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Mental health and wellbeing after humanitarian emergencies: what do we know about support programmes for children and young people in low- and middle-income countries?

By UCL Global Youth, on 6 November 2017

To celebrate Humanitarian Evidence Week (6-12th November), we have a guest blog post by Kelly Dickson and Mukdarut Bangpan, EPPI-Centre, Social Science Research Unit, UCL Institute of Education

Figure 1_v2The United Nations Children’s Fund estimate that a quarter of the world’s children are living in countries affected by conflict or natural disasters. We know that these events can have a long-term impact on children’s and young people’s mental health and psychosocial wellbeing, and while many programmes have been designed to support children and young people dealing with the consequences, our knowledge of what works and why is still developing. To address this gap, Oxfam and the Feinstein International Center humanitarian evidence programme, commissioned us, as part of a wider review, to draw together a synthesis of outcome evaluations from across the world to gain a view of research effort in this area. Our review sought to capture the full range of approaches taken to provide mental health and psychosocial support (MHPSS) for children and young people (CYP) in countries affected by conflict or natural disasters, and the outcomes they seek to improve.

What did we find?
We found that evaluations of MHPSS programmes for children and young people are still relatively new with few conducted before 2004, and most appearing in the last five years. A rich diversity of approaches are currently being tested for their efficacy, measuring a wide range of outcomes. For example, programmes might incorporate trauma-focused approaches e.g. using psychological techniques tailored to meet the needs of CYP experiencing emotional and psychological difficulties or take a strength-based approach, focusing on CYP’s individual resilience and family and social networks to develop positive coping strategies.

Common psychotherapeutic modalities such as cognitive behaviour therapy or narrative exposure therapy were most likely to address and measure mental health outcomes such as post-traumatic stress disorder, depression, functioning or anxiety. They also measured psychosocial outcomes such as pro-social behaviours (e.g. actions which benefit someone other than yourself) and, less frequently, hope and resilience. Psychosocial programmes were similarly ambitious in their aims, measuring a range of both mental health and psychosocial outcomes.

Figure 1 Types of programmes and outcomes measured

figure 2_v2

Of the 45 MHPSS programmes identified in our review, many took advantage of whole-school or classroom-based settings to deliver programmes to children and young people in groups rather than 1:1 settings. Although not possible to outline each programme in detail, two case examples, indicative of the need for support, programme components and outcomes measured in the field, are provided below:

MHPSS after the 2008 earthquake in Sichuan province, China
A large number of young people were exposed to the harrowing events of the 2008 earthquake in the Sichuan province, China. Many of those who survived showed signs of being extremely fearful and anxious and went on to develop psychological problems, such as post-traumatic stress disorder (PTSD) and depression. In 2010, a short-term (six sessions) group cognitive behaviour programme was designed to support adolescents, who had lost one or both parents, manage trauma-based fears and negative thought patterns. The programme aimed to teach young people relaxation techniques and imagination skills, such as finding a ‘safe place’ in their mind. They were also supported to cope with intrusive flashbacks through guided meditation and nightmares through dream intervention exercises.

The programme needed to be adapted from the original manual (‘Children and Disaster: Teaching Recovery Techniques’, initially developed by the Norway, Foundation for Children and War) to ensure it was suitable to a Chinese context. Firstly, by removing exploration of avoidance behaviours, as they are often viewed as important adaptive strategies, to help people cope with change. Secondly by including the use of culturally specific examples of how to view events, ideas and emotions in a more positive way (cognitive re-framing). The aim of the programme was not only to ameliorate symptoms of PTSD and depression, but also to provide young people with the psychological resilience to recover and thrive as they made the transition from adolescence to adulthood.

MHPSS in conflict-affected contexts
War affected communities in the Democratic Republic of Congo continue to live under constant threat of attack and/or abduction by militia operating in the region. Growing up in armed conflict settings can destabilise familial relations and lead to emotional and behavioural difficulties in children and young people. To improve CYP’s mental health and psychosocial outcomes, (such as PTSD, conduct problems, prosocial behaviours) a family focused, community-based psychosocial intervention was designed for children aged 7–18. Programme activities included: psychoeducation about the impact of war, a life skills leadership course, relaxation techniques and mental imagery exercises, effective communication and conflict resolution skills and short video clips to address discrimination and stigma towards former child soldiers who had returned to the community.

Programmes activities were adapted to be culturally familiar to the local population by using culturally familiar songs, games and rituals, and drawing on local cultural and spiritual beliefs about how to address MHPSS well-being. The programme was also highly relational, focusing on building positive and trusting relationships with young people and enhancing community ties. Programme providers sought to encourage positive family interactions and community acceptance through these approaches to help mediate and improve the mental health and psychosocial of war affected youth.

Theory as a missing link
However, despite these efforts to build an empirical evidence base, studies commonly lack an explicit description of the programme theory underpinning their design. Further theorisation on the links between programme aims and focus, choice of programme components, delivery and anticipated mechanisms for improving outcomes for CYP could provide a more nuanced understanding of how and why MHPSS may or may not work. This programme theorization could also benefit from an understanding of how characteristics of young people, such as age, gender or other individual or social characteristics also interact with and mediate the impact of programmes in natural disaster and war affected settings.

