Despite operating in a state of emergency, the RPCA deployed a well-trained local team to conduct research among a cross-sectional representative sample of adults at the height of the Ebola Virus Disease (EVD) epidemic (2014-2015) in order to examine how mental health and past trauma contributed to uptake of public health messages and participation in both risky and health promoting behavior among a community sample. Findings indicated that effects of war-related trauma on both EVD risk and EVD prevention behaviors are mediated through two key mental health variables: depression and post-traumatic stress symptoms.
A 17-year study of former child soldiers and other youth affected by war began in 2002. This longitudinal analysis demonstrated that poor mental health in former child soldiers resulted from both war-related trauma and post-conflict experiences such as stigma, social support, and access to school. It found that stressors such as childhood exposure to war/armed conflict are not deterministic and documented the need for greater attention to the post-conflict environment and the nature of family, peer, and community relationships that surround young people who have lived through war-related trauma. We are currently in the fourth phase of this project which includes data collection with the index sample and their intimate partners/children. This early research was critical to our subsequent work in Sierra Leone to develop and test the Youth Readiness Intervention (YRI).
Previously, research to address the mental health of war-affected youth had focused on classic elements of PTSD offering exposure-based PTSD treatment with little attention to the issues of anger and interpersonal difficulties that can impede future success as war-affected youth pursue educational and employment opportunities. Our research indicates that malleable protective factors (e.g., social support, staying in school, securing a livelihood) were key influences associated with better life outcomes and deserved priority attention in intervention development. The Youth Readiness Intervention (YRI) integrates six cognitive behavioral therapy-based practice elements, which are empirically supported and shown to have transdiagnostic efficacy across disorders ranging from major depressive disorder to PTSD and conduct disorders. The YRI is an integral part of our newest project ‘Youth FORWARD’.
Youth FORWARD (Youth Functioning and Organizational Success for West African Regional Development) will establish an implementation science hub in West Africa with a dual mission: (a) to accelerate scaling up innovative and sustainable delivery of evidence-based mental health interventions for youth exposed to violence and other forms of adversity across a range of delivery settings; and (b) to serve as a global hub for capacity building in mental health services research on children, youth and families facing adversity and to conduct implementation science on the delivery of evidence-based mental health services via alternate delivery systems such as youth employment programs in West Africa. Youth FORWARD will establish partnerships that leverage the expertise and resources of the Harvard T.H. Chan School of Public Health, University of Georgia College of Public Health, CARITAS, World Bank, the governments of Sierra Leone and Liberia, and a network of youth service providers and universities. A proposed Scale-Up Study will use a hybrid implementation- effectiveness trial design across N=24 youth employment programs to evaluate an innovative approach to training and supervision-Interagency Collaborative Teams (ICTs)-and their influence on integration, fidelity, cost and sustainment of a quality mental health intervention-the Youth Readiness Intervention (YRI)-into a national youth employment program-the Youth Employment Scheme (YES). The concurrent effectiveness trial will assess youth mental health, emotion regulation, functioning and economic self-sufficiency among N=960 Sierra Leonean male and female youth aged 15-24 over time to determine effects of the YRI when implemented under this new delivery platform. Guided by the EPIS implementation model, qualitative data on attitudes towards mental health and barriers and facilitators to the integration of mental health services into youth employment programs will be collected. A Capacity Building Core will build sustainable capacity to conduct and apply mental health services and implementation research by fostering exchange and mutual learning between sites, through the development and delivery of innovative and locally relevant training and technical assistance programs for stakeholders including West African faculty, students, government partners, and NGO leaders. Links between the Scale-Up Study and Capacity Building Core will provide opportunities for on-the-job learning in quantitative and qualitative research to increase capacity for implementation science. These capacity building efforts will accelerate the scale up of evidence-based mental health programs to address the treatment gap in West Africa and will help government stakeholders make greater use of the evidence-base in policy and program development and evaluation methods to measure program effectiveness.
The proposed study links with and leverages an ongoing scale up study of a cognitive behavioral therapy (CBT) based intervention, the Youth Readiness Intervention (YRI), among youth facing adversity in Sierra Leone that is currently being implemented in partnership with the Government of Sierra Leone (GoSL) and the Gesellschaft für Internationale Zusammenarbeit (GIZ). The YRI has demonstrated feasibility and effectiveness for improving emotion regulation and daily functioning in youth. This study aims to harness the mechanisms of natural diffusion of CBT techniques learned among peer groups and spillover phenomenon in reduction of burden to cohabitating caregivers. Preliminary studies of the YRI in Sierra Leone indicate both mechanisms occur. Researchers from the Boston College School of Social Work will examine the potential of the YRI to reach a larger segment of the population by examining the extent to which indirect effects result in measureable incremental health benefits (symptoms and functioning) among nonparticipants. Study aims are to investigate (1) mechanism of diffusion—the untargeted and unplanned spread of new practices among social network members—of YRI components and mental health benefits experienced by nonparticipant peers who learn YRI practices from YRI participants; (2) indirect mental health benefits experienced by nonparticipants among cohabitating caregivers of YRI participants (spillover effects); and (c) incremental health costs and benefits among YRI participants' caregivers and peers through cost-effectiveness and return on investment analysis. Study design includes a control group (current YRI participants and YRI nonparticipants). YRI participants and control participants who consent to the current study will nominate 3 peers in their social networks aged 18-24 and will also identify their primary cohabitating caregiver. Following consent, peers and caregivers will be assessed at baseline and 6-month follow-up on mental health, emotion regulation, daily functioning, and sense of burden (caregivers only). Study outcomes also incorporate common indicators for implementation science, including measures of project context, evaluation, and scale-up, to enhance knowledge exchange across global research networks. Assessing implementation research outcomes, including penetration of YRI effects and cost-effectiveness of the YRI as distinct outcomes will provide key information about the success of YRI implementation, thereby supporting decisions about whether to increase scale up efforts in Sub-Saharan Africa and other LMICs. Findings on diffusion of the YRI will inform the feasibility of peer-led interventions and the development of additional educational materials to amplify YRI components identified as most transferrable. Findings on spillover effects will inform the potential reach and penetration of evidence-based practices in LMICs. Lessons learned will inform the GoSL, GIZ, and development actors on investing in evidence-based mental health interventions in low-resource settings.