied. Of 9,048 potentially eligible citations, 12 studies with a total of 1,437 participants met the inclusion criteria. Only one study was a randomized controlled trial. The findings from all studies suggest a positive impact of PFA, with most reporting reduced symptoms of anxiety, depression, posttraumatic stress, and distress, as well as improved ratings of mood, the experience of safety, connectedness, and a sense of control, among youth and adults. Risk of bias was generally high. Inconsistent intervention components, insufficient evaluation methodologies, and a high risk of bias within the reviewed studies present challenges in assessing PFA efficacy, and an imbalance between popular support for PFA and scant evidence of outcome data exists. Further research is needed to justify the proliferation of PFA.

What can we learn about polytrauma typologies by comparing population-representative to trauma-exposed samples: A Nepali example.

BACKGROUND: Potentially traumatic events (PTEs) are common and associated with detrimental outcomes over the life-course. Previous studies exploring the causes and consequences of PTE-exposure profiles are often from high-income settings and fail to explore the implications of sample selection (i.e., population-representative versus PTE-restricted). METHODS: Among individuals in the Nepal Chitwan Valley Family Study, latent class analyses (LCA) were performed on 11 self-reported PTEs collected by the Nepali version of the World Mental Health Consortium's Composite International Diagnostic Interview 3.0 from 2016 to 2018, in a population-representative sample (N = 10,714), including a PTE-restricted subsample (N = 9183). Multinomial logistic regressions explored relationships between sociodemographic factors and class membership. Logistic regressions assessed relationships between class membership and psychiatric outcomes. RESULTS: On average, individuals were exposed to 2 PTEs in their lifetime. A five-class solution showed optimal fit for both samples; however, specific classes were distinct. No single sociodemographic factor was universally associated with PTE class membership in the population-representative sample; while several factors (e.g., age, age at incident PTE, education, marital status, and migration) were consistently associated with class membership in the PTE-subsample. PTE class membership differentiated psychiatric outcomes in the population-representative sample more than the PTE-subsample. LIMITATIONS: Primary limitations are related to the generalizability to high-income settings, debate on LCA model fit statistic usage for final class selection, and cross-sectional nature of data collection. CONCLUSIONS: Although population-representative samples provide information applicable to large-scale, population-based programming and policy, PTE-subsample analyses may provide additional nuance in PTE profiles and their consequences, important for specialized prevention efforts.

Community-Level Social Support Infrastructure and Adult Onset of Major Depressive Disorder in a South Asian Postconflict Setting.

IMPORTANCE: Individual-level social support protects against major depressive disorder (MDD) among adults exposed to trauma. Little is known about the consequences of community-level interventions in the general population. OBJECTIVE: To determine the potential consequences of neighborhood social infrastructure on incident MDD in a high-risk general population. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, multilevel study estimated associations between a neighborhood-level program in a case-control design and subsequent individual outcomes across 10 years (2006-2015) in a cohort of young adults. Exogenously placed social programs simulate natural experiment conditions in a high-poverty population experiencing armed conflict (1998-2006). The western Chitwan valley in Nepal has a general population at high risk of MDD, with neighborhoods exposed to interventions to improve social support. From a random sample (response rate 93%) selected to represent the general population in 2016, participants aged 25 to 34 years in 2006 were studied. These individuals resided within 149 neighborhoods that varied in their availability of active social support programs. The analyses were conducted between October 2020 and November 2021. EXPOSURES: The Small Farmers Development Program (SFDP) uses shared, joint liability financial credit among neighbors to build social capital and cohesion within neighborhoods. MAIN OUTCOMES AND MEASURES: Onset of DSM-IV MDD after the conflict, assessed by the Nepal-specific, clinically validated World Mental Health Composite International Diagnostic Interview with a life history calendar. The hypothesis tested was that exposure to SFDP reduced adult onset of MDD. RESULTS: Of the 1917 survey participants, 886 (46.2%) were women, and 856 (44.7%) were of Brahmin or Chhetri ethnicity. Of the 149 neighborhoods, 21 had an active SFDP group, and 156 of 1917 (8.1%) participants experienced MDD between 2006 and 2015. Discrete-time hazard models showed participants living in neighborhoods with an SFDP experienced incident MDD at nearly half the rate as others (odds ratio = 0.55; 95% CI, 0.30-1.02; P = .06). A multivariate, multilevel matching analysis showed the incidence of MDD among adults living in neighborhoods with an SFDP was 19 of 256 (7.4%), compared with 33 of 256 (12.9%) in the matched sample with no SFDP (z = 2.05; P = .04). CONCLUSIONS AND RELEVANCE: Living in a neighborhood with community-level social support infrastructure was associated with reduced subsequent rates of adult-onset MDD, even in this high-risk population. Investments in such infrastructure may reduce population-level MDD, supporting clinical focus on potentially unpreventable cases.

