Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises.

BACKGROUND: Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health. OBJECTIVES: To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour. MAIN RESULTS: We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults. AUTHORS' CONCLUSIONS: To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries.

BACKGROUND: Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low- and middle-income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. OBJECTIVES: To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. SEARCH METHODS: We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. SELECTION CRITERIA: All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 66 RCTs with 17,626 participants. Sixty-two of these trials contributed to the meta-analysis. Sixty-three studies were conducted in middle-income countries (MICs), and the remaining three studies were conducted in low-income countries (LICs). Twenty-five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty-two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive-behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive-behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=-0.43, 95% confidence interval (CI): -0.61 to -0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use.   Thirty-one trials reported rates of retention in the intervention. Meta-analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. AUTHORS' CONCLUSIONS: In LMICs there is low-certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta-analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries.

BACKGROUND: There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES: To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA: Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS: Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS: Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS: The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Ten years of tracking mental health in refugee primary health care settings: an updated analysis of data from UNHCR's Health Information System (2009-2018).

BACKGROUND: This study examines mental, neurological, and substance use (MNS) service usage within refugee camp primary health care facilities in low- and middle-income countries (LMICs) by analyzing surveillance data from the United Nations High Commissioner for Refugees Health Information System (HIS). Such information is crucial for efforts to strengthen MNS services in primary health care settings for refugees in LMICs. METHODS: Data on 744,036 MNS visits were collected from 175 refugee camps across 24 countries between 2009 and 2018. The HIS documented primary health care visits for seven MNS categories: epilepsy/seizures, alcohol/substance use disorders, mental retardation/intellectual disability, psychotic disorders, severe emotional disorders, medically unexplained somatic complaints, and other psychological complaints. Combined data were stratified by 2-year period, country, sex, and age group. These data were then integrated with camp population data to generate MNS service utilization rates, calculated as MNS visits per 1000 persons per month. RESULTS: MNS service utilization rates remained broadly consistent throughout the 10-year period, with rates across all camps hovering around 2-3 visits per 1000 persons per month. The largest proportion of MNS visits were attributable to epilepsy/seizures (44.4%) and psychotic disorders (21.8%). There were wide variations in MNS service utilization rates and few consistent patterns over time at the country level. Across the 10 years, females had higher MNS service utilization rates than males, and rates were lower among children under five compared to those five and older. CONCLUSIONS: Despite increased efforts to integrate MNS services into refugee primary health care settings over the past 10 years, there does not appear to be an increase in overall service utilization rates for MNS disorders within these settings. Healthcare service utilization rates are particularly low for common mental disorders such as depression, anxiety, post-traumatic stress disorder, and substance use. This may be related to different health-seeking behaviors for these disorders and because psychological services are often offered outside of formal health settings and consequently do not report to the HIS. Sustained and equitable investment to improve identification and holistic management of MNS disorders in refugee settings should remain a priority.

The EmpaTeach intervention for reducing physical violence from teachers to students in Nyarugusu Refugee Camp: A cluster-randomised controlled trial.

