Abstract
Background: Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most. Methods: We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasi-randomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed with rating scales administered immediately (0–4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods. This study is registered with PROSPERO, number CRD42013006960. Findings: We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] −0·33, 95% CI −0·52 to −0·14) that was maintained at follow-up (–0·21, −0·42 to −0·01). We also identified benefits at the endpoint for functional impairment (–0·29, −0·43 to −0·15) and for strengths: coping (–0·22, −0·43 to −0·02), hope (–0·29, −0·48 to −0·09), and social support (–0·27, −0·52 to −0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15–18 years (–0·43, −0·63 to −0·23), in non-displaced children (–0·40, −0·52 to −0·27), and in children living in smaller households (<6 members; −0·27, −0·42 to −0·11). Interpretation: Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. Funding: European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship) and the National Institute on Aging.
| Original language | English (US) |
|---|---|
| Pages (from-to) | e390-e400 |
| Journal | The Lancet Global Health |
| Volume | 6 |
| Issue number | 4 |
| DOIs | |
| State | Published - Apr 2018 |
ASJC Scopus subject areas
- Medicine(all)
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In: The Lancet Global Health, Vol. 6, No. 4, 04.2018, p. e390-e400.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - Focused psychosocial interventions for children in low-resource humanitarian settings
T2 - a systematic review and individual participant data meta-analysis
AU - Purgato, Marianna
AU - Gross, Alden L.
AU - Betancourt, Theresa
AU - Bolton, Paul
AU - Bonetto, Chiara
AU - Gastaldon, Chiara
AU - Gordon, James
AU - O'Callaghan, Paul
AU - Papola, Davide
AU - Peltonen, Kirsi
AU - Punamaki, Raija Leena
AU - Richards, Justin
AU - Staples, Julie K.
AU - Unterhitzenberger, Johanna
AU - van Ommeren, Mark
AU - de Jong, Joop
AU - Jordans, Mark J.D.
AU - Tol, Wietse A.
AU - Barbui, Corrado
N1 - Funding Information: To our knowledge, this analysis of IPD from more than 3000 children and adolescents represents the largest synthesis of evidence with rigorous standards of systematic review and IPD meta-analysis comparing focused psychosocial support interventions versus control condition in children exposed to traumatic events in humanitarian settings in LMICs. Focused psychosocial support interventions appeared to have a beneficial effect on PTSD symptoms, which was maintained at follow-up. Our findings have the following limitations. First, we included interventions with broadly similar aims and methods in countries with similar income status. However, the diversity of approaches and the different sociocultural and health-care system contexts in which these interventions were implemented might have contributed to the identified heterogeneity in results. For example, the sociocultural groups included in the 11 trials are likely to have used different cultural concepts of distress with a different overlap between cultural concepts of distress and the symptoms measured through checklists, resulting in differences in precision with which locally relevant symptoms were assessed. Second, there appears to be a mismatch between some of the stated aims of included studies and the chosen outcome measures. For instance, whereas several studies claim a central focus on prevention (eg, by targeting strengths hypothesised to protect children and adolescents against developing psychological symptoms at further exposure to adversity), most studies used a reduction in psychological symptoms as primary outcomes (instead of a reduction of incidence of symptoms). We would encourage evaluation of preventive interventions to measure incidence of new psychological distress and disorders over longer follow-up periods, as well as testing whether targeted strengths are associated with reduced incidence as hypothesised. Third, our meta-analysis included focused psychosocial support interventions, in accordance with consensus-based language commonly used by international humanitarian practitioners. However, the included studies evaluated interventions with different targeting procedures and content, defying easy categorisation and thus requiring some variability in boundaries. For example, some studies 43 have features of clinical interventions whereas others 44 have features of IASC pyramid level two interventions (family and community supports). Also, most studies 12,37–41 evaluated interventions with populations screened for psychological distress, without excluding children scoring very high on symptom measures. Without comparing the focused psychosocial support interventions to more formalised psychotherapeutic clinical interventions, we cannot directly determine what type of intervention might be more effective for children who are likely to meet formal diagnostic criteria. Fourth, due to the brevity of the RCTs, we are unable to draw conclusions regarding maintenance of symptom reduction in the long term after trial completion. Fifth, we did not collect data on fidelity to intervention protocols among treated participants that might have contributed to the observed statistical heterogeneity. Sixth, from a methodological point of view, the absence of masking in