Parenting and family interventions in lower and middle-income countries for child and adolescent mental health: A systematic review.

BACKGROUND: Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential. METHOD: This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0-24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes. MAIN FINDINGS: We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs. PRELIMINARY CONCLUSIONS: Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.

Advancing sustainable implementation of an evidence-based mental health intervention in Sierra Leone's schools: protocol for a hybrid type 3 implementation-effectiveness trial.

BACKGROUND: Mental health disorders among youth contribute substantially to the global burden of disease, which is exacerbated in low- and middle-income countries (LMICs) due to large mental health treatment gaps. In Sierra Leone, a West African country with a long history of complex adversity, the mental health treatment gap is estimated at 98%. Implementing innovative mental health interventions that can be sustained at scale is a priority. The Youth Readiness Intervention (YRI) is an evidence-based mental health intervention for youth that can be delivered feasibly by lay health workers/nonspecialists. Using mobile-based technologies to assist implementation could improve the reach and sustainability of the YRI in Sierra Leone. This study aims to train teachers to deliver the YRI in Sierra Leone's secondary schools and test the feasibility, acceptability, cost, and fidelity to the YRI of a mobile-based supervision model compared with standard, in-person supervision. METHODS: We will conduct a hybrid type 3 implementation-effectiveness cluster randomized trial to assess the feasibility, acceptability, costs and fidelity to the YRI implemented by teachers receiving mobile-based supervision vs. standard supervision. Enrolled schools (N = 50) will be randomized to YRI + mobile supervision (N = 20), YRI + standard supervision (N = 20) or waitlist control (N = 10). We will recruit and enroll four teachers per intervention-condition school (N = 160) and 1200 youth. We will collect data on implementation outcomes among teachers, principals and youth via a mixed methods approach at baseline and post-intervention. We will also collect quantitative data on youth mental health and functioning as secondary outcomes at baseline and post-intervention, as well as cost-effectiveness data at 12-month follow-up. DISCUSSION: Study findings have the potential to expand the reach of mental health services among youth in low-resource settings via a teacher workforce. The use of mobile tools, if successful, could support further scale out and sustainment of the YRI to other regions of Sierra Leone and West Africa more broadly, which could help address the mental health treatment gap. TRIAL REGISTRATION: Clinical Trial Network: NCT05737667.

Ebola Virus Disease Sensitization: Community-Driven Efforts in Sierra Leone.

The 2014-2016 West Africa Ebola outbreak was the largest in history, resulting in approximately 11,000 deaths. Despite the outbreak's eventual end, national and international health sensitization and containment efforts were subject to criticism. This study investigates disease-related knowledge and beliefs, as well as trusted sources of health information among EVD-survivors and their family members, highlighting the importance of community-informed public health responses. Participants (n = 134) were adults who were either EVD-infected, affected families/caregivers, or community leaders. In-depth interviews and focus groups explored EVD-related experiences, including health effects, stigma, and community relationships. Using a grounded theory and thematic content analysis approach, transcripts were coded for evidence of health sensitization, as well as compliance with mitigation measures and trusted sources of information. Participants displayed a high level of knowledge around EVD and reported compliance with mandated and personal prevention measures. Levels of health sensitization and subsequent reintegration of survivors were reported to be largely the products of community-based efforts, rather than the top-down, national public health response. Primary sources of trusted information included EVD survivors acting as peer educators; local leaders; and EVD sensitization by community health workers. This study highlights the importance of a community-based response for increasing the effectiveness of public health campaigns. Participants expressed that relying on the experiences of trusted cultural insiders led to a deeper understanding of Ebola compared to top-down public health campaigns, and helped infected and affected community members reintegrate. Future public health efforts should incorporate community-based participatory approaches to address infectious disease outbreaks.

The adaptation of a youth mental health intervention to a peer-delivery model utilizing CBPR methods and the ADAPT-ITT framework in Sierra Leone.