BACKGROUND: School-based violence prevention interventions offer enormous potential to reduce children's experience of violence perpetrated by teachers, but few have been rigorously evaluated globally and, to the best of our knowledge, none in humanitarian settings. We tested whether the EmpaTeach intervention could reduce physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. METHODS AND FINDINGS: We conducted a 2-arm cluster-randomised controlled trial with parallel assignment. A complete sample of all 27 primary and secondary schools in Nyarugusu Refugee Camp were approached and agreed to participate in the study. Eligible students and teachers participated in cross-sectional baseline, midline, and endline surveys in November/December 2018, May/June 2019, and January/February 2020, respectively. Fourteen schools were randomly assigned to receive a violence prevention intervention targeted at teachers implemented in January-March 2019; 13 formed a wait-list control group. The EmpaTeach intervention used empathy-building exercises and group work to equip teachers with self-regulation, alternative discipline techniques, and classroom management strategies. Allocation was not concealed due to the nature of the intervention. The primary outcome was students' self-reported experience of physical violence from teachers, assessed at midline using a modified version of the ISPCAN Child Abuse Screening Tool-Child Institutional. Secondary outcomes included student reports of emotional violence, depressive symptoms, and school attendance. Analyses were by intention to treat, using generalised estimating equations adjusted for stratification factors. No schools left the study. In total, 1,493 of the 1,866 (80%) randomly sampled students approached for participation took part in the baseline survey; at baseline 54.1% of students reported past-week physical violence from school staff. In total, 1,619 of 1,978 students (81.9%) took part in the midline survey, and 1,617 of 2,032 students (79.6%) participated at endline. Prevalence of past-week violence at midline was not statistically different in intervention (408 of 839 students, 48.6%) and control schools (412 of 777 students, 53.0%; risk ratio = 0.91, 95% CI 0.80 to 1.02, p = 0.106). No effect was detected on secondary outcomes. A camp-wide educational policy change during intervention implementation resulted in 14.7% of teachers in the intervention arm receiving a compressed version of the intervention, but exploratory analyses showed no difference in our primary outcome by school-level adherence to the intervention. Main study limitations included the small number of schools in the camp, which limited statistical power to detect small differences between intervention and control groups. We also did not assess the test-retest reliability of our outcome measures, and interviewers were unmasked to intervention allocation. CONCLUSIONS: There was no evidence that the EmpaTeach intervention effectively reduced physical violence from teachers towards primary or secondary school students in Nyarugusu Refugee Camp. Further research is needed to develop and test interventions to prevent teacher violence in humanitarian settings. TRIAL REGISTRATION: clinicaltrials.gov (NCT03745573).

Masculinity and mental health treatment initiation for former political prisoners in Yangon, Myanmar - a qualitative investigation.

BACKGROUND: Men living in low- and middle-income countries are unlikely to seek mental health care, where poor healthcare infrastructure, differences in illness conceptualization, and stigma can impact treatment seeking. Vulnerable groups, such as former political prisoners, are more likely than others to experience potentially traumatic events that may lead to negative mental health outcomes. To improve the likelihood of successful engagement of vulnerable men in psychotherapy, it is necessary to identify factors that influence treatment adherence, and to better understand men's attitudes surrounding decisions to seek and initiate care. The purpose of this investigation was to explore themes of masculinity, treatment seeking, and differences between male former political prisoners who accepted and declined therapy in an urban low-income context. METHODS: We conducted a qualitative, interview-based investigation with 30 former political prisoners in Yangon, Myanmar who were eligible to receive mental health counseling provided by the non-governmental organization (NGO), Assistance Association for Political Prisoners. Men were initially screened using a composite questionnaire with items related to depression, anxiety, and posttraumatic stress symptom severity. After screening, if potential clients were identified as having probable mental health problems, they were asked if they would like to participate in a multi-session cognitive behavioral therapy program. Semi-structured, open-ended interviews were conducted with 15 participants who accepted and 15 participants who declined therapy. Interviews were transcribed and translated by local partners and thematically coded by the authors. We used thematic analysis to identify and explore differences in treatment-seeking attitudes between men who accepted and men who declined the intervention. RESULTS: Men described that being a community leader, self-reliance, morality, and honesty were defining characteristics of masculinity. A focus on self-correction often led to declining psychotherapy. A general lack of familiarity with psychological therapy and how it differed from locally available treatments (e.g. astrologists) was connected to stigma regarding mental health treatment. CONCLUSIONS: Masculinity was described in similar terms by both groups of participants. The interpretation of masculine qualities within the context of help-seeking (e.g. self-reliance as refusing help from others versus listening to others and applying that guidance) was a driving factor behind men's decision to enter psychotherapy.

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.

Psychological and social interventions for the prevention of mental disorders in people living in low- and middle-income countries affected by humanitarian crises.

