Alastair Ager

Mental health in complex emergencies

Mental health is becoming a central issue for public health complex emergencies. In this review we present a culturally valid mental health action plan based on scientific evidence that is capable of addressing the mental health effects of complex emergencies. A mental health system of primary care providers, traditional healers, and relief workers, if properly trained and supported, can provide cost-effective, good mental health care. This plan emphasises the need for standardised approaches to the assessment, monitoring, and outcome of all related activities. Crucial to the improvement of outcomes during crises and the availability to future emergencies of lessons learned from earlier crises is the regular dissemination of the results achieved with the action plan. A research agenda is included that should, in time, fill knowledge gaps and reduce the negative mental health effects of complex emergencies.

A Systematic Review of Prevalence Studies of Gender-Based Violence in Complex Emergencies

Current methods to estimate the incidence of gender-based violence in complex emergencies tend to rely on nonprobability samples. Population-based monitoring is undertaken relatively infrequently. This article provides a systematic review of published literature that represents attempts to quantify the magnitude of gender-based violence in emergency settings. Searches adopted a Boolean procedure, which led to initial selection of material that was then reviewed against set criteria. Only 10 studies met the final criteria for inclusion. Intimate partner violence, physical violence, and rape were the three categories of violence most frequently measured. Rates of intimate partner violence tended to be quite high across all of the studies—much higher than most of the rates of wartime rape and sexual violence perpetrated by individuals outside of the home. Direct comparisons of rates of violence were hindered by different case definitions, recall periods, and other methodological features. Recommendations for future studies are offered based on lessons learned from the studies reviewed.

The impact of the school-based Psychosocial Structured Activities (PSSA) program on conflict-affected children in northern Uganda

BACKGROUND Children in northern Uganda have undergone significant psychosocial stress during the regions lengthy conflict. A Psychosocial Structured Activities (PSSA) program was implemented in 21 schools identified as amongst those most severely affected by conflict-induced displacement across Gulu and Amuru Districts. The PSSA intervention comprised a series of 15 class sessions designed to progressively increase childrens resilience through structured activities involving drama, movement, music and art (with additional components addressing parental support and community involvement). METHOD Eight schools were selected by random quota sampling from those schools receiving the PSSA intervention. Two hundred and three children were identified in these schools as being scheduled to receive intervention, and were followed up 12 months later following engagement with PSSA activities. A comparison group comprised 200 children selected from schools that had met inclusion criteria for receipt of intervention, but were not scheduled for intervention coverage until later. Preliminary research used participatory focus group methodology to determine local indicators of child well-being as viewed by parents, teachers, and children respectively. Pre- and post- assessments focused on ratings for each child - by parents, teachers and children - with respect to these indicators. RESULTS Significant increases in ratings of child well-being were observed in both intervention and comparison groups over a 12-month period. However, the well-being of children who had received the PSSA intervention increased significantly more than for children in the comparison group, as judged by child and parent (but not teacher) report. This effect was evident despite considerable loss-to-follow-up at post-testing as a result of return of many households to communities of origin. CONCLUSION General improvement in child well-being over a 12-month period suggests that recovery and reconstruction efforts in Northern Uganda following the onset of peace had a substantive impact on the lives of children. However, exposure to the PSSA program had an additional positive impact on child well-being, suggesting its value in post-conflict recovery contexts.

Annual Research Review: Resilience and child well-being – public policy implications

BACKGROUND There has been an 8-fold increase in use of the term resilience within scientific and scholar literature over the last twenty years. The arena of public policy has also seen increasing use made of the concept, both with respect to child well-being and development and wider issues. METHOD A focal sample of literature comprising 108 papers addressing public policy implications of work on child resilience was identified by a structured bibliographic search. RESULTS This literature suggests that current work: is characterized by a breadth of sectoral engagement across the fields of education, social work, and health; demonstrates diversity with regard to the systemic levels--individual (biological and psychological), communal (including systems of faith and cultural identity), institutional and societal--with which it engages; but is based more upon conceptual rather than empirical analysis. Major themes of policy recommendation target strengthened family dynamics, increased capacity for counseling and mental health services, supportive school environments, development of community programs, promotion of socioeconomic improvement and adoption of a more comprehensive conception of resilience. Evaluations of resiliency-informed policy initiatives are limited in number, with greatest rigor in design associated with more discrete programmatic interventions. CONCLUSION A number of strategies to strengthen research-policy linkages are identified. These include greater commitment to operationalize indicators of resilience at all levels of analysis; more coherent engagement with the policy making process through explicit knowledge translation initiatives; and developing complex adaptive systems models amenable to exploring policy scenarios.