the included RCTs might be considered a source of bias and heterogeneity between studies, as no masking in RCTs is an important threat to the objectivity of the findings. In studies evaluating complex psychosocial interventions, maintaining masking to intervention allocation is challenging, and assessor independence needs to be considered when interpreting results. Finally, we cannot exclude investigator bias as some of the published reports of the RCTs have a co-author who helped develop the intervention. Notwithstanding these limitations, this study resulted in important findings. A major finding of our analysis is that focused psychosocial support interventions are effective in reducing PTSD symptoms both at endpoint and at follow-up, whereas no effect was identified for depressive and anxiety symptoms. These results are consistent with results from a systematic review 48 that used standard meta-analysis to evaluate the effectiveness of a broad range of MHPSS interventions, including clinical interventions, for PTSD and depression in children exposed to mass violence. Our work additionally analysed outcomes that focused on strengths, a focus prioritised by humanitarian practitioners 49 but often ignored in evaluation studies, including those studies in humanitarian settings. Our meta-analyses showed an effect of focused psychosocial support interventions over waiting list on coping, hope, and social support. We also found intervention benefits for reducing functional impairment. Previous individual studies of focused psychosocial interventions in humanitarian settings in LMICs have shown complex and sometimes conflicting results. For example, in an RCT 39 of a classroom-based psychosocial intervention in Sri Lanka, post-hoc analysis found that subgroups of girls in the waitlist arm showed better trajectories on PTSD symptoms compared with the intervention arm, whereas in the post-hoc analysis of an RCT 12 of the same intervention in Indonesia girls in the intervention arm showed a larger improvement than boys for this outcome. To shed light on such inconsistent findings, we did IPD meta-analyses exploring subgroups defined by variables of gender, age, displacement, region, and household size. We found that interventions were effective across gender, age, and displacement status, but that they were more effective for particular subgroups, that is, children aged 15–18 years, non-displaced children, and children living in smaller households. Unlike previous single RCTs, we did not find different intervention benefits by gender. These findings show the importance of not concluding prematurely from post-hoc subgroup analyses of single RCTs that are underpowered for identifying subgroup effects. The finding that older children benefitted more from intervention deserves further research—eg, the analysis of qualitative process evaluations of younger and older participants or further quantitative analysis of associations of age with other characteristics, but might potentially be explained by the fact that most interventions had cognitive behavioural elements. These interventions might hypothetically be more easily implemented with cognitively more developed older youth. The finding with regard to lower effects of intervention in displaced populations is in line with socioecological theory. The ecological theory developed by Bronfenbrenner 50 examines child development within the context of different levels of the social environment, from macrosystem to microsystem—ie, considering influences on child development from the level of overall culture and society, to the smallest and immediate environment in which the child interacts regularly, comprising home and peer group. In accordance with this framework, it can be hypothesised that a focused psychosocial support intervention would have greater benefits for children that can rely on higher levels of protective factors (eg, smaller households might have more financial and social resources for each member) and who have to face lower levels of risk factors (eg, displaced children will be more likely to confront ongoing stressors). 51 These findings raise important questions around intervention design. For example, developing focused psychosocial support interventions according to basic demographic characteristics of the target population (eg, age, displacement status, and household size) could possibly be useful in optimising scarce resources and maximising benefits. Simultaneously, restricting the intervention to particular subgroups has ethical implications and requires reliable and potentially complex targeting procedures. Additional research, aimed at unpacking the effective ingredients of focused psychosocial interventions would be helpful to identify which intervention components might be more likely to be universally effective and which more contextually dependent. Our present work also has some important strengths. First, the focus on strengths as well as symptoms in the included intervention makes the review interesting from a public mental health perspective. The identified effects of focused psychosocial support interventions on children's strengths are promising, because these kind of interventions were developed to improve wellbeing broadly, in larger groups of children in accessible settings. Second, a methodological strength of this study is the IRT approach, used for the first time in an IPD meta-analysis. Despite