BACKGROUND: People living in 'humanitarian settings' in low- and middle-income countries (LMICs) are exposed to a constellation of physical and psychological stressors that make them vulnerable to developing mental disorders. A range of psychological and social interventions have been implemented with the aim to prevent the onset of mental disorders and/or lower psychological distress in populations at risk, and it is not known whether interventions are effective. OBJECTIVES: To compare the efficacy and acceptability of psychological and social interventions versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at preventing the onset of non-psychotic mental disorders in people living in LMICs affected by humanitarian crises. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMD-CTR), the Cochrane Drugs and Alcohol Review Group (CDAG) Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), PsycINFO (OVID), and ProQuest PILOTS database with results incorporated from searches to February 2020. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing psychological and social interventions versus control conditions to prevent the onset of mental disorders in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure). DATA COLLECTION AND ANALYSIS: We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy) and at medium term (one to four months after intervention). No data were available at long term (six months or longer). We used GRADE to assess the quality of evidence. MAIN RESULTS: In the present review we included seven RCTs with a total of 2398 participants, coming from both children/adolescents (five RCTs), and adults (two RCTs). Together, the seven RCTs compared six different psychosocial interventions against a control comparator (waiting list in all studies). All the interventions were delivered by paraprofessionals and, with the exception of one study, delivered at a group level. None of the included studies provided data on the efficacy of interventions to prevent the onset of mental disorders (incidence). For the primary outcome of acceptability, there may be no evidence of a difference between psychological and social interventions and control at endpoint for children and adolescents (RR 0.93, 95% CI 0.78 to 1.10; 5 studies, 1372 participants; low-quality evidence) or adults (RR 0.96, 95% CI 0.61 to 1.50; 2 studies, 767 participants; very low quality evidence). No information on adverse events related to the interventions was available. For children's and adolescents' secondary outcomes of prevention interventions, there may be no evidence of a difference between psychological and social intervention groups and control groups for reducing PTSD symptoms (standardised mean difference (SMD) -0.16, 95% CI -0.50 to 0.18; 3 studies, 590 participants; very low quality evidence), depressive symptoms (SMD -0.01, 95% CI -0.29 to 0.31; 4 RCTs, 746 participants; very low quality evidence) and anxiety symptoms (SMD 0.11, 95% CI -0.09 to 0.31; 3 studies, 632 participants; very low quality evidence) at study endpoint. In adults' secondary outcomes of prevention interventions, psychological counselling may be effective for reducing depressive symptoms (MD -7.50, 95% CI -9.19 to -5.81; 1 study, 258 participants; very low quality evidence) and anxiety symptoms (MD -6.10, 95% CI -7.57 to -4.63; 1 study, 258 participants; very low quality evidence) at endpoint. No data were available for PTSD symptoms in the adult population. Owing to the small number of RCTs included in the present review, it was not possible to carry out neither sensitivity nor subgroup analyses. AUTHORS' CONCLUSIONS: Of the seven prevention studies included in this review, none assessed whether prevention interventions reduced the incidence of mental disorders and there may be no evidence for any differences in acceptability. Additionally, for both child and adolescent populations and adult populations, a very small number of RCTs with low quality evidence on the review's secondary outcomes (changes in symptomatology at endpoint) did not suggest any beneficial effect for the studied prevention interventions. Confidence in the findings is hampered by the scarcity of prevention studies eligible for inclusion in the review, by risk of bias in the studies, and by substantial levels of heterogeneity. Moreover, it is possible that random error had a role in distorting results, and that a more thorough picture of the efficacy of prevention interventions will be provided by future studies. For this reason, prevention studies are urgently needed to assess the impact of interventions on the incidence of mental disorders in children and adults, with extended periods of follow-up.

Improving estimation of the association between alcohol use and intimate partner violence in low-income and middle-income countries.

BACKGROUND: Alcohol use is a consistent correlate of intimate partner violence (IPV) in low-income and middle-income countries (LMICs). However, the magnitude of this association differs across studies, which may be due to contextual and methodological factors. This study aims to estimate and explore sources of heterogeneity in the association between alcohol use and IPV in 28 LMICs (n=109 700 couples). METHODS: In nationally representative surveys, partnered women reported on IPV victimisation and male partner's alcohol use. We estimated the relationship between alcohol use and IPV using logistic regression and full propensity score matching to account for confounding. Country-specific ORs were combined using a random-effects model. Country-level indicators of health and development were regressed on ORs to examine sources of variability in these estimates. RESULTS: Partner alcohol use was associated with a 2.55-fold increase in the odds of past-year IPV victimisation (95% CI 2.27 to 2.86) with substantial variability between regions (I2=70.0%). Countries with a low (<50%) prevalence of past-year alcohol use among men displayed larger associations between alcohol use and IPV. Exploratory analyses revealed that colonisation history, religion, female literacy levels and substance use treatment availability may explain some of the remaining heterogeneity observed in the strength of the association between alcohol use and IPV across countries. CONCLUSION: Partner alcohol use is associated with increased odds of IPV victimisation in LMICs, but to varying degrees across countries. Prevalences of male alcohol use and cultural factors were related to heterogeneity in these estimates between countries.