COVID-19 worries, concerns and mitigation behaviours: A snapshot of Nepal during the first wave.

OBJECTIVES: To understand COVID-19 worries and how they influence COVID-19 mitigation behaviours, especially in communities prior to case surges, in Nepal. METHODS: Data related to COVID-19 impacts on life disruptions were collected from households in the Chitwan Valley Family Study, a 25-year community panel study, during February-April 2021. COVID-19 worry was measured by the extent of respondent concern for themselves or household members getting COVID-19 in the prior 2 weeks. 11 items examined COVID-19 mitigation behaviours. Logistic regression models assessed associations between socio-demographic characteristics and COVID-19 worry and then the influence of worry on any mitigation behaviour and behaviour type adjusting for age, education, sex, ethnicity and COVID-19 exposure, accounting for neighbourhood clustering. RESULTS: Of 2,678 households with a responding adult, ages 18-88, 394 (14.7%) reported moderate-to-extreme COVID-19 worry and 1,214 (45.3%) engaged in three or more mitigation behaviours. Prevalence of mitigation behaviours was higher among those with COVID-19 worry (e.g. avoided crowds: 62.7% versus 40.5% in those with minimal worry). Respondents self-reporting COVID-19 had higher odds of worry (adjusted odds ratio [aOR]: 2.73, 95% confidence interval [CI]: 1.13, 6.57). Odds of any mitigation behaviour were higher among those with COVID-19 worry compared to those with minimal worry (aOR: 6.19, 95% CI = 1.88, 20.35). CONCLUSIONS: COVID-19 mitigation behaviours were more common in people with COVID-19 worry. To address current and potential future waves of the pandemic, public health efforts should include informational campaigns about mitigation behaviours particularly for those unconcerned with COVID-19 risks.

Mental Health First Aid: A Systematic Review of Trainee Behavior and Recipient Mental Health Outcomes.

OBJECTIVE: Mental Health First Aid (MHFA) is a globally disseminated course that trains members of the public to recognize and respond to mental health issues in their communities. Although substantial evidence suggests that MHFA training is associated with positive changes in knowledge, attitudes, and behavioral intent, little is known about how MHFA trainee-delivered aid supports mental health needs. This systematic review sought to summarize the extant research evaluating MHFA trainees' helping behaviors and the impacts of these behaviors on people experiencing a mental health problem (i.e., recipients). METHODS: Electronic databases were searched for MHFA evaluations published before or on March 9, 2021. Studies that evaluated at least one outcome related to trainee helping behavior or recipient mental health were included in the synthesis. Outcomes were organized into three categories: trainee use of MHFA skills, helpfulness of trainees' actions, and recipients' mental health. Only studies that compared pre- and posttraining outcomes, included a control group, and directly evaluated MHFA were used to assess its efficacy. RESULTS: The search identified 31 studies, nine of which met criteria to assess MHFA efficacy. The findings of the nine studies indicated that MHFA had mixed effects on trainees using the skills taught in the course and no effects on the helpfulness of trainees' actions or on recipient mental health. CONCLUSIONS: The findings indicate that there is insufficient current evidence that MHFA improves the helping behaviors of trainees or the mental health of those receiving helping behaviors. They highlight a crucial research gap that should be prioritized as MHFA continues to grow in popularity.

Protocol for a caregiver psychosocial support intervention for populations affected by displacement in Uganda.