Low- and middle-income countries (LMICs) carry a significant proportion of the global burden of untreated mental health disorders. Peer-delivered programs offer LMICs with limited mental health professionals an opportunity to increase mental health service access. This study describes the process of adapting a lay-worker-delivered evidence-based youth mental health intervention to a peer-delivery model in Sierra Leone using participatory methods. We convened Youth Community Advisory Boards (YCABs) as partners to develop a peer-delivery model for an evidence-based intervention. In collaboration with YCABs, the Assessment, Decision, Administration, Production, Topical experts, Integration, Training, Testing (ADAPT-ITT) framework was applied to guide the adaptation. The ADAPT-ITT framework is an eight-step process to adapt evidence-based interventions. The ADAPT-ITT framework facilitated the adaptation of the Youth Readiness Intervention (YRI), an evidence-based mental health program intervention that has been delivered by adult lay-workers to the youth peer-delivery platform in Sierra Leone. The YCABs identified program modifications, including the incorporation of storytelling, refinement of metaphors, and alterations to make delivery more accessible to low-literacy youth with particular attention to gender. YCABs also provided recommendations on how to support youth facilitators in providing psychosocial support, emphasizing self-care and boundary setting to ensure high-quality intervention delivery and do-no-harm principles. Study findings suggest that the ADAPT-ITT framework can be feasibly applied to guide the intervention adaptation process in LMICs. The use of participatory methods generated modifications that reflected youth experiences, needs, and concerns as facilitators and participants. Next steps include refinement and pilot testing of the adapted intervention.

Navigating the Tension between Fatherhood Ideals and Realities of a Post-Conflict Setting: A Phenomenological Study of Former Child Soldiers in Sierra Leone.

The concept of "fatherhood" in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and responses to recent crises such as the Ebola pandemic and the aftermath of a civil war. Very little is understood about how male former children associated with armed forces and armed groups (CAAFAG) are navigating fatherhood and understanding their roles as fathers, particularly as many have grown up without fathers or parents themselves and experienced violence. Our study builds upon previous ethnographic research in Sierra Leone, and uses a phenomenological approach to understand 1) the meaning and importance of fatherhood to former child soldiers in Sierra Leone, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care as well as violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG fathers in Sierra Leone are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially. CAAFAG fathers experienced the greatest tension between their ideals of fatherhood and their socio-economic circumstances in terms of financial support, such as paying school fees. In other words, fathers felt inhibited in becoming the types of fathers they hoped to be due to their experiences in a post-conflict, resource-constrained environment.

Integrating Youth Readiness Intervention and Entrepreneurship in Sierra Leone: A Hybrid Type II Cluster Randomized Trial.

OBJECTIVE: Conflict-affected youth are at risk for poor psychological and social outcomes, yet few receive mental health services. Strategies to expand access and sustain evidence-based interventions (EBIs) across novel delivery platforms must be tested. The present study was a hybrid type II implementation-effectiveness trial using a cluster randomized design. The primary goal was to evaluate feasibility and impact of using the collaborative team approach to deliver the Youth Readiness Intervention (YRI), an EBI, integrated into a youth entrepreneurship program (ENTR) with quality control in post-conflict Sierra Leone. METHOD: Youth were screened and randomly assigned to control, ENTR, or combined YRI and ENTR (YRI+ENTR). Implementation outcomes were dissemination and implementation indicators, competence, and fidelity. Effectiveness outcomes were emotion regulation, psychological distress, and interpersonal functioning. Secondary outcomes were third-party reporter assessments of youth functioning and behavior. RESULTS: Data were collected and analyzed from 1,151 youth participants and 528 third-party reporters. Scores on implementation constructs, competence, and fidelity demonstrated acceptable intervention response and quality. YRI+ENTR participants showed overall improvements in depression (ß = -.081, 95% CI -0.124 to -0.038, d = -0.154) and anxiety (ß = -.043, 95% CI -0.091 to -0.005, d = 0.082) symptoms compared with control participants. Community leaders indicated that YRI+ENTR participants demonstrated improvements in overall work or training performance compared with control participants (ß = -.114, 95% CI 0.004 to 0.232, d = 0.374). CONCLUSION: Integration of EBIs such as the YRI into youth employment programs has the potential to address limited reach of EBIs in conflict and post-conflict settings. A collaborative team implementation approach can facilitate integration and fidelity. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. One or more of the authors of this paper received support from a program designed to increase minority representation in science. CLINICAL TRIAL REGISTRATION INFORMATION: Youth FORWARD Phase 2 YRI and EPP Study; https://clinicaltrials.gov/; NCT03542500.