Barriers to contraceptive careseeking: the experience of Eritrean asylum-seeking women in Israel.

Objectives: In recent years, there has been a mass migration of Eritreans (many seeking political asylum) into Israel after precarious irregular movement across international borders. This study qualitatively explores the structural barriers to family planning (i.e. contraceptive services) for Eritrean women in Israel that are rooted in their temporary legal status and the patchwork of family planning services.Design/Methods: From December 2012 to September 2013, we interviewed 25 key informants (NGO workers, researchers, Eritrean community activists, International NGO representatives and Ministry of Health officials) and 12 Eritrean asylum seekers. We also conducted 8 focus groups with Eritrean asylum seekers. Data were analyzed using both inductive and deductive coding.Results: We identified 7 main barriers to accessing family planning services: (1) distance to health facilities; (2) limited healthcare resources; (3) fragmentation of the healthcare system; (4) cost of contraceptive services; (5) low standard of care in private clinics; (6) discrimination; and (7) language barriers.Conclusion: The political, economic and social marginalization of Eritrean asylum-seeking women in Israel creates structural barriers to family planning services. Their marginalization complicates providers' efforts (NGO and governmental) to provide them with comprehensive healthcare, and hinders their ability to control their sexual and reproductive health. Failure to act on this evidence may perpetuate the pattern of unwanted pregnancies and social and economic disparities in this population.

Preventing violence against children in schools (PVACS): protocol for a cluster randomised controlled trial of the EmpaTeach behavioural intervention in Nyarugusu refugee camp.

BACKGROUND: We aim to test the effectiveness of the EmpaTeach intervention to prevent physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. EmpaTeach is a 10-week, 14-session, classroom management and cognitive-behavioural therapy-based intervention for groups of teachers for delivery by lay personnel in resource-constrained settings. METHODS: We will conduct a two-arm cluster randomized controlled trial (RCT) with parallel assignment and an approximately 1:1 allocation ratio. All primary and secondary schools in Nyarugusu will be invited to participate. Whole schools will be stratified according to whether they are Congolese or Burundian, and primary or secondary schools, then randomised to active intervention or wait-list control conditions via a public meeting with headteachers. We will collect survey data from n = 500 teachers and at least n = 1500 students before the intervention, soon after, and at least 6 months after the end of the intervention. The primary outcome measure will be students' self-reports of experience of physical violence from school staff in the past week, measured using a modified version of the International Society for the Prevention of Child Abuse and Neglect Screening Tool-Child Institutional at the first follow-up after the intervention. Secondary outcomes include emotional violence, depressive symptoms and educational test scores. Analysis will be intention to treat, using repeat cross-sectional data from individuals. DISCUSSION: If successful, the EmpaTeach intervention would represent one of a handful of proven interventions to reduce violence from teachers to students in any setting. IRC provides an immediate platform for scale up of the intervention via its current work in more than 40 conflict-affected countries. TRIAL REGISTRATION: NCT03745573 , registered November 19, 2018 at clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT03745573 .

Trauma Exposure, Posttraumatic Stress Disorder Symptoms Trajectory, and Disability Level Among Hospitalized Injury Survivors in Kenya.

