1. 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

2. Presentation Contents 1.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

3. Background/ Rationale 1.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

4. 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

5. Criteria for research techniques 1.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

6. How criteria are addressed 1.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

7. 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

8. 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

9. 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

10. Development of tools: screening Research aims: -Development of brief multi-informant screener based on broad ‘psychosocial distress’ construct (multi-indicator: vulnerability & resilience) -Test validity & reliability of screener Methods: -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

11. Development of tools: screening Results: -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

12. Development of tools: function impairment Research 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

13. 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

14. Treatment mechanisms: n=1 Research 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

15. Treatment mechanisms: n=1 Results: Detailed changes in wellbeing (multiple indicators) over time can be observed per child Specific intervention components can be linked to changes in wellbeing

16. Treatment mechanisms: LGM Research 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

17. 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