BACKGROUND: Child psychological distress in refugee settings is a significant public health concern, which is exacerbated by poor caregiver mental health and functioning. However, there are limited studies about effective interventions to improve caregiver mental health in support of child wellbeing. The objective of the current study is to evaluate the effectiveness and implementation of the Journey of Life (JoL) intervention to improve caregiver mental health in a refugee camp in Western Uganda. METHODS: A waitlist-control quasi-experimental design is being implemented in the Kiryandongo refugee settlement (intervention n = 600, control n = 600). Caregiver mental distress, measured using the Kessler-6, was selected as the primary outcome. Secondary outcomes include (a) functioning measured by the World Health Organization Disability Assessment Schedule, (b) social support measured by the Medical Outcomes Study Social Support Survey, and (c) caregiving behaviors according to the Parental Acceptance and Rejection Questionnaire and the Child Protection Index. The study aims to examine the implementation of the JoL intervention through qualitative assessments of intervention feasibility, adaptations, and reach. DISCUSSION: This trial will add much-needed evidence for the implementation of caregiver psychosocial programming within the humanitarian community. Findings will be disseminated amongst local, regional, and global actors in order to guide potential scale up within humanitarian settings. TRIAL REGISTRATION: Clinical Trials NCT04817098 (Registered: 3/24/21).

The Child PTSD Symptom Scale: Psychometric Properties among Earthquake Survivors.

Evidence for a single underlying factor structure of posttraumatic stress disorder (PTSD) in children remains elusive. We assessed the underlying factor structure of the Child PTSD Symptom Scale through exploratory (EFA) and confirmatory factor analyses (CFA) in 570 survivors of the 2015 Gorkha earthquake in Nepal. The EFA suggests that the three-factor DSM-IV model fit these data best. The CFA suggests that while the DSM-IV model adequately fit these data, the four-factor King model fit them better. There was no evidence of differential item functioning by age or gender, and internal consistency of the scale was high. PTSD (overall or by factor) was not correlated with functional impairment. Inconsistent psychometric results across contexts and methodologies suggest that our current theoretical conceptualizations and empirical models of posttraumatic stress are lacking. Future studies must both document the instrument properties to assure internal validity and cross-study comparisons and, bolstered by increased psychometric data and analyses, rework theoretical models of PTSD with improved cross-cultural validity.

Exposure to Armed Conflict in Childhood vs Older Ages and Subsequent Onset of Major Depressive Disorder.

Importance: This study offers a rare opportunity to evaluate life-course differences in the likelihood of developing major depressive disorder (MDD) after exposure to georeferenced neighborhood-level violence during an armed conflict. Objective: To examine age cohort (age <11 vs ≥11 years) differences in associations of neighborhood-level violence with subsequent depression onset, independently of individual exposure and other key characteristics. Design, Setting, and Participants: The Chitwan Valley Family Study is a population-representative panel study (1995 to present) conducted in Western Chitwan in Nepal, a low-income country that experienced a medium-intensity armed conflict from 2000 to 2006. Data for violent events were collected during the armed conflict and were linked to lifetime histories of MDD (collected in 2016-2018). The present cohort study analyzes 10 623 participants within 151 neighborhoods, systematically selected and representative of Western Chitwan. All residents aged 15 to 59 years at MDD assessment were eligible (response rate, 93%). Data analysis was performed from May 2019 to July 2020. Exposures: Georeferenced number of armed conflict-related physical beatings within 1 km of residential neighborhood. Main Outcomes and Measures: The main outcome was onset of MDD, as defined by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), during or after the conflict, stratified by children (aged <11 years) and older individuals (aged ≥11 years), assessed by the Nepal-specific World Mental Health-Composite International Diagnostic Instrument 3.0 with a life history calendar. Results: In total, 10 623 participants (5745 female [54.08%]; 4074 [38.35%] aged <11 years at the conflict start) contributed 171 899 person-years of exposure to the risk of MDD. Two or more beatings occurred within 1 km of 15 neighborhoods (9.9%). Discrete-time survival models showed that children (but not older individuals) living in neighborhoods with 2 or more beatings had a higher likelihood of developing MDD than those who lived in a community with no beatings (odds ratio, 1.82; 95% CI, 1.17-2.84; P = .008); there was also a significant interaction between age group and neighborhood beatings (odds ratio, 1.85; 95% CI, 1.27-2.70; P = .001). A confirmatory, multivariable, multilevel matching analysis showed a neighborhood association for children (z = -2.66; P = .008), but not older individuals (z = -0.454; P = .65). The mean (SE) incidence of MDD among children living in neighborhoods with 2 or more beatings nearby was 12.69% (2.37%) vs 5.08% (1.56%) in the matched unexposed sample. Conclusions and Relevance: The youngest individuals may be the most at risk during times of violence, with mental health consequences lasting long after conflicts have subsided and should be a priority for population-level interventions. Future research should consider other disorders, other types of violence, and elderly individuals.