Promoting positive development among refugee adolescents.

Of the estimated 35.3 million refugees around the world (UNHCR, Figures at a Glance, 2022), approximately 50% are children under the age of 18. Refugee adolescents represent a unique group as they navigate developmental tasks in an unstable and often threatening environment or in resettlement contexts in which they often face marginalization. In addition to physiological, social, and psychological changes that mark adolescence, refugee youth often face traumatic experiences, acculturative stress, discrimination, and a lack of basic resources. In this consensus statement, we examine research on refugee adolescents' developmental tasks, acculturative tasks, and psychological adjustment using Suárez-Orozco and colleague's integrative risk and resilience model for immigrant-origin children and youth proposed by Suárez-Orozco et al. Finally, we discuss recommendations-moving from proximal to more distal contexts.

Exploring potential mental health spillover effects among caregivers and partners of youth in Sierra Leone: A qualitative study.

Given the large mental health treatment gap in low- and middle-income countries (LMICs), particularly in post-conflict settings like Sierra Leone, and the limited healthcare infrastructure, understanding the wider benefits of evidence-based mental health interventions within households is critical. This study explored potential mental health spillover effects - the phenomenon of beneficial effects among nonparticipants - among cohabitating caregivers and partners of youth who participated in an evidence-based mental health intervention in Sierra Leone. We recruited a sub-sample of cohabitating caregivers and partners (N = 20) of youth intervention participants; caregivers had enrolled in a larger study investigating indirect benefits of the evidence-based intervention in Sierra Leone (MH117359). Qualitative interviews were conducted at two time points to explore the following: (a) potential mental health spillover effects and (b) through which mechanisms spillover may have occurred. Two trained coders reviewed transcripts and analyzed qualitative data, assisted by MaxQDA. Qualitative findings suggested that spillover effects likely occurred and supported three potential mechanisms: decreased caregiving burden, behavior changes among Youth Readiness Intervention participants and improved interpersonal relationships. Mental health spillover effects may occur following youth intervention participation in a post-conflict LMIC. Investing in evidence-based services may offer indirect benefits that extend beyond those directly receiving services.

Measuring the cost-effectiveness of a home-visiting intervention to promote early child development among rural families linked to the Rwandan social protection system.

Early childhood development (ECD) programmes are heralded as a way to improve children's health and educational outcomes. However, few studies in developing countries calculate the effectiveness of quality early childhood interventions. This study estimates the cost and cost-effectiveness of the Sugira Muryango (SM) trial, a home-visiting intervention to improve ECD outcomes through positive parent-child relationships. Cost-effectiveness analysis of ECD interventions is challenging given their potential to have multiple benefits. We propose a cost-effectiveness method using a single outcome, in this case the improvement in cognitive development per home-visit session, as an indication of efficiency comparable across similar interventions. The trial intervention cost US$456 per family. This cost will likely fall below US$200 if the intervention is scaled through government systems. The cost-effectiveness analysis suggests that while SM generated a relatively small impact on markers of early development, it did so efficiently. The observed improvements in cognitive development per home-visit are similar to other home-visiting interventions of longer duration. SM by focusing on the family had benefits beyond ECD, including reductions in violence against children and intermate partner violence, further analysis is needed to include these returns in the economic evaluation.

Adverse childhood experiences and lifelong health.

With the advent of the sustainable development goals, the field of global child health has shifted its focus from reducing mortality to improving health, nutrition and development outcomes - often measured as human capital. A growing knowledge of the biology of development and neuroscience has highlighted the importance of adverse environmental exposures, collectively termed adverse childhood experiences (ACEs) on health outcomes. ACEs are associated with short-term, medium-term and long-term negative consequences for health and development and their effects may be multiplicative, especially during critical periods of sensitivity and developmental plasticity. Some of these effects are compounded by emerging global threats such as climate change, conflict and population displacement. In this Review, we discuss the key mechanisms linking ACEs to health outcomes and consider promising strategies to prevent and mitigate their effects, highlighting evidence from programs in low-income and middle-income countries. Finally, we emphasize the need for early recognition of ACEs and delivery of packages of interventions spanning key sectors such as health, education, women's empowerment and social protection.