HEW Logo V2How did we get these findings?

We conducted a comprehensive search of 12 bibliographic databases and 25 websites. We included studies published in English from 1980 onwards, if they delivered MHPSS programmes to one group of children in LMIC and compared their findings against another group of children who did not participate in a programme. To find out more about the systematic review and evidence on the effectiveness of programmes, please see the evidence summary of the full report here.

Acknowledgements

The research was funded by The Humanitarian Evidence and Communications Programme (HEP), a partnership between Oxfam and the Feinstein International Center, Tufts University on behalf of the Department for International Development. To find out more about the systematic review and evidence on the effectiveness of programmes, please see the evidence summary of the full report.

 

The multiple roles that young people play in conflict-affected contexts

By Dr Laila Kadiwal, on 2 June 2017

Increasingly, attention is being directed internationally to the important role of youth in violence and conflict. In my research with the Research Consortium on Education and Peacebuilding on youth in armed conflict-affected settings, I have noticed that there are five roles that are commonly ascribed to young people in contexts of violent conflict.

Youth model

Youth as perpetrators of violent conflict: This perspective sees young people as risks, threats and active agents in perpetuating conflict and in undermining national or international security. Youth are often described as soldiers, combatants, fighters, terrorists, militants, rebel, abductors, suicide bombers, drug dealers, gang members, violent extremists, and criminals.

Youth as victims in violent conflict: Conflict affects young people negatively in many ways. According to recent figures, more than 25 million young people are currently living in crisis situations (UNICEF 2016). Conflict violates their basic human right – namely, ‘the right to life, liberty and security of person’. They are at increased risk of being killed, injured, orphaned, abducted, or raped in conflict. They are also often forced into roles that make them even more vulnerable, such as: providers of sexual services, couriers, cooks, spies, child soldiers, unwilling abductees and suicide bombers. Most of the young people in zones of conflict are cut off from sustained humanitarian aid and basic services. Studies suggest that conflict hugely harms young people even psychologically as they experience strong feelings of guilt, fear, desire for vengeance and an overwhelming sense of loss and hopelessness in conflict.

Youth as bystanders in peace processes: This perspective views youth mainly as passive onlookers in conflict and peace processes. Many conflict contexts do not have the institutional apparatuses, resources, and /or political will to involve young people or address youth issues, which results in a marginalization of youth from dialogue and reform. Youth are frequently accorded an implicit and indirect place within broader international and governmental initiatives (Lopes Cardozo, et al. 2016).

Youth as an asset in peace processes: Despite this, a substantial policy discourse, promoted more recently by international and local actors, revolves around viewing young people as resourceful agents for rebuilding communities, state and society. Young people are characterized as leaders, ‘capital’ and assets. The findings of the Research Consortium on Education and Peacebuilding from four conflict contexts suggest that the economic dimensions of youth agency receive the most emphasis within the broader national and international economic policies. Youth is often narrowly conceived as an economic asset, whose primary role is to support the neoliberal agenda of the national and international elites rather than as critical agents who question the very basis of inequalities and conflict.

Youth as peacebuilders: This perspective views a youth as a transformative agent, who mitigate social, economic and political drivers of conflict for just and sustainable peace. The characterisation of youth as peacebuilders does not reductively see their role as merely ensuring ‘negative peace’ (as the absence of war and violence), or ‘liberal peace’ (as the promotion of democracy and free trade) but enables them to play a critical role in challenging the root causes of violent conflict. It is this role which receives the least attention in contemporary peace processes.

peace youth

Problems with the descriptions of youth in conflict
While the above labels serve as analytical categories, in practice their application is contextual, incoherent, and problematic in at least three ways.

First, in different contexts and settings, a youth may simultaneously play multiple roles. An armed youth could be seen as both a terrorist and a victim of the broader structure. This means that youths’ peacebuilding agency cannot be understood in isolation to how their surroundings influence them and in turn how they influence their environment.

Secondly, different actors ascribe different labels to the youth depending on their interests and agenda. For instance, earlier this year, I attended a Sikh Vaisakhi festival at a Gurudwara (a Sikh place of worship) near London. Inside, I saw photos of young men that were killed in a violent conflict with the Indian army during the 1970s and ‘80s. While the Sikh diaspora of this Gurudwara venerated these youth as holy martyrs, who sacrificed their lives for an independent Sikh homeland, the state of India view them as militants whose separatist rebellion threatened the national integrity.

Thirdly, different notions of peace underpin different assumptions about the role of youth in conflict. Whether peace means maintaining security, promoting free trade, implementing democracy or promoting a more transformational process determines how the role of youth is viewed in peace process.

In short, youth are simultaneously seen as threats, victims, bystanders, assets and socially conscious actors in conflict and peace processes and these contrasting views tell us of the very different (and often contradictory) roles that are ascribed to young people in conflict by different actors.