Resilience and adjustment trajectories amongst children in displacement-affected communities in Zarqa, Jordan.

BACKGROUND: The experiences of protracted conflict and displacement are clear threats to children's developmental progress. Understanding the factors that shape the trajectories of children's well-being and adjustment in such contexts is important for informing interventions. METHODS: We collected data at three time points from a sample of Syrian refugee and Jordanian children (n=650) residing in Zarqa, Jordan who met eligibility criteria for humanitarian programming. We assessed primary outcomes of protection concerns, caregiver stress, mental health, and developmental assets at three time points: baseline (T1), three months later (T2), and fifteen months after baseline (T3). RESULTS: Over the fifteen-month study period (T1-T3) child protection concerns and mental health symptoms improved, caregiver stress remained constant, and developmental assets deteriorated. School attendance was independently associated with improvements in protection concerns (ß = -1.05, P=0.01), caregiver stress (ß = -0.66, P =0.02), and developmental assets (ß = 3.84, P =0.02). Concern over lost livelihoods significantly predicted higher protection concerns (ß = 4.08, P <0.001) and caregiver stress (ß = 2.32, P <0.001). Attending child-focused programming did not significantly impact primary outcomes. CONCLUSIONS: This study documents the capacity for adjustment and adaptation of children in the context of protracted displacement. The significant influences of attending school and concern over lost livelihoods on observed trajectories indicate the importance of addressing structural factors, such as education and employment, in supporting processes of resilience in these populations. Programmatic activities for children may secure valuable shorter-term impacts but here, as elsewhere, failed to impact outcomes longer-term.

Child friendly spaces impact across five humanitarian settings: a meta-analysis.

BACKGROUND: Humanitarian crises present major threats to the wellbeing of children. These threats include risks of violence, abduction and abuse, emotional distress and the disruption of development. Humanitarian response efforts frequently address these threats through psychosocial programming. Systematic reviews have demonstrated the weak evidence-base regarding the impact of such interventions. This analysis assesses the impact of Child Friendly Spaces (CFS), one such commonly implemented intervention after humanitarian emergencies. METHODS: We completed baseline and endline (three-six months post-baseline) assessments regarding protection concerns, psychosocial wellbeing, developmental assets and community resources for a total of 1010 children and 1312 carers in catchment areas for interventions with humanitarian populations in Ethiopia, Uganda, Iraq, Jordan, and Nepal. We estimated intervention effect-sizes with Cohen's d for difference in mean difference scores between attenders and non-attenders - who proved comparable on baseline measures - by site. We then pooled findings for a meta-analysis summarizing overall impacts across domains. RESULTS: Amongst children aged 6-11, significant intervention impacts were observed through site-level analysis for protection concerns (Ethiopia, Cohen's d = 0.48, 95% CI 0.08-0.88), psychosocial wellbeing (Ethiopia, d = 0.51, 95% CI 0.10-0.91; and Uganda, d = 0.21, 95% CI 0.02-0.40), and developmental assets (Uganda, d = 0.37, 95% CI 0.15-0.59; and Iraq, d = 0.86, 95% CI 0.18-1.54). Pooled analyses for this age group found impacts of intervention to be significant only for psychosocial wellbeing (d = 0.18, 95% CI 0.03-0.33). Among children aged 12-17, site-level analysis indicated intervention impact for protection concerns in one site (Iraq, d = 0.58, 95% CI 0.07-1.09), with pooled analysis indicating no significant impacts. CONCLUSION: CFS can provide - albeit inconsistently - a protective and promotive environment for younger children. CFS show no impact with older children and in connecting children and carers with wider community resources. A major reappraisal of programming approaches and quality assurance mechanisms is required.