Mental health among older Bhutanese with a refugee life experience: A mixed-methods latent class analysis study.

There are disparities in the mental health of refugee populations compared to individuals who have not experienced forced migration. It is important to identify individuals with a refugee life experience who are most in need of mental health care and prioritize their engagement in services. The objectives of this convergent mixed-methods study are to quantitatively identify the association between exposure to pre- and postresettlement traumas and stressors and mental health among older adults with a refugee life experience, qualitatively identify typologies of narratives of forced migration, and integrate findings to provide a more comprehensive understanding of the relationship between trauma and symptoms of posttraumatic stress disorder (PTSD). Study participants were Bhutanese with a refugee life experience living in a metropolitan area in New England (United States). We used quantitative surveys to identify exposures to traumas and symptoms of PTSD. We used latent class analysis to identify subgroups of trauma exposure and association with symptoms of PTSD. A subset of individuals participated in qualitative interviews. Narrative thematic analysis was used to explore typologies of life history narratives. Quantitatively, we identified four classes of patterns of trauma exposure throughout the refugee life trajectory. These classes were associated with current symptoms of PTSD. Qualitatively, we identified four narrative types that indicate participants interpreted and made sense of their life trajectories in a variety of ways. Integration of findings indicate that caution is needed in identifying individuals in need of mental health services and the best approach for interventions that promote psychosocial well-being. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Family Violence Reduction Within a Parenting Intervention in Rwanda: A Mixed-Methods Study.

BACKGROUND AND OBJECTIVES: A mixed-methods study of mechanisms of change through which a home-visiting-based early childhood development intervention, Sugira Muryango ("strong family"), reduced violent discipline and intimate partner violence in Rwanda. METHODS: The cluster-randomized trial of Sugira Muryango enrolled socioeconomically vulnerable families with children aged 6 to 36 months in rural Rwanda. We interviewed 18 female caregivers early in the intervention, and 21 female caregivers and 11 male intimate partners were interviewed after the intervention. Coded interviews identify risk factors for violence and mechanisms of intervention-related change in violence. Quantitative analyses included 931 caregivers (52.6% female) who lived with an intimate partner to examine risk factors for violence, intervention effects, and mechanisms of violence reduction. RESULTS: The qualitative data identified daily hardships and alcohol problems as risk factors for violent discipline and intimate partner violence. Through Sugira Muryango, caregivers learned that strong relationships between partners and engagement of male caregivers in child care has positive impacts on children's development. Techniques taught by community lay workers improved communication, promoted positive parent-child interactions, and reduced intimate partner violence and violent discipline. Quantitative analyses also found that daily hardships predict violent discipline and intimate partner violence. Sugira Muryango reduced violent discipline, increased father engagement, and increased female caregiving warmth. Moreover, pre- to postintervention change in caregiving warmth was associated with reduced use of violent discipline among female caregivers and marginally associated with reduced female victimization. CONCLUSIONS: Violence reduction can be integrated into early child development programs to reduce violent discipline and intimate partner violence.

Mental health and psychosocial support in humanitarian settings: research priorities for 2021-30.

We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries.

Exploring Naturalistic Diffusion of an Evidence-Based Mental Health Intervention across Peer Networks of Youth in Sierra Leone.

BACKGROUND: Understanding the mechanisms by which evidence-based interventions (EBIs) for mental health are naturally diffused among youth in low-and middle-income countries-particularly those with histories of violence and civil unrest-can illuminate which intervention elements are most transferrable and inform scale-up decisions that support youth adjustment. This study explored the diffusion of an evidence-based mental health intervention-the Youth Readiness Intervention (YRI)-among peer networks of Sierra Leonean youth (aged 18-30) who participated in a trial of the intervention as integrated into youth entrepreneurship programs. METHODS: Trained research assistants recruited index participants who had completed the YRI integrated within entrepreneurship training (N = 165) and control index participants (N = 165). Index participants nominated three of their closest peers. Nominated peers were recruited and enrolled in the current study (N = 289). A sub-sample of index participants and peers participated in dyadic interviews (N = 11) and focus group discussions (N = 16). Multivariate regression analysis compared YRI knowledge levels among YRI participants' peers relative to control participants' peers. RESULTS: Qualitative findings supported the diffusion of several YRI skills and components across peer networks (i.e., progressive muscle relaxation and diaphragmatic breathing). Quantitative findings indicated that YRI knowledge was significantly higher for YRI participants' peers (ß = 0.02, p < 0.00) compared to control participants' peers. CONCLUSION: Findings suggest that diffusion of evidence-based intervention components can occur naturally among peers in post-conflict LMIC settings. Developing tools to promote the diffusion of the most transferrable EBI components across peer networks could help maximize the benefits of mental health interventions for youth adjustment and resilience in post-conflict settings.

