Who benefits from psychosocial support interventions in humanitarian settings?
Authors: Brandon A Kohrt, Suzan J Song
Journal: The Lancet Global Health (2018)

In this issue of The Lancet Global Health, Marianna Purgato and colleagues1Purgato M Gross AL Betancourt T et al.Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis.Lancet Glob Health. 2018; 6: e390-e400Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar evaluate the outcomes of focused psychosocial support for children and adolescents in humanitarian settings. This support is a vital area of research for global health because of the disproportionate burden in humanitarian settings of mental and physical health problems entangled with negative outcomes in education and livelihood, as well as vulnerability to and perpetration of violence. Focused psychosocial support can have an important role in protecting against negative outcomes and promoting wellbeing. Purgato and colleagues find moderate effect sizes of focused psychosocial support for improvement in psychosocial outcomes: functioning, hope, coping, and social support. Post-traumatic stress disorder (PTSD) symptoms show reductions, which were maintained at follow-up. Their findings raise three important questions regarding how focused psychosocial support is conceptualised and evaluated. First, are focused psychosocial support interventions a repackaging of clinical interventions, with the inclusion of psychosocial secondary outcomes—ie, psychiatric symptom improvement mediates improved psychosocial outcomes (figure A)? Framed in this way, focused psychosocial support operates via pathways similar to clinical services, with a range of indirect psychosocial benefits. Purgato and colleagues1Purgato M Gross AL Betancourt T et al.Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis.Lancet Glob Health. 2018; 6: e390-e400Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar observed that many of the focused psychosocial support interventions evaluated were based on clinical cognitive psychotherapy treatments. However, as clinical interventions, focused psychosocial support has limitations. Depression and anxiety outcomes were not significant compared with waiting list controls, and effects for PTSD were predominantly among older adolescents (15–18 years old; standardised mean difference −0·43, 95% CI −0·63 to −0·23), presumably because of this reliance on cognitive mechanisms. Moreover, the conditions under which focused psychosocial support interventions work favourably—among youth who are not displaced and living with small household sizes—do not represent severe humanitarian emergencies, which are characterised by displacement and large numbers of family members in crowded living conditions. Second, are focused psychosocial support interventions intended to address psychosocial outcomes as protective factors for the prevention of or recovery from mental illness—ie, psychosocial factors mediate protective effects on mental illness (figure B)? Most humanitarian practitioners would not frame focused psychosocial support as a substitute for clinical services. The mental health and psychosocial support pyramid differentiates focused psychosocial support as a distinct approach, which benefits a larger population compared with clinical services. From this perspective, Purgato and colleagues'1Purgato M Gross AL Betancourt T et al.Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis.Lancet Glob Health. 2018; 6: e390-e400Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar findings can be interpreted as focused psychosocial support improving psychosocial outcomes and subsequently reducing severity of PTSD symptoms, mitigating the need for some clinical services. However, available focused psychosocial support interventions are not significantly protective for depression and anxiety, which might reflect a restricted ecological scope of some focused psychosocial support programmes. For younger children, youth affected by forced displacement, and youth with depression and anxiety, focused psychosocial support might require greater involvement of families and community members.2Tol WA Jordans MJD Kohrt BA Betancourt TS Komproe IH Promoting mental health and psychosocial well-being in children affected by political violence: part I–current evidence for an ecological resilience approach.in: Fernando C Ferrari M Handbook of resilience in children of war. Springer, New York, NY2013: 11-27Crossref Scopus (31) Google Scholar, 3de Jong JVM Berckmoes L Kohrt B Song S Tol W Reis R A public health approach to address the mental health burden of youth in situations of political violence and humanitarian emergencies.Curr Psychiatry Rep. 2015; 17: 60Crossref PubMed Scopus (36) Google Scholar Targeting of mental health and psychosocial wellbeing of caregivers, teachers, and other community members has benefitted children in humanitarian settings.4Kohrt BA Jordans MJD Koirala S Worthman CM Designing mental health interventions informed by child development and human biology theory: a social ecology intervention for child soldiers in Nepal.Am J Human Biol. 2015; 27: 27-40Crossref PubMed Scopus (23) Google Scholar, 5Mutamba