Short- and longer-term impacts of Child Friendly Space Interventions in Rwamwanja Refugee Settlement, Uganda.

BACKGROUND: The establishment of Child Friendly Spaces (CFSs) has become a widespread intervention targeting protection and support for displaced children in humanitarian contexts. There is a lack of evidence of impact of these interventions with respect to both short-term outcomes and longer-term developmental trajectories. METHODS: We collected data from caregivers of Congolese refugee children residing in Rwamwanja Refugee Settlement at three timepoints. To assess short-term impact of CFSs, we compared indicators assessed shortly after refugees' arrival (baseline, T1) and endline (T2, three to six months after CFS implementation) amongst 430 CFS attenders and 161 nonattenders. Follow-up assessments after the end of CFS programming were conducted 18 months post-baseline (T3) with caregivers of 249 previous CFS attenders and 77 CFS nonattenders. RESULTS: In the short-term, attendance at CFSs was associated with better maintenance of psychosocial well-being (PSWB; ß = 2.093, p < .001, Cohen's d = .347) and greater increases in developmental assets (ß = 2.517, p < .001, Cohen's d = .231), with significantly stronger impacts for girls. CFS interventions meeting higher programing quality criteria were associated with greater impact on both PSWB and development assets (ß = 2.603 vs. ß = 1.793 and ß = 2.942 vs. ß = 2.337 for attenders at higher and lower-quality CFSs c.f. nonattenders, respectively). Amongst boys, benefits of program attendance were only indicated for those attending higher-quality CFS (ß = 2.084, p = .006 for PSWB). At follow-up, however, there were no discernable impacts of prior CFS attendance on any measures. Age and school attendance were the only characteristics that predicted an outcome - developmental assets - at follow-up. CONCLUSIONS: Attendance at CFSs - particularly involving higher-quality programming - supported children's well-being and development. However, sustained impact beyond active CFS programming was not demonstrated. Intervention goals and strategies in humanitarian contexts need to address the challenge of connecting children to other resources to facilitate developmental progress in conditions of protracted displacement.

School violence, perceptions of safety and school attendance: results from a cross-sectional study in Rwanda and Uganda.

BACKGROUND: Adolescents displaced by conflict face a number of risks, and access to education has potential to have multiple protective aspects in humanitarian settings. Yet, the impact of violence experienced at school by adolescents in humanitarian contexts is poorly understood, especially in terms of impacts on educational outcomes. METHODS: A household survey of adolescents in a refugee camp in Rwanda (n=274) and in two refugee settlements in Uganda (n=763) was conducted. Multiple logistic regression models were used to assess the influence of violence experienced at school on school attendance, feelings of fear and feelings of safety at school. RESULTS: In multiple logistic regression models, adjusting for socio-demographic variables, exposure to school violence was significantly associated with feelings of safety at school (adjusted odds ratio (AOR)=2.29, 95% confidence interval (CI)=1.20-4.38) and days of school missed (AOR=3.28, 95% CI=1.54-7.01) in Rwanda. In Uganda, exposure to violence was significantly associated with all outcomes: school fear (AOR=2.26, 95% CI=1.48-3.44), school safety (AOR=1.90, 95% CI=1.23-2.92) and school attendance (AOR=2.39, 95% CI=1.52-3.74). Gender-stratified analyses indicated that in both contexts exposure to school violence is significantly associated with school attendance, school fear, and school safety for girls, but the association is weaker amongst boys (with experience of violence significantly associated with school attendance for boys in Uganda, but not for other outcomes and not in Rwanda). CONCLUSIONS: This study presents some initial and novel findings on the relationships between violence experienced at school and educational outcomes amongst adolescents displaced by conflict.