Potentially traumatic events (PTEs) have been consistently associated with posttraumatic stress disorder (PTSD). However, the extent of association and attribution to subsequent disability has varied, with limited studies conducted in urban low-income contexts. This longitudinal study estimated the trajectory of PTSD symptoms up to 7 months after hospitalization and the associated disability level among adult patients who had been hospitalized due to injury. Adult injury patients (N = 476) admitted to Kenyatta National Hospital in Nairobi, Kenya, were interviewed in person in the hospital, and via phone at 1, 2-3, and 4-7 months after hospital discharge. Using latent growth curve modeling, two trajectories of PTSD symptoms emerged: (a) persistently elevated PTSD symptoms (9.2%), and (b) low PTSD symptoms (90.8%). Number of PTEs experienced remained moderately associated with the elevated trajectory after controlling for in-hospital depressive symptoms. Having previously witnessed killings or serious injuries, AOR = 2.32, 95% CI [1.07, 5.05]; being female, AOR = 4.74, 95% CI [4.53, 4.96]; elevated depressive symptoms during hospitalization, AOR = 2.96, 95% CI [1.28, 6.83]; and having no household savings/assets, AOR = 1.28, 95% CI [1.13, 1.44], were associated with the elevated PTSD symptoms trajectory class after controlling for other risk factors. Latent membership in the elevated PTSD trajectory was associated with a significantly higher level of disability several months after hospital discharge, p < .001, after controlling for injury and demographic characteristics. These results underline the associations among in-hospital depressive symptoms, witnessing atrocities, and poverty, and an elevated PTSD symptoms trajectory.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Exposición al trauma, Trayectoria de los síntomas del trastorno de estrés postraumático y nivel de discapacidad entre los Sobrevivientes de lesiones hospitalizados en Kenia TRAYECTORIAS DE LOS SíNTOMAS DE TEPT EN SOBREVIVIENTES DE TRAUMAS DE KENIA Los eventos potencialmente traumáticos (EPT) se han asociado sistemáticamente con el trastorno de estrés postraumático (TEPT). Sin embargo, el grado de asociación y la atribución a la discapacidad posterior ha variado, con estudios limitados realizados en contextos urbanos de bajos ingresos. Este estudio longitudinal estimo la trayectoria de los síntomas de TEPT hasta 7 meses después de la hospitalización y el nivel de discapacidad asociado entre los pacientes adultos que habían sido hospitalizados debido a una lesión. Pacientes adultos con lesiones (n = 476) ingresados en el Hospital Nacional Kenyatta en Nairobi, Kenia, fueron entrevistados en persona en el hospital y por teléfono a 1, 2-3 y 4-7 meses después de que el hospital los dio de alta. Utilizando el modelo de curva de crecimiento latente, surgieron dos trayectorias de los síntomas de TEPT: síntomas de TEPT persistentemente elevados (9.2%) y (b) síntomas de TEPT bajos (90.8%). El número de las EPT experimentados permanecieron moderadamente asociados con la trayectoria elevada después de controlar los síntomas depresivos en el hospital. Haber previamente presenciado asesinatos o lesiones graves, AOR = 2,32; IC del 95% [1,07, 5,05]; ser mujer, AOR = 4.74, IC 95% [4.53, 4.96]; tener síntomas depresivos elevados durante la hospitalización, AOR = 2.96, IC 95% [1.28, 6.83]; y carencia de ahorros / activos de los hogares, AOR = 1.28, IC del 95% [1.13, 1.44], se asociaron con la clase de trayectoria de síntomas de trastorno de estrés postraumático elevados después de controlar otros factores de riesgo. La membresía latente en la trayectoria del trastorno de estrés postraumático elevada se asoció con un nivel de discapacidad significativamente mayor varios meses después del alta hospitalaria, p <.001, después de controlar por características de lesiones y demografía. Estos resultados subyacen a las asociaciones entre los síntomas depresivos intrahospitalarios, presenciar atrocidades y pobreza y una trayectoria de síntomas de TEPT elevada.

Violence en route: Eritrean women asylum-seekers experiences of sexual violence while migrating to Israel.