Stress, Mental Health, and Burnout in National Humanitarian Aid Workers in Gulu, Northern Uganda

This study examined the mental health of national humanitarian aid workers in northern Uganda and contextual and organizational factors predicting well-being. A cross-sectional survey was conducted among 376 national staff working for 21 humanitarian aid agencies. Over 50% of workers experienced 5 or more categories of traumatic events. Although, in the absence of clinical interviews, no clinical diagnoses were able to be confirmed, 68%, 53%, and 26% of respondents reported symptom levels associated with high risk for depression, anxiety disorders, and posttraumatic stress disorder (PTSD), respectively. Between one quarter and one half of respondents reported symptom levels associated with high risk regarding measured dimensions of burnout. Female workers reported significantly more symptoms of anxiety, depression, PTSD, and emotional exhaustion than males. Workers with the United Nations and related agencies reported fewest symptoms. Higher levels of social support, stronger team cohesion, and reduced exposure to chronic stressors were associated with improved mental health. National humanitarian staff members in Gulu have high exposure to chronic and traumatic stress and high risk of a range of poor mental health outcomes. Given that work-related factors appear to influence the relationship between the two strategies are suggested to support the well-being of national staff working in such contexts.

Developing culturally relevant indicators of reintegration for girls, formerly associated with armed groups, in Sierra Leone using a participative ranking methodology

This article describes a participative ranking methodology for identifying local understanding of reintegration and adjustment of potential value in programme planning and evaluation. It was applied in the specific context of girls formerly associated with fighting forces in Sierra Leone. Fourteen discussion groups, utilizing spontaneous listing and participative ranking activities, within a focus group framework, were conducted in 10 communities. Discussions served to identify family support, marriage, involvement in communal activities and income generating activities as locally seen as significant indicators of a girls successful reintegration after the war. This method offers a flexible approach to identifying culturally relevant indictors of reintegration that have the potential for wide use in programme planning and evaluation.

Predeployment Mental Health and Trauma Exposure of Expatriate Humanitarian Aid Workers: Risk and Resilience Factors

Expatriate aid workers (n = 214) representing 19 nongovernmental organizations (NGOs) completed a predeployment survey, including measures of mental health (depression, anxiety, and posttraumatic stress disorder [PTSD]); risk factors (childhood trauma, family risk, and adult trauma exposure); and resilience factors (coping, social support, and healthy lifestyle) to assess their baseline mental health during preparation for deployment. Multiple regression analysis indicated that childhood trauma/family risk was not significantly related to depression, anxiety, or PTSD symptoms when controlling for report of prior mental illness; yet, adult trauma exposure was significantly related to all three. Social support contributed significant variance to depression and PTSD. NGOs can help applicants recognize the effects of recent trauma and the resilience provided by a healthy social network.

Child Protection Assessment in Humanitarian Emergencies: Case Studies from Georgia, Gaza, Haiti and Yemen.