Applying Human-Centered Design in Global Mental Health to Improve Reach Among Underserved Populations in the United States and India.

INTRODUCTION: Human-centered design (HCD) refers to a diverse suite of interactive processes that engage end users in the development of a desired outcome. We showcase how 2 global mental health research teams applied HCD to develop mobile health tools, each directed at reducing treatment gaps in underserved populations. CASE STUDY 1: Refugees face higher risks for mental health problems, yet these communities face structural and cultural barriers that reduce access to and use of services. To address these challenges, the Research Program on Children and Adversity at the Boston College School of Social Work, in partnership with resettled refugee communities in the northeastern United States, used codesign methodology to digitally adapt delivery of the Family Strengthening Intervention for Refugees-a program designed to improve mental health and family functioning among resettled families. We describe how codesign methods support the development of more feasible, acceptable, and sustainable interventions. CASE STUDY 2: Sangath, an NGO in India focused on mental health services research, in partnership with Harvard Medical School, designed and evaluated a digital training program for community health workers to deliver an evidence-based, brief psychological treatment for depression as part of primary care in Madhya Pradesh, India. We describe how HCD was applied to program development and discuss our approach to scaling up training and capacity-building to deliver evidence-based treatment for depression in primary care. IMPLICATIONS: HCD involves a variety of techniques that can be flexibly adapted to engage end users in the conceptualization, implementation, scale-up, and sustainment of global mental health interventions. Community solutions generated using HCD offer important benefits for key stakeholders. We encourage widespread adoption of HCD within global mental health policy, research, and practice, especially for addressing mental health disparities with underserved populations.

Alternative Delivery Platforms for Expanding Evidence-based Mental Health Interventions for Youth in Sierra Leone: A Pilot Study.

Given the high rates of mental health problems and poor service access among youth in war-affected countries throughout Sub-Saharan Africa, incorporating evidence-based mental health interventions into alternative delivery platforms could improve service access in these settings. We conducted a randomized controlled pilot study with high-risk Sierra Leonean youth to investigate the feasibility of implementing the Youth Readiness Intervention (YRI), a cognitive behavioral and interpersonal therapy-based group intervention, within an employment promotion program (EPP) and preliminary effects of the YRI on mental health outcomes. Participants were 175 youth (females=62%) ages 18-30 recruited via flyers and radio announcements. Participants were assigned to geographic clusters stratified by gender; clusters were randomized into YRI+EPP (n=58) or EPP-only (n=57). Statistically matched controls were recruited from comparable chiefdoms (n=60). The 12-session YRI was delivered bi-weekly, following EPP completion. Qualitative findings indicated that the YRI was highly feasible and acceptable as integrated into the EPP. Mixed linear effects models showed promising trends. Compared with controls, both YRI+EPP and EPP-only males reported significantly reduced post-traumatic stress symptoms, and YRI+EPP reported marginally significantly reduced emotional regulation difficulties. EPP-only females reported significantly reduced functional impairment compared to controls. Findings suggest that the YRI can be feasibly implemented within an EPP. Integrating the YRI into existing delivery platforms may help increase access to mental health care in Sierra Leone and provide a leverage point for scaling up evidence-based mental health interventions in other low-resource settings globally. [Clinicaltrials.gov; NCT0360361; 5/18/18].

Understanding mechanisms of change in a family-based preventive mental health intervention for refugees by refugees in New England.

