No abstract

BackgroundStrengthening the evidence base for humanitarian interventions that provide psychosocial support to war‐affected youth is a key priority. We tested the impacts of an 8‐week programme of structured activities informed by a profound stress attunement (PSA) framework (Advancing Adolescents), delivered in group‐format to 12–18 year‐olds in communities heavily affected by the Syrian crisis. We included both Syrian refugee and Jordanian youth.MethodsWe followed an experimental design, comparing treatment youth and wait‐list controls over two programme implementation cycles, randomizing to study arm in cycle 2 (ClinicalTrials.gov ID: NCT03012451). We measured insecurity, distress, mental health difficulties, prosocial behaviour and post‐traumatic stress symptoms at three time‐points: baseline (n = 817 youth; 55% Syrian, 43% female), postintervention (n = 463; 54% Syrian, 47% female), and follow‐up (n = 212, 58% Syrian, 43% female). Regression models assessed: prospective intervention impacts, adjusting for baseline scores, trauma exposure, age, and gender; differential impacts across levels of trauma exposure and activity‐based modality; and sustained recovery 1 year later. We analysed cycle‐specific and cycle‐pooled data for youth exclusively engaged in Advancing Adolescents and for the intent‐to‐treat sample.ResultsWe found medium to small effect sizes for all psychosocial outcomes, namely Human Insecurity (β = −7.04 (95% CI: −10.90, −3.17), Cohen's d = −0.4), Human Distress (β = −5.78 (−9.02, −2.54), d = −0.3), and Perceived Stress (β = −1.92 (−3.05, −0.79), d = −0.3); and two secondary mental health outcomes (AYMH: β = −3.35 (−4.68, −2.02), d = −0.4; SDQ: β = −1.46 (−2.42, −0.50), d = −0.2). We found no programme impacts for prosocial behaviour or post‐traumatic stress reactions. Beneficial impacts were stronger for youth with exposure to four trauma events or more. While symptoms alleviated for both intervention and control groups over time, there were sustained effects of the intervention on Human Insecurity.ConclusionsFindings strengthen the evidence base for mental health and psychosocial programming for a generation affected by conflict and forced displacement. We discuss implications for programme implementation and evaluation research.

BackgroundPatients’ reported opinions of the health system need to be understood in order to provide patient-centered care. We investigated determinants of women’s ratings of the quality of care during their most recent facility delivery.MethodsWe conducted a census of all deliveries in the 6 weeks to 12 months preceding the survey, in villages served by 24 primary care clinics in rural Pwani Region, Tanzania. Women who had delivered children in a study facility were included in this analysis (n = 855). We interviewed women about demographic and obstetric factors and the quality of their obstetric care using a structured questionnaire. We created a composite index of perceived quality from six quality questions. We also assessed the functioning of the local health clinic using structured surveys. We used a multi-level model to analyze factors associated with women’s rating of the quality of care during delivery.Results14% of respondents rated the overall quality of care received during delivery as excellent. Women who listened to the radio daily reported lower quality composite scores (β: -0.99, p < 0.001). Women who reported receiving more services in ANC had higher quality scores (β: 0.46, p = 0.001), as did women receiving more delivery services (β: 0.55, p < 0.001). Women who reported disrespect and abuse during delivery had significantly lower quality scores (β: -4.13, p < 0.001).ConclusionsA woman’s expectations and prior and current experiences influence her perception of the quality of care she received. Health facility characteristics did not influence ratings of overall quality. Focusing on improving the process rather than inputs of service delivery during ANC visits and delivery may increase perceived quality of delivery care in low-resource settings.Trial registrationISRCTN17107760

Objectives To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage. Methods Cross-sectional data from a population-based survey of women residing in rural areas of Pwani Region were linked to health facility locations. We fitted multi-level logistic models to examine individual and community factors associated with home delivery. Results 752 (27.95%) of the 2691 women who completed the survey delivered their last child at home. Women were less likely to deliver at home if they had any primary education (odds ratio [OR] 0.62; 95% confidence interval [CI]: 0.50, 0.79), were primiparous (OR: 0.52; 95% CI: 0.37, 0.73), had more exposure to media (OR: 0.80; 95% CI: 0.66, 0.96), or had received more (OR: 0.78; 95% CI: 0.63, 0.96) or better quality antenatal care (ANC) services (OR: 0.48; 95% CI: 0.34, 0.67). Increased wealth was strongly associated with lower odds of home delivery (OR: 0.27; 95% CI: 0.18, 0.39), as was living in a village that grew cash crops (OR: 0.56; 95% CI: 0.35, 0.88). Farther distance to hospital, but not to lower level facilities, was associated with higher likelihood of home delivery (OR 2.49; 95% CI: 1.60, 3.88). Conclusions Poverty, multiparity, weak ANC, and distance to hospital were associated with persistence of home delivery in a region with high coverage of facility delivery. A pro-poor path to universal coverage of safe delivery requires a greater focus on quality of care and more intensive outreach to poor and multiparous women.

BackgroundLittle is known about violence against children in refugee camps and settlements, and the evidence-base concerning mental health outcomes of youth in refugee settings in low and middle-income countries is similarly small. Evidence is needed to understand patterns of violence against children in refugee camps, and associations with adverse mental health outcomes.MethodsSurveys were conducted with adolescent refugees (aged 13–17) in two refugee contexts – Kiziba Camp, Rwanda (n = 129) (refugees from Democratic Republic of Congo) and Adjumani and Kiryandongo refugee settlements, Uganda (n = 471) (refugees from South Sudan). Latent Class Analysis was utilized to identify classes of violence exposure (including exposure to witnessing household violence, verbal abuse, physical violence and sexual violence). Logistic regressions explored the association between latent class of violence exposure and symptoms of depression and anxiety.ResultsIn Rwanda, a two-class solution was identified, with Class 1 (n = 33) representing high levels of exposure to violence and Class 2 (n = 96) representing low levels of exposure. In Uganda, a three-class solution was identified: Class 1 (high violence; n = 53), Class 2 (low violence, n = 100) and Class 3 (no violence, n = 317). Logistic regression analyses indicated that latent violence class was associated with increased odds of high anxiety symptoms in Rwanda (AOR 3.56, 95% CI 1.16–0.95), and high v. no violence class was associated with depression (AOR 3.97, 95% CI 1.07–7.61) and anxiety symptoms (AOR 2.04, 95% CI 1.05–3.96) in Uganda.ConclusionsThe present results support the existing evidence-base concerning the association between violence and adverse mental health outcomes, while identifying differences in patterns and associations between refugee youth in two different contexts.