OBJECTIVES The paper reviews the experiences of conducting child protection assessments across four humanitarian emergencies where violence and insecurity, directly or indirectly, posed a major threat to children. We seek to identify common themes emerging from these experiences and propose ways to guide the planning and implementation of assessments that effectively identify, and suggest means of response to, threats to childrens rights and well-being in emergency settings. METHODS In the context of a field evaluation of an inter-agency resource kit, crisis settings where an inter-agency assessment of child protection had been considered in the period August 2008 to July 2010 were identified. Email correspondence, telephone-based structured interviews and documentary review collated information from child protection coordinating agencies from a total of twenty sites, the minority of which had proceeded to complete an assessment. This paper presents case studies of the experience in Georgia (following the conflict between Russian and Georgian forces in August 2008), Gaza (following the Israeli military incursion beginning in December 2008), Haiti (following the earthquake of January 2010), and Yemen (following the ceasefire agreement between the government and rebel forces in early 2010). CASE STUDY FINDINGS: In each setting the context of the humanitarian emergency is outlined. The processes of the planning (and, where appropriate, implementation) of the child protection assessment is described. Where available, the findings of the child protection assessment and their use in shaping interventions are summarized. PRACTICE IMPLICATIONS Case studies document experience across humanitarian settings widely divergent in terms of the nature of the emergency, social-political context, and institutional capacity. Despite such differences, analysis suggests securing inter-agency coordination, preparation and capacity building, and means of ensuring timeliness of findings to be recurrent themes in the effective mobilization of an effective assessment able to inform programming.

Measuring the incidence and reporting of violence against women and girls in liberia using the 'neighborhood method'

BackgroundThis paper reports on the use of a “neighborhood method” to measure the nature and incidence of violence against women and girls in post-conflict Liberia.MethodsThe study population comprised females in Montserrado and Nimba counties. Study participants were randomly selected for interviews using multi-stage cluster sampling. 30 clusters of households were sampled in each county. Information on incidents of domestic violence and rape within the preceding 18 months was collected with regard to females of all ages in the respondent’s household, and those of her four closest neighbors to make up the full sample.FindingsHouseholds in the sample contained 7015 females (1687 girls, 4586 women, 742 age missing) in Montserrado and 6632 (2070 girls, 4167 women, 95 age missing) in Nimba. In the previous 18 months 54.1% (CI 53.1-55.1) and 55.8% (CI 54.8-56.8) of females in Montserrado and Nimba respectively were indicated to have experienced non-sexual domestic abuse; 19.4% (CI 18.6-20.2) and 26.0% (CI 25.1-26.9) of females in Montserrado and Nimba respectively to have been raped outside of marriage; and 72.3% (CI 70.7-73.9) and 73.8% (CI 72.0-75.7) of married or separated women in Montserrado and Nimba respectively to have experienced marital rape. Husbands and boyfriends were reported as the perpetrators of the vast majority of reported violence. Strangers were reported to account for less than 2% of the perpetrators of rape in either county. Incidents were most commonly disclosed to other family members or to friends and neighbors, and less often to formal authorities such as the police, court or community leaders. Incidents were approaching fifty times more likely to be reported to police if perpetrated by strangers rather than intimate partners.ConclusionsViolence against women and girls is widespread in the areas studied. Programming needs to address the fact that this violence is primarily occurring in the household, where most incidents go unreported outside the immediate family or social circle. Police and hospital reports severely under-represent these known perpetrators. Inter-interviewer variance and differences in reports for self and neighbors for some outcomes caution the precision and validity of some estimates. However, the potential utility of the neighborhood method for estimating prevalence rates with an accuracy suitable for programmatic purposes in conflict-affected and post-conflict settings is noted.

Children and fighting forces: 10 years on from Cape Town

It is 10 years since the adoption of the Cape Town Principles and Best Practices on the Prevention of Recruitment of Children into the Armed Forces and on Demobilization and Social Reintegration of Child Soldiers in Africa. The field of programming for the reintegration of children associated with armed forces and armed groups has made significant strides in this period. However, important gaps in the knowledge base remain. This paper examines empirical evidence that supports lessons learned from work with children formerly connected with fighting forces. It evaluates what is known, where promising practice exists, and lacunae in five programming areas: psychosocial support and care; community acceptance; education, training and livelihoods; inclusive programming for all war-affected children; and follow-up and monitoring. While the 2007 Paris Commitments to Protect Children from Unlawful Recruitment or Use by Armed Forces or Groups mark an emerging consensus on many issues, there is still a critical need for more systematic studies to develop the evidence base supporting intervention in this area.