Abstract
BackgroundMulti-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. We developed an integrated health and protection intervention to reduce psychological distress and intimate partner violence (IPV), and tested its delivery by lay facilitators in a low-resource refugee setting.MethodsFormative research to develop the intervention consisted of a structured desk review, consultation with experts and local stakeholders (refugee incentive workers, representatives of humanitarian agencies, and clinical experts), and qualitative interviews (40 free list interviews with refugees, 15 key informant interviews). Given existing efforts by humanitarian agencies to prevent gender-based violence in this particular refugee camp, including with (potential) perpetrators, we focused on a complementary effort to develop an integrated intervention with potential to reduce IPV and associated mental health impacts with female IPV survivors. We enrolled Congolese refugee women with elevated psychological distress and past-year histories of IPV (n = 60) who received the intervention delivered by trained and supervised lay refugee facilitators. Relevance, feasibility and acceptability of the intervention were evaluated through quantitative and qualitative interviews with participants. We assessed instrument test-retest reliability (n = 24), inter-rater reliability (n = 5 interviews), internal consistency, and construct validity (n = 60).ResultsWe designed an 8-session intervention, termed Nguvu (‘strength’), incorporating brief Cognitive Processing Therapy (focused on helping clients obtaining skills to overcome negative thoughts and self-perceptions and gain control over the impact these have on their lives) and Advocacy Counseling (focused on increasing autonomy, empowerment and strengthening linkages to community supports). On average, participants attended two-thirds of the sessions. In qualitative interviews, participants recommended adaptations to specific intervention components and provided recommendations regarding coordination, retention, safety concerns and intervention participation incentives. Analysis of the performance of outcome instruments overall revealed acceptable reliability and validity.ConclusionsWe found it feasible to develop and implement an integrated, multi-sectoral mental health and IPV intervention in a refugee camp setting. Implementation challenges were identified and may be informative for future implementation and evaluation of multi-sectoral strategies for populations facing ongoing adversity.Trial registrationISRCTN65771265, June 27, 2016.
Highlights
Multi-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants in settings of ongoing adversity
Phase 1: intervention design Desk review and site visit Findings from the desk review [60] and consultations with stakeholders during the site visit consistently reported that gender-based violence, intimate partner violence (IPV), was prevalent among Congolese women from the eastern Democratic Republic of the Congo (DRC), including refugees who were displaced from this region
The lack of and need for interventions addressing psychological distress in the context of IPV in Nyarugusu refugee camp was reaffirmed in discussions with representatives from UNHCR, the Tanzania Red Cross, International Rescue Committee, as well as refugee incentive workers
Summary
Multi-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. Refugees may experience a range of adversities, occurring in the period preceding displacement, during displacement, and in the post-migration environment [1, 2] Stressors can include both past and present potentially traumatic events (PTEs) (e.g., gender-based violence perpetrated by fighting forces; abduction; torture; disappearance of family members) as well as ongoing stressors (e.g., poverty, intimate partner and other forms of violence in refugee camps, lack of access to health care, post-migration living difficulties) [2,3,4,5]. Cultural norms and gender inequality may exacerbate the impact that these stressors have on psychosocial wellbeing, interpersonal relationships and violence, and coping strategies This becomes apparent in traditional patriarchal societies where conflict-related traumatic events and displacement may precipitate rapidly changing gender roles through financial instability, conflict-related violence, loss of identity, and other mechanisms [13]
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