Migrating irregularly, without access to support, may increase female asylum-seekers' vulnerability to sexual violence. In this study, the authors applied a public health lens to explore the risk for sexual violence experienced by female asylum-seekers en route from Eritrea to Israel. The study team conducted 13 in-depth interviews and 8 focus groups with Eritreans in Israel between April and September of 2013. Participants in the study described their experiences occurring in three segments. The combination of irregular movement through dangerous, difficult and often isolated terrain, dependence on human smugglers, and vulnerability to traffickers led to the systematization and normalization of sexual violence en route. Such factors heighten vulnerability to sexual violence among these Eritrean women asylum-seekers, as well as others who find themselves in similar circumstances.

Psychosocial interventions for disruptive behaviour problems in children in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Most of the evidence for psychosocial interventions for disruptive behaviour problems comes from Western, high-income countries. The transferability of this evidence to culturally diverse, low-resource settings with few mental health specialists is unknown. METHODS: We conducted a systematic review with random-effects meta-analysis of randomized controlled trials examining the effects of psychosocial interventions on reducing behaviour problems among children (under 18) living in low- and middle-income countries (LMIC). RESULTS: Twenty-six randomized controlled trials (representing 28 psychosocial interventions), evaluating 4,441 subjects, met selection criteria. Fifteen (54%) prevention interventions targeted general or at-risk populations, whereas 13 (46%) treatment interventions targeted children selected for elevated behaviour problems. Most interventions were delivered in group settings (96%) and half (50%) were administered by non-specialist providers. The overall effect (standardized mean difference, SMD) of prevention studies was -0.25 (95% confidence interval (CI): -0.41 to -0.09; I2 : 78%) and of treatment studies was -0.56 (95% CI: -0.51 to -0.24; I2 : 74%). Subgroup analyses demonstrated effectiveness for child-focused (SMD: -0.35; 95% CI: -0.57 to -0.14) and behavioural parenting interventions (SMD: -0.43; 95% CI: -0.66 to -0.20), and that interventions were effective across age ranges. CONCLUSIONS: Our meta-analysis supports the use of psychosocial interventions as a feasible and effective way to reduce disruptive behaviour problems among children in LMIC. Our study provides strong evidence for child-focused and behavioural parenting interventions, interventions across age ranges and interventions delivered in groups. Additional research is needed on training and supervision of non-specialists and on implementation of effective interventions in LMIC settings.

Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: a qualitative study in eastern Uganda.

BACKGROUND: Limited knowledge exists to inform the selection and introduction of locally relevant, feasible, and effective mental health interventions in diverse socio-cultural contexts and health systems. We examined stakeholders' perspectives on mental health-related priorities, help-seeking behaviors, and existing resources to guide the development of a maternal mental health component for integration into non-specialized care in Soroti, eastern Uganda. METHODS: We employed rapid ethnographic methods (free listing and ranking; semi-structured interviews; key informant interviews and pile sorting) with community health workers (n = 24), primary health workers (n = 26), perinatal women (n = 24), traditional and religious healers (n = 10), and mental health specialists (n = 9). Interviews were conducted by trained Ateso-speaking interviewers. Two independent teams conducted analyses of interview transcripts following an inductive and thematic approach. Smith's Salience Index was used for analysis of free listing data. RESULTS: When asked about common reasons for visiting health clinics, the most salient responses were malaria, general postnatal care, and husbands being absent. Amongst the free listed items that were identified as mental health problems, the three highest ranked concerns were adeka na aomisio (sickness of thoughts); ipum (epilepsy), and emalaria (malaria). The terms epilepsy and malaria were used in ways that reflected both biomedical and cultural concepts of distress. Sickness of thoughts appeared to overlap substantially with major depression as described in international classification, and was perceived to be caused by unsupportive husbands, intimate partner violence, chronic poverty, and physical illnesses. Reported help-seeking for sickness of thoughts included turning to family and community members for support and consultation, followed by traditional or religious healers and health centers if the problem persisted. CONCLUSION: Our findings add to existing literature that describes 'thinking too much' idioms as cultural concepts of distress with roots in social adversity. In addition to making feasible and effective treatment available, our findings indicate the importance of prevention strategies that address the social determinants of psychological distress for perinatal women in post-conflict low-resource contexts.

Psychological therapies for the treatment of mental disorders in low- and middle-income countries affected by humanitarian crises.