the analytic complexity of the approach, harmonisation of outcome scores based on factor analyses consistent with IRT is appropriate when questions assessing the outcomes vary across studies because the approach facilitates, in an appropriate way, using all available questions. The approach does this in two ways. (i) Relative weights of questions for each outcome in the factor score are based on correlations with other items, thus upweighting questions more relevant to the construct of interest. (ii) The IRT approach simultaneously identifies an appropriate relative placement of thresholds of specific questions, as explained in the Methods. The approach is ultimately extendable not only to other studies that have some (but not necessarily all) questions in common for a domain, but also to differing assessments over developmental time periods. 52 The use of the IRT approach and the inclusion of trials with a randomised design might have reduced the potential cultural biases related to the different sociocultural and health-care system contexts in which the interventions were delivered. Finally, we were able to collect individual participant's data from 100% of the included RCTs, a major strength for this methodology, because often IPD meta-analyses are able to collect participant data only for a fraction of the available evidence. In conclusion, through the analysis of pooled data from more than 3000 children and adolescents affected by humanitarian crises, we were able to precisely estimate the intervention benefits of focused psychosocial support interventions across 11 RCTs in low-resource settings. We found broad intervention benefits for symptoms of PTSD (both at immediate follow-up and mid-term follow-up), for multiple strengths (coping, hope, and social support), and for functional impairment. Intervention effects were stronger for older, non-displaced children and for children living in smaller households. Contributors MP, CBa, and WAT designed the study. MP and CBa drafted the manuscript. WAT, TB, PB, DP, CG, JG, PO'C, KP, R-LP, JR, JKS, JU, and MJDJ contributed to the database preparation and double check. ALG and CBo analysed data. MP, DP, and CG assessed the quality of evidence. MvO and JdJ critically revised the manuscript. All authors commented on and approved the draft and final manuscripts. The authors alone are responsible for the views expressed in this Article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. Declaration of interests We declare no competing interests. Acknowledgments MP was supported by the European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship [acronym CHILD TRAUMA IN LMIC], proposal number 626466). ALG was supported by K01-AG050699 from the National Institute on Aging. Publisher Copyright: © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license
PY - 2018/4
Y1 - 2018/4
N2 - Background: Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most. Methods: We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasi-randomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed with rating scales administered immediately (0–4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods. This study is registered with PROSPERO, number CRD42013006960. Findings: We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] −0·33, 95% CI −0·52 to −0·14) that was maintained at follow-up (–0·21, −0·42 to −0·01). We also identified benefits at the endpoint for functional impairment (–0·29, −0·43 to −0·15) and for strengths: coping (–0·22, −0·43 to −0·02), hope (–0·29, −0·48 to −0·09), and social support (–0·27, −0·52 to −0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15–18 years (–0·43, −0·63 to −0·23), in non-displaced children (–0·40, −0·52 to −0·27), and in children living in smaller households (<6 members; −0·27, −0·42 to −0·11). Interpretation: Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. Funding: European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship) and the National Institute on Aging.
AB - Background: Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most. Methods: We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasi-randomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed with rating scales administered immediately (0–4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods. This study is registered with PROSPERO, number CRD42013006960. Findings: We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] −0·33, 95% CI −0·52 to −0·14) that was maintained at follow-up (–0·21, −0·42 to −0·01). We also identified benefits at the endpoint for functional impairment (–0·29, −0·43 to −0·15) and for strengths: coping (–0·22, −0·43 to −0·02), hope (–0·29, −0·48 to −0·09), and social support (–0·27, −0·52 to −0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15–18 years (–0·43, −0·63 to −0·23), in non-displaced children (–0·40, −0·52 to −0·27), and in children living in smaller households (<6 members; −0·27, −0·42 to −0·11). Interpretation: Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. Funding: European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship) and the National Institute on Aging.
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U2 - 10.1016/S2214-109X(18)30046-9
DO - 10.1016/S2214-109X(18)30046-9
M3 - Article
C2 - 29530422
AN - SCOPUS:85043242246
SN - 2214-109X
VL - 6
SP - e390-e400
JO - The Lancet Global Health
JF - The Lancet Global Health
IS - 4
ER -