IACAPAP 2008 Istanbul

Bridging research and practice for designing psychosocial interventions with children

affected by political violence

Wietse A. Tol - HealthNet TPO/ VU University Amsterdam

Mark J.D. Jordans - HealthNet TPO/ VU University Amsterdam

Ivan H. Komproe - HealthNet TPO, Amsterdam

Joop T.V.M. de Jong - VU University Amsterdam/ Boston University School of Medicine

Presentation Contents1. Introduction

– Background & rationale

– Objectives & criteria

2. Combining qualitative and quantitative methodology– Rapid ethnographic research preceding evaluation

3. Constructing new instrumentation– Screening tool

– Assessment of function impairment

4. Studying treatment mechanisms– Case studies

– Advanced statistical methods

5. Conclusion

Background/ Rationale1. Very little public mental health research (epidemiological,

evaluation, etc.) in LAMIC interventionists left in dark when designing programs

2. Cross-cultural debates:– Importance of PTSD

– Validity of DSM-IV constructs

– Resilience vs. vulnerability

3. Different public health setting– Lack of human resources in LAMIC

– Different prioritization of needs

Objective

• To present an overview of a number of research methods to support the design of psychosocial interventions for children affected by war in low- and middle-income countries

Criteria for research techniques1. Aimed at creating an evidence base for LAMIC

– Evaluate interventions in a new setting/ exploratory phase

– Look for treatment mechanisms for possible adaptation

2. Aimed at being contextually valid– Adapted and new tools necessary & assess psychometric properties

– Assess vulnerabilities (i.e. psychosocial problems) and resources (e.g. available healing traditions & help-seeking strategies)

3. Address local public mental health issues– Work with paraprofessionals

– Screen larger groups of children, rather than focus on specific disorders

– Not assume needs, but assess local priorities

– Impossible to control external variables as in academic clinic

How criteria are addressed1. Combining qualitative and quantitative methods

– Rapid ethnographic study preceding randomized controlled trials

2. Development of new instrumentation– Screening tool

– Function impairment

3. Explore working mechanisms of treatment– Case study methodology (n=1)

– Latent growth curve modeling

Combining qualitative & quantitative research methods

Research aims: – Assess context before randomized controlled trials

– Research questions: A) How do people perceive and prioritize the impact of political violence on children’s psychosocial wellbeing? B) What kind of methods are people employing to deal with this impact?

Methods:– Focus Group Discussions with children, parents, and teachers

– Semi-structured interviews with children and families affected by political violence

– Key Informant interviews with community members providing care for children affected by political violence

Results:• Increase contextual validity, i.e. avoiding ‘category fallacy’

– Selecting instrumentation for CRT e.g. social capital in Burundi

– Adapting instrumentation for CRT adding locally relevant items to DSM constructs, e.g. somatic ‘trauma’ items in Indonesia

– Constructing new instrumentation for CRT lists of locally relevant idioms, e.g. supernatural complaints in Burundi (witchcraft, poisoning, posession

Combining qualitative & quantitative research methods

• Can help in guiding conducting & interpreting quantitative analyses

– Latent Growth Curve Modeling can be guided by qualitative results

– extensive damage to complete socio-ecological system in Burundi

• Can help in formulating hypotheses for effective adaptations of interventions

– somatic items in Indonesia not addressed, but shown as important in qualitative research

– Place mental health needs within the broader impact of political violence in communities, e.g. addressing poverty/ reconciliation needs in Indonesia

Combining qualitative & quantitative research methods

Development of tools: screeningResearch aims:- Development of brief multi-informant screener based on

broad ‘psychosocial distress’ construct (multi-indicator: vulnerability & resilience)

- Test validity & reliability of screenerMethods:- Common template with 7 questions on exposure, non-

specific distress, coping, social support and school attendance

- Inclusion of child & teacher perspectives (social ecology)- Contextualized through inclusion of locally salient probes,

identified through Focus Groups

Development of tools: screeningResults:

- Contextualized tool with good psychometric properties- Concurrent validity (n=65): AUC for caseness .81 (.84 sens/ .60 spec)

- Construct validity (n=2240): robust & invariant factor structure using multi-sample factor analysis

- Cross-cultural validity (n=10019) of psychosocial distress construct across settings (3 out of 4 countries) with context specific deviations and robustness of such common underlying theoretical 3-factor structure within the 3 countries

- Reliability: TRR=.83

- Able to detect children with (mild) psychosocial distress, to identify children in need for secondary or tertiary prevention interventions

- Easy to use by paraprofessionals and for large-scale interventions (i.e. CBI), albeit with contextual adaptations

Development of tools: function impairmentResearch aims:

• Develop a short rating scale that assesses impairment in functioning

• Include contextually salient daily activities

• Test reliability & validity of scale

Methods:

• Adaptation of Bolton & Tang (2002)

• Three steps:– Brief participant observation

– Diaries

– Focus groups

Results:

• Rating scales with good psychometric properties (Bur/Ind):– Convergent and discriminant validity (mild to moderate correlations

with symptom and resilience constructs)

– Construct validity (good fit of theoretical factor structure)

– Reliability: IC: .801/ .772; TRR:.731/ .783; IRR: 1.00/ .99

• Assess mental health needs that are associated with impairment in contextually relevant daily activities

• Move beyond debated DSM constructs to assess efficacy of interventions in relation to functioning

Development of tools: function impairment

Treatment mechanisms: n=1Research aims:• Monitor client progress• Increased understanding of mechanisms of change (e.g.

specific intervention strategies, session narrative, treatment perception, # sessions, socio-demographics, life events) during psychosocial counseling; i.e. the how of change

Methods:• Series of single case studies with select group of children

(Bur n=11, Sud n=7)• Repeated assessments per child (pre[4]-during[8]-post[4])• Assessment of symptoms & open questions on session

content and treatment perception

Treatment mechanisms: n=1Results:• Detailed changes in wellbeing

(multiple indicators) over time can be observed per child

• Specific intervention components can be linked to changes in wellbeing

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Case Number

0,00

10,00

20,00

30,00

40,00

50,00

60,00

Valu

e

dsrs total 18 items (recoded)

anx total scared 37 items

sdq total (recoded)

cpss total 17 items

chs total 6 items

Treatment mechanisms: LGMResearch aims:

• Explore influence of socio-demographics on change during treatment

• Explore influence of possible treatment mechanisms, like changed coping/ social support

• Identify subgroups with specific longitudinal trajectories

• Correct for cluster effects and external variables

Methods:

• Model change in terms of a) a starting point (the intercept) and b) growth over time

• Identify those factors that influence (a) and (b) through a structural equation modeling approach

Conclusion• Rigorous research is possible in instable, low-income

settings

• In our opinion, research can greatly benefit the development and evaluation of interventions, especially a) in a field where the evidence base is weak, b) where basic assumptions are debated

• Advocate for multi-method research methods