Children of War: Implementation of Non-Specialist Mental Health Interventions

Saturday, 29 July 2017

Adria Spinelli, BSN
School of Nursing, University of North Carolina Chapel Hill School of Nursing, Chapel Hill, NC, USA
Jennifer Leeman, DrPH
School of Nursing, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, USA
Gillian Litynski, BSN
School of Nursing, University of North Carolina Chapel Hill, Chapel Hill, NC, USA

Purpose:  Over one billion children live in countries or territories affected by armed conflict or war. Of these, 88.9% of those events occur within Low and Middle Income Countries (UNHCR, 2015; Uppsala Conflict Data Program, 2015). A growing number of mental health interventions exist that reduce children’s trauma symptoms with varied levels of effectiveness (Betancourt, Meyers-Phki, Charrow, & Tol, 2013; Barry, Clarke, Jenkins, & Patel, 2013). Frequently, nurses and other health care professionals who are not specialized in mental health are providing these interventions (Jordans, Pigott, & Tol, 2016). A possible reason for interventions’ varied effectiveness is inconsistent implementation. The purpose of this review is to determine the extent to which implementation findings are reported, according to Fixsen’s Core Components for Implementation, among interventions provided to children affected by armed conflict.

Methods: A search was performed using PubMed, CINHAL, and PsycINFO to identify empirical studies testing mental health interventions for children in conflict who experienced a traumatic event. The search combined key words and MeSH terms related to “conflict” or “war” or “refugee” with those for “mental health” or “psychosocial” “interventions”. The date range for articles was October 2011 – November 2016. Studies were examined if they occurred in a Low or Middle Income Country and the study sample was children. Data were extracted on intervention type, study design, sample demographics, information on the intervention and outcome data. To describe implementation, data was extracted on implementation strategies (based on Fixsen’s implementation components; e.g., training, coaching, staff performance evaluation); implementation outcomes (based on Proctor’s taxonomy; e.g., fidelity, feasibility); and on contextual factors that influenced implementation (Fixsen, Blase, Naoom, & Wallace, 2009; Proctor et al., 2011).

Results:  The initial search produced 450 studies of which 54 underwent full text review and 20 met inclusion criteria. The interventions occurred in Palestine, Sudan, Nepal, Rwanda, Democratic Republic of the Congo, Uganda, Burundi, Indonesia, Sri Lanka and Bosnia and Herzegovina. Countries included those in armed conflict and post conflict. The interventions included Cognitive Behavioral Therapy (CBT), Trauma-Focused CBT, Classroom-Based CBT, Writing Therapy and Child-Friendly Spaces. Authors provided only limited information on the strategies used to implement interventions, intervention outcomes, and contextual factors that influenced implementation. Less than half of the interventions reported activities that fall within Fixsen’s Core Components for Implementation.

Conclusion:  Few studies reported implementation strategies and none of the studies mentioned implementation theories or frameworks that guided the research. This is problematic because effectiveness of these interventions could increase if implementation strategies were used. For instance, effectiveness of mental health interventions in the U.S. has increased by using implementation techniques (Kilbourne et al., 2014). Prior to conducting research using implementation techniques, research is needed to understand which of those techniques are best suited for nurses and other non-specialized health workers. Ultimately, by using implementation technqiues, intervention effectiveness will increase and could improve the well-being of children affected by armed conflict in Low and Middle Income Countries.