The shifting roles of youth in post-conflict Cote d’Ivoire: the role of political discussion and intergenerational learning

By UCL Global Youth, on 5 May 2017

Posted by Dr Marika Tsolakis, ESRC Global Challenges Research Fund Postdoctoral Fellow

Marika

 

Côte d’Ivoire provides an important example of how youth and elders are navigating new realities in a post-conflict era through participation in community-based discussion groups called agoras and grins. These spaces helped to propel youth to the forefront of the country’s political crisis in the 1990s and 2000s and, alongside youth militias, facilitated the manipulation and instrumentalisation of youth in violent conflict.

My recent study of 38 agoras and grins included 118 observation hours and 30 in-depth interviews sheds some light on how youth and elders live and learn together in these spaces. In particular, I found that inter-generational activities can benefit both younger and older people and can contribute to reconstruction at a societal level. These findings suggest that ‘youth’ oriented peace projects should consider a multi-age approach.

Youth Identity in Local Political Discussion Groups

In 2010-2011, Côte d’Ivoire experienced four months of post-electoral violence that resulted in over 3,000 fatalities. This was the culmination of a decade of political divisions that cut across ethnic, religious and regional differences. Since 2011, attempts at peace and reconciliation have had varying levels of efficacy and youth violence has steadily increased.

A dynamic culture of public discussion and debate was cultivated over these tumultuous decades, through public discussion forums called agoras and grins. Agoras generally supported the former president Laurent Gbagbo, now on trial at the International Criminal Court, and at the height of the crisis each space amassed hundreds of people in vacant lots or squares to listen to speakers deliberate on political issues. Over 300 agoras (also known as parlements and Sorbonnes) sprang up during the crisis, and most met on a daily basis.

Grins, on the other hand, consisted of smaller familiar groupings, traditionally of men, who would discuss pressing issues during a three-cup tea ceremony. Members of these spaces generally supported then-opposition leader and current president Alassane Ouattara and often identified as Muslim, Northern Ivoirian, or/ of foreign origin. This demographic had suffered discrimination and suppression under the Gbagbo regime.

In both agoras and grins, young (predominantly male) people often eschewed tradition to become speakers and leaders, reflecting their newly enhanced agency as politically powerful actors.

Different age, different knowledge 

My research found that agoras and grins remained relevant sites of intergenerational learning three years after the post-electoral crisis. Members of both groups acknowledged that each individual, regardless of age, contributed to a discussion space through life experience, religious devotion, profession or otherwise. One young male agora member reported that in their agora, ‘things weren’t done by age anymore,’ indicating a shift from prevalent societal norms.

Rather, members attributed ‘young’ knowledge to matters of technology (specifically on-the-job knowledge) and other skills, sometimes including literacy. In some cases, it also related to political insider information or analysis. On the other hand, elder knowledge generally consisted of life skills, religion, cultural values, and professional networks.

Youth, particularly in grins, sought discussion spaces with older members. Displaced from their families due to conflict or poverty, they desired contact with adults to ‘stay on track’ and to avoid veering towards new forms of violence and social exclusion.

We say what we want, but with manners

However, participants of all ages admitted to following certain age-based protocols. For example, youth could disagree with elders in debate, but it involved following delicate processes of ‘manners’ and politeness in arguing one’s point.

One grin member explained, ‘there are certain behaviours to have. In front of elders…. Me, for example who is 40 years old, won’t talk to someone who is 60 as if I was talking to my equal.’ This 40-year old was an elder to some, but to his seniors he still need to respect age-based hierarchical norms.

Elders, however, felt a responsibility to teach younger members with an attitude of care, love and respect. A Quranic school teacher who hosted a grin felt that learning could not happen in the absence of a loving environment, evoking concepts prevalent in critical pedagogy and dialogic education.

Creating Creative Leadership Solutions

In order to maintain this delicate age balance, agoras and grins found new ways to allocate leadership roles. A 28-year old male grin member explained that ‘for things to work,’ elders occupied a leadership board called the Council of Wise Men, whereas younger members held the more modern positions of President, Secretary and Treasurer.

I observed this creative strategy in a number of spaces and noted that it permitted youth leadership without devaluing older members’ contributions.

Intergenerational Approaches to Reconciliation               

Many post-conflict projects in Côte d’Ivoire and beyond focus on youth empowerment and dialogue. However, this study illustrates that youth often place a high value on the opinions and knowledge of their older counterparts and actively seek out spaces of interaction in their daily life. Multigenerational approaches could not only appeal to younger participants but also facilitate a broader societal healing.

More so, elders in Côte d’Ivoire may not face the same social and economic vulnerabilities that youth do, especially in terms of fear of retaliation. Although the political crisis has abated, one participant explained that young people are ‘still scared,’ unlike old people who had not participated in violence or divisive speech that could invite retaliation or indictment. This fear was compounded by the wider political climate, in which peace and justice has not been accomplished by the current Ouattara regime. A perception of ‘two-speed justice’ and discrimination against ethnicities that traditionally supported Gbagbo has meant that some youth have hesitated from voicing opinions unfavourable to the government or associating with agoras.

However, this project found that intergenerational spaces of dialogue and learning can help to protect young people from further violence through mentorship and access to safety networks. Community-based projects such as these could thus be a useful model for other post-conflict settings to use to help to re-integrate youth after violence and political upheaval.