BACKGROUND: People living in humanitarian settings in low- and middle-income countries (LMICs) are exposed to a constellation of stressors that make them vulnerable to developing mental disorders. Mental disorders with a higher prevalence in these settings include post-traumatic stress disorder (PTSD) and major depressive, anxiety, somatoform (e.g. medically unexplained physical symptoms (MUPS)), and related disorders. A range of psychological therapies are used to manage symptoms of mental disorders in this population. OBJECTIVES: To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (Wiley), MEDLINE (OVID), Embase (OVID), and PsycINFO (OVID), with results incorporated from searches to 3 February 2016. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing psychological therapies versus control conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) to treat adults and children with mental disorders living in LMICs affected by humanitarian crises. DATA COLLECTION AND ANALYSIS: We used standard Cochrane procedures for collecting data and evaluating risk of bias. We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy); at medium term (one to four months after therapy); and at long term (six months or longer). GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) was used to assess the quality of evidence for post-traumatic stress disorder (PTSD), depression, anxiety and withdrawal outcomes. MAIN RESULTS: We included 36 studies (33 RCTs) with a total of 3523 participants. Included studies were conducted in sub-Saharan Africa, the Middle East and North Africa, and Asia. Studies were implemented in response to armed conflicts; disasters triggered by natural hazards; and other types of humanitarian crises. Together, the 33 RCTs compared eight psychological treatments against a control comparator.Four studies included children and adolescents between 5 and 18 years of age. Three studies included mixed populations (two studies included participants between 12 and 25 years of age, and one study included participants between 16 and 65 years of age). Remaining studies included adult populations (18 years of age or older).Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). Psychological therapies were categorised mainly as cognitive-behavioural therapy (CBT) in 23 comparisons (including seven comparisons focused on narrative exposure therapy (NET), two focused on common elements treatment approach (CETA), and one focused on brief behavioural activation treatment (BA)); eye movement desensitisation and reprocessing (EMDR) in two comparisons; interpersonal psychotherapy (IPT) in three comparisons; thought field therapy (TFT) in three comparisons; and trauma or general supportive counselling in two comparisons. Although interventions were described under these categories, several psychotherapeutic elements were common to a range of therapies (i.e. psychoeducation, coping skills).In adults, psychological therapies may substantially reduce endpoint PTSD symptoms compared to control conditions (standardised mean difference (SMD) -1.07, 95% confidence interval (CI) -1.34 to -0.79; 1272 participants; 16 studies; low-quality evidence). The effect is smaller at one to four months (SMD -0.49, 95% CI -0.68 to -0.31; 1660 participants; 18 studies) and at six months (SMD -0.37, 95% CI -0.61 to -0.14; 400 participants; five studies). Psychological therapies may also substantially reduce endpoint depression symptoms compared to control conditions (SMD -0.86, 95% CI -1.06 to -0.67; 1254 participants; 14 studies; low-quality evidence). Similar to PTSD symptoms, follow-up data at one to four months showed a smaller effect on depression (SMD -0.42, 95% CI -0.63 to -0.21; 1386 participants; 16 studies). Psychological therapies may moderately reduce anxiety at endpoint (SMD -0.74, 95% CI -0.98 to -0.49; 694 participants; five studies; low-quality evidence) and at one to four months' follow-up after treatment (SMD -0.53, 95% CI -0.66 to -0.39; 969 participants; seven studies). Dropout rates are probably similar between study conditions (19.5% with control versus 19.1% with psychological therapy (RR 0.98 95% CI 0.82 to 1.16; 2930 participants; 23 studies, moderate quality evidence)).In children and adolescents, we found very low quality evidence for lower endpoint PTSD symptoms scores in psychotherapy conditions (CBT) compared to control conditions, although the confidence interval is wide (SMD -1.56, 95% CI -3.13 to 0.01; 130 participants; three studies;). No RCTs provided data on major depression or anxiety in children. The effect on withdrawal was uncertain (RR 1.87 95% CI 0.47 to 7.47; 138 participants; 3 studies, low quality evidence).We did not identify any studies that evaluated psychological treatments on (symptoms of) somatoform disorders or MUPS in LMIC humanitarian settings. AUTHORS' CONCLUSIONS: There is low quality evidence that psychological therapies have large or moderate effects in reducing PTSD, depressive, and anxiety symptoms in adults living in humanitarian settings in LMICs. By one to four month and six month follow-up assessments treatment effects were smaller. Fewer trials were focused on children and adolescents and they provide very low quality evidence of a beneficial effect of psychological therapies in reducing PTSD symptoms at endpoint. Confidence in these findings is influenced by the risk of bias in the studies and by substantial levels of heterogeneity. More research evidence is needed, particularly for children and adolescents over longer periods of follow-up.