Transnational migration of refugees is associated with poor mental health, particularly among children. We conducted a pilot trial of the Family Strengthening Intervention for Refugees (FSI-R), using a community-based participatory research (CBPR) approach to deliver a home-based intervention "for refugees by refugees" to improve family functioning and child mental health. N = 80 refugee families in the Greater Boston area participated in the study (n = 40 Somali Bantu families; n = 40 Bhutanese families) with n = 41 families randomized to care-as-usual. Of the 39 families who received FSI-R, n = 36 caregivers and children completed qualitative exit interviews. We present findings from these interviews to identify the mechanisms through which a family-strengthening intervention for refugees can be acceptable, feasible, and effective at improving family functioning and children's mental health outcomes. Authors applied Grounded Theory to code interview transcripts and detailed field notes and used an iterative process to arrive at final codes, themes, and a theoretical framework. The greatest contributors to acceptability and feasibility included flexibility in scheduling intervention sessions, the interventionist being a community member, and improvements to family communication and time spent together. All of these factors were made possible by the CBPR approach. Our findings suggest that given the socio-political context within the U.S. and the economic challenges faced by refugee families, the successful implementation of such interventions hinges on culturally-grounding the intervention design process, drawing heavily on community input, and prioritizing community members as interventionists.

Social distancing, community stigma, and implications for psychological distress in the aftermath of Ebola virus disease.

BACKGROUND: The 2013-2016 Ebola virus disease (EVD) epidemic resulted in more infections and deaths than all prior outbreaks in the 40-year history of this virus combined. This study examines how experiences of EVD infection, and preventive measures such as social distancing, were linked to experiences of stigma and social exclusion among those reintegrating into their communities. METHODS: Key informant interviews (n = 42) and focus group discussions (n = 27) were conducted in districts with a high prevalence of EVD and representing geographical and ethnic diversity (n = 228 participants). The final sample was composed of adults (52%) and children (48%) who were EVD-infected (46%) and -affected (42%) individuals, and community leaders (12%). Data were coded using a Grounded Theory approach informed by Thematic Content Analysis, and analyzed using NVivo. Interrater reliability was high, with Cohen's κ = 0.80 or higher. FINDINGS: Participants described two main sources of EVD-related stress: isolation from the community because of social distancing and other prevention measures such as quarantine, and stigma related to infected or affected status. Participants linked experiences of social isolation and stigma to significant distress and feelings of ostracization. These experiences were particularly pronounced among children. Sources of support included community reintegration over time, and formal community efforts to provide education and establish protection bylaws. INTERPRETATION: This study found that social distancing and EVD-related stigma were each prominent sources of distress among participants. These results suggest that isolation because of infection, and the enduring stigmatization of infected individuals and their families, demand coordinated responses to prevent and mitigate additional psychosocial harm. Such responses should include close engagement with community leaders to combat misinformation and promote community reintegration.

Investigating Outcomes of a Family Strengthening Intervention for Resettled Somali Bantu and Bhutanese Refugees: An Explanatory Sequential Mixed Methods Study.

Pre- and post-migration stressors can put resettled refugee children at risk of poor mental health outcomes. The Family Strengthening Intervention for Refugees (FSI-R) is a peer-delivered preventative home visiting program for resettled refugees that aims to draw upon families' strengths to foster improved family communication, positive parenting, and caregiver-child relationships, with the ultimate goal of reducing children's risk of mental health problems. Using an explanatory sequential mixed methods design, this study draws upon qualitative interviews with caregivers (n = 19) and children (n = 17) who participated in a pilot study of the FSI-R intervention in New England, as well as interventionists (n = 4), to unpack quantitative findings on mental health and family functioning from a randomized pilot study (n = 80 families). Most patterns observed in the quantitative data as published in the pilot trial were triangulated by qualitative data. Bhutanese caregivers and children noted that children were less shy or scared to speak up after participating in the FSI-R. Somali Bantu families spoke less about child mental health and underscored feasibility challenges like language barriers between caregivers and children. Interventionists suggested that families with higher levels of education were more open to implementing behavior change. In both groups, families appreciated the intervention and found it to be feasible and acceptable, but also desired additional help in addressing broader family and community needs such as jobs and literacy programs.