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Meta-Analysis
. 2024 May 21;5(5):CD014300.
doi: 10.1002/14651858.CD014300.pub2.

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

Davide Papola  1   2   3 , Eleonora Prina  1   2 , Caterina Ceccarelli  4 , Camilla Cadorin  1   2 , Chiara Gastaldon  1   2   5 , Madalena C Ferreira  6 , Wietse A Tol  7   8 , Mark van Ommeren  9 , Corrado Barbui  1   2 , Marianna Purgato  1   2
Affiliations
Meta-Analysis

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

Davide Papola et al. Cochrane Database Syst Rev. .

Abstract

Background: Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.

Objectives: To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.

Search methods: We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.

Selection criteria: Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.

Main results: We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.

Authors' conclusions: To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

PubMed Disclaimer

Conflict of interest statement

DP: declares a grant from the European Commission HORIZON‐MSCA‐2021‐PF‐01 research programme (grant agreement No 101061648) to the University of Verona, which has control over it. The funder had no role in the design, conduct or decision to publish the review.

EP: none.

CCec: works for SOS Children's Villages Italy.

CCad: none.

CG: none.

MCF: Public Health Medical Resident at the Public Health Unit in Portugal.

WAT: none.

MvO: works for the WHO.

CB: works as a psychiatrist at the University of Verona and is affiliated with the WHO. He is the Co‐ordinator for Cochrane Global Mental Health and Editor with Cochrane Common Mental Disorders. He was not involved in the editorial process for this review.

MP: none.

The review authors alone are responsible for the views expressed in this article, which do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 1: Mental well‐being at study endpoint: children
1.2
1.2. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 2: Mental well‐being at follow‐up: children
1.3
1.3. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 3: Mental well‐being at study endpoint: adults
1.4
1.4. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 4: Mental well‐being at follow‐up: adults
1.5
1.5. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 5: Functioning at study endpoint: children
1.6
1.6. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 6: Functioning at follow‐up: children
1.7
1.7. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 7: Resilience at study endpoint: children
1.8
1.8. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 8: Resilience at follow‐up: children
1.9
1.9. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 9: Coping at study endpoint: children
1.10
1.10. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 10: Hope at study endpoint: children
1.11
1.11. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 11: Prosocial behaviour at study endpoint: children
1.12
1.12. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 12: Prosocial behaviour at follow‐up: children
1.13
1.13. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 13: Acceptability at study endpoint: children
1.14
1.14. Analysis
Comparison 1: Psychological and social interventions versus control, Outcome 14: Acceptability at study endpoint: adults
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Neville 2022 {published data only}
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Orengo‐Aguayo 2022 {published data only}
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Sangraula 2020 {published data only}
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Sangraula 2023 {published data only}
    1. NCT05477355. Adapting Group PM+ for Venezuelan refugees and migrants in Colombia [Increasing mental health and psychosocial social support for Venezuelan refugees and migrants: adapting group problem management plus (Group PM+) for Venezuelan refugees and migrants in Colombia]. clinicaltrials.gov/study/NCT05477355 (first received 28 July 2022).
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Tam 2020 {published data only}
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Tol 2008 {published data only}
    1. Tol WA, Komproe IH, Susanty D, Jordans MJ, Macy RD, De Jong JT. School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial. JAMA 2008;300(6):655-62. [DOI: 10.1001/jama.300.6.655] - DOI - PubMed
Tol 2014 {published data only}
    1. Tol WA, Komproe IH, Jordans MJ, Ndayisaba A, Ntamutumba P, Sipsma H, et al. School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial. BMC Medicine 2014;12:56. [DOI: 10.1186/1741-7015-12-56] - DOI - PMC - PubMed
Tol 2020 {published data only}
    1. Tol WA, Leku MR, Lakin DP, Carswell K, Augustinavicius J, Adaku A, et al. Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. Lancet Global Health 2020;8(2):e254-63. [DOI: 10.1016/S2214-109X(19)30504-2] - DOI - PMC - PubMed
Weiss 2015 {published data only}
    1. Weiss WM, Murray LK, Zangana GA, Mahmooth Z, Kaysen D, Dorsey S, et al. Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial. BMC Psychiatry 2015;15:249. [DOI: 10.1186/s12888-015-0622-7] - DOI - PMC - PubMed
Welton‐Mitchell 2018 {published data only}
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References to studies awaiting assessment

ACTRN12618000892213 {published data only}
    1. ACTRN12618000892213. Developing and evaluating a parent-level intervention to address child mental health needs in humanitarian contexts. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375118 (first received 25 May 2018).
NCT03760627 {published data only}
    1. NCT03760627. Evaluation of a mindfulness resiliency training program for refugees living in Jordan. clinicaltrials.gov/show/NCT03760627 (first received 16 November 2018).

References to ongoing studies

Jansen 2022 {published data only}
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