Life on the margins: the experiences of sexual violence and exploitation among Eritrean asylum-seeking women in Israel.

BACKGROUND: Eritrean migrants in Israel, the majority of whom are seeking asylum, have limited access to institutional support. While the temporary group protection granted to Eritreans by Israel ensures that they are not deported, it does not confer permanent legal status, nor does it allow access to the formal work sector. This study qualitatively explores how political and economic marginalization increases the risk of sexual and other forms of violence as well as the exploitation of Eritrean women asylum seekers living in Israel. METHODS: Twenty-five interviews with key informants, twelve individual interviews (six with men and six with women), and eight focus group discussions (four with men and four with women) were conducted among Eritreans of reproductive age in Tel Aviv, Israel. Qualitative data analysis was conducted using open, focused, and axial coding. RESULTS: Participants reported that Israel's restrictive immigration policies laid the foundation for the political and economic marginalization of asylum seekers. This manifested in limited access to institutional support during and after arrival, and hindered access to formal employment and its associated protections. The Israeli government's decision to grant provisional status with a stipulation banning Eritreans from the formal work sector was perceived to create direct and indirect conditions for a heightened sense of structural vulnerability, particularly for women. Participants reported that this structural vulnerability increased the risk of sexual and domestic violence in addition to the risk for the exploitation of women asylum seekers. CONCLUSIONS: Israel's immigration policies may contribute to women asylum seekers' vulnerability to sexual violence upon arrival in their host country. These policies shape the social realities of women asylum seekers, potentially increasing their risk of violence and exploitation during their time in Israel. This study provides an example of the effects of political and economic marginalization on violence against women, a concept that may apply to other settings globally.

Predicting the Mental Health and Functioning of Torture Survivors.

The psychological effects of war represent a growing public health concern as more refugees and asylum seekers migrate across borders. This study investigates whether sociodemographic, premigration and postmigration, and psychosocial factors predict adverse psychiatric symptoms in refugees and asylum seekers exposed to torture (N = 278). Hierarchical linear regressions revealed that female sex, older age, and unstable housing predicted greater severity of anxiety, posttraumatic stress disorder (PTSD), and depression. Cumulative exposure to multiple torture types predicted anxiety and PTSD, while mental health, basic resources (access to food, shelter, medical care), and external risks (risk of being victimized at home, community, work, school) were the strongest psychosocial predictors of anxiety, PTSD, and depression. Also, time spent in the United States before presenting for services significantly predicted anxiety, PTSD, and depression. Consequently, public-sector services should seek to engage this high-risk population immediately upon resettlement into the host country using a mental health stepped care approach.

Challenges and opportunities for implementation of substance misuse interventions in conflict-affected populations.

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.

Resilience Among Nepali Widows After the Death of a Spouse: "That Was My Past and Now I Have to See My Present".

Responses to the death of a spouse vary; although some are at increased risk of poorer physical and mental health outcomes, others have more resilient responses. In light of the limited scope of research on widows' experiences in Nepal, a setting where widows are often marginalized, we explore themes of resilience in Nepali widows' lives. Drawing from a larger qualitative study of grief and widowhood, a thematic narrative analysis was performed on narratives from four widows that reflected resilient outcomes. Individual assets and social resources contributed to these widows' resilient outcomes. Forgetting, acceptance, and moving forward were complemented by confidence and strength. Social support and social participation were key to widows' resilient outcomes. These four narratives reflect the sociocultural context that shape widows' resilient outcomes in Nepal. Future studies on the emergent themes from this exploratory study will help identify how best to encourage resilient outcomes among widows.