BB Kane JC De Jong J Okello J Musisi S Kohrt BA Psychological treatments delivered by community health workers in low-resource government health systems: effectiveness of group interpersonal psychotherapy for caregivers of children affected by Nodding Syndrome in Uganda.Psychol Med. 2018; (published online Feb 15.)DOI:10.1017/S0033291718000193Crossref PubMed Scopus (24) Google Scholar Additionally, Purgato and colleagues do not address behavioural disorders, which might be the mental health outcome most sensitive to focused psychosocial support. Behavioural disorders are the most common child and adolescent class of conditions and are associated with vulnerability to and perpetration of violence. A meta-analysis6Burkey MD, Hosein M, Morton I, et al. Psychosocial interventions for disruptive behavior problems in children in low- and middle-income countries: a systematic review and meta-analysis. J Child Psychol Psychiatry (in press).Google Scholar of interventions in low-income and middle-income countries, including many of the studies in Purgato and colleagues' analysis, shows that psychosocial interventions have a large beneficial role in prevention and treatment of behavioural disorders, including improvement for younger children and positive subgroup outcomes for family approaches through parenting interventions. Finally, what are the roles of psychosocial outcomes as promotive factors for positive effects in multiple areas of life—ie, psychosocial outcomes mediate improvements across life domains (figure C)? The previous two pathways emphasise psychiatric symptoms as mediators or outcomes, however, a contribution of focused psychosocial support is its conceptualisation beyond clinical processes. Many life domains require investigation in focused psychosocial support intervention research. One example is education, which is prioritised in psychosocial programmes in humanitarian settings. In one focused psychosocial support programme,7Betancourt TS McBain R Newnham EA Akinsulure-Smith AM Brennan RT Weisz JR A behavioral intervention for war-affected youth in Sierra Leone: a randomized controlled trial.J Am Acad Child Adolesc Psychiatry. 2014; 53: 1288-1297Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar included in Purgato and colleagues' analysis, a major benefit was improved school attendance. A second domain is economic productivity. A retrospective study8Jordans MJD Komproe IH Tol WA Ndayisaba A Nisabwe T Kohrt BA Reintegration of child soldiers in Burundi: a tracer study.BMC Public Health. 2012; 12: 905Crossref PubMed Scopus (17) Google Scholar found that social integration and economic opportunity had similar outcomes among former child soldiers in Burundi. A third domain is reduced engagement in criminal and political violence, including youth's involvement in armed groups, which is likely to be affected by hope, social support, and coping.9Morley CA Kohrt BA Impact of peer support on PTSD, hope, and functional impairment: a mixed-methods study of child soldiers in Nepal.J Aggress Maltreat Trauma. 2013; 22: 714-734Crossref Scopus (29) Google Scholar, 10Kohrt BA Yang M Rai S Bhardwaj A Tol WA Jordans MJ Recruitment of child soldiers in Nepal: mental health status and risk factors for voluntary participation of youth in armed groups.Peace Confl. 2016; 22: 208-216Crossref PubMed Scopus (12) Google Scholar Finally, these psychosocial outcomes could affect reproductive health, including vulnerability to HIV/AIDS and adolescent pregnancies, which is vital to address given intergenerational effects on youth.3de Jong JVM Berckmoes L Kohrt B Song S Tol W Reis R A public health approach to address the mental health burden of youth in situations of political violence and humanitarian emergencies.Curr Psychiatry Rep. 2015; 17: 60Crossref PubMed Scopus (36) Google Scholar, 11Song SJ Tol W de Jong J Indero: intergenerational trauma and resilience between Burundian former child soldiers and their children.Fam Process. 2014; 53: 239-251Crossref PubMed Scopus (42) Google Scholar Ultimately, focused psychosocial support interventions do not need to be pigeonholed as having a single function related to clinical, protective, or promotive functions, but greater clarity is needed in the design, implementation, and evaluation of interventions. In particular, a coherence among conceptualisation, hypothesised mechanisms, and outcomes is indispensable. Overlaying of psychiatric clinical trial designs and outcomes onto focused psychosocial support misses opportunities to identify the unique contribution of this field. Lessons learned from the current systematic review and meta-analysis should inform study designs to elucidate why focused psychosocial support interventions are important to comprehensively address health and wellbeing of children and adolescents in humanitarian settings. BAK is supported by the US National Institute of Mental Health (K01MH104310). The funder had no role in this Comment and the views expressed are solely those of the authors. We declare no competing interests. Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysisOverall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. Full-Text PDF Open Access