Introduction

According to several studies, Intimate Partner Violence (IPV) is the most common form of violence against women, exposing them to mental health issues such as post-traumatic stress disorder (PTSD), depression, anxiety, and eating disorders.

Women become even more vulnerable to IPV in humanitarian settings such as refugee camps (Hossain et al, 2020), where studies have shown the incidence of mental health issues is three times higher than settings unaffected by conflict (Greene M. et. al., 2021). Yet, despite the prevalence of mental health issues among refugees, few studies have focused on their causes and ways to mitigate them, especially among refugee populations in low- and middle-income countries (LMICs).

A new study by M. Claire Greene, Samuel Likindikoki et. al. sheds some light on this issue by providing evidence on the evaluation of an integrated intervention to reduce psychological distress and IPV among refugee women. The intervention, named Nguvu, a Kiswahili term for strength and power, was developed in 2010 in the eastern Democratic Republic of Congo (DRC) and implemented later in the Nyarugusu refugee camp in northwestern Tanzania in 2017.

In this post, I highlight the intervention approach as well as study findings and implications, which I believe are valuable because they highlight the efficacy of tailoring mental health approaches to meet the needs of survivors of IPV in a humanitarian setting.

Background

Target Area and Population

As of 2018, 150,000 refugees resided at the Ngyarugusu refugee camp in northwestern Tanzania. Most of the refugees in the camp came from countries like Burundi and the DRC. Local women’s groups in the camp organized to support the strengthening of social networks and provide skills training like cooking, financial planning and loans, and weaving, among other services. Given the large size of the refugee camp, the International Rescue Committee facilitated the organization of women’s groups into villages within the camp.

Intervention

For the targeted population, the Nguvu intervention integrated Cognitive Processing Therapy (CPT), a cognitive-behavioral therapy that focuses on trauma, previously found effective in assessing Congolese women that lived in the DRC (Bass J et al., 2013). as well as social support and advocacy counseling, which included information about coping with IPV.

A total of eight sessions were delivered weekly over an eight-week period. The CPT utilized in this intervention was a modified version with six sessions and two advocacy counseling sessions combined. The sessions began with an individual consultation by one facilitator, followed by seven weekly group sessions including 6-13 women moderated by a pair of facilitators.

The primary outcomes of the intervention, psychological distress and IPV, were measured using an Abuse Assessment Screening based on the Hopkins Symptoms Checklist and Harvard Trauma Questionnaire. This screening assessed physical and sexual violence and psychological distress including anxiety, depression, and PTSD.

Study Design

M. Claire Greene and Samuel Likindikoki et. al. conducted a cluster randomized controlled trial in the Ngyarugusu refugee camp from April to September 2017. The trial evaluated the relevance, acceptability, and feasibility of the Nguvu intervention in addition to its effectiveness in a complex refugee setting.

The researchers screened a total of 401 women who were part of 43 operational women’s groups in the camp, and ultimately enrolled 311 women into the intervention. Women were enrolled based on having reported experiencing IPV in the year prior as well as elevated psychological distress. A total of 96 participants were ineligible, and some more were unable to enroll or inaccurately assessed. Randomization of the 43 groups led to 21 groups enrolled in the Nguvu intervention group (158 women), and 22 groups (153 women) enrolled in the control group of usual care conditions.

The experimental groups received the prescribed Nguvu intervention treatment, while the control group received usual care with a simple, unrestricted randomization approach through different investigators. The women in the control group received information about protection and mental health services in Nyarugusu. The Abuse Assessment Screening was conducted at baseline and end line. The end line was nine weeks post-enrollment. A task-shifting approach was utilized during implementation of the intervention. Congolese refugees who worked as incentive workers providing support for social services in the camp were utilized as research assistants. The incentive workers had no prior experience about the implementation of psychological interventions except for basic psychological support program. however, they were provided with 10 days of training sessions.

Findings

Outcomes

At baseline, participants indicated elevated psychological distress and IPV-related injury (67.2 percent psychological; 82.3 percent physical and/or 95.2 percent sexual) in the past two weeks. However, symptoms seemed higher among the control group than those in the group treated with the Nguvu intervention.

Over time, there was a change in primary outcomes. The reduction of psychological distress and IPV severity was moderate along with small changes in functioning, such as the ability to complete common life tasks. The end line showed lower psychological distress for all outcomes (depression, anxiety, PTSD, and frequency of sexual IPV) in the Nguvu intervention group in comparison to control group. However, the differences were not significant overall for functional impairment or IPV from baseline to end line in both the groups. This result was partly due to the complexity and sensitivity of the change in mental health attributed to various external factors such as changes in participant’s living conditions.

Acceptability

Acceptability of the intervention, measured based on how many people participated in the sessions, had mixed results since more than 58.2 percent of participants in the Nguvu intervention completed all the sessions. Here, the average session attendance was 5.4 out of 8 sessions. The mixed results are likely due to limited feasibility of the intervention, indicated by a high attrition rate of 11.6 percent loss in follow-up for the Nguvu group and 13.5 percent for the control group.

Analysis

The implemented Nguvu intervention is useful to understanding mental health issues among IPV survivors in humanitarian settings. However, despite limited acceptability and feasibility, the intervention provides a promising approach that can be modified to identify adverse events and avoid high attrition. According to the researchers, the low attendance was partially due to the severity of IPV profiles that made it difficult for the participants to attend all the sessions. The variations in attendance, thus, influenced the outcomes.

Despite these shortcomings, the strengths of the intervention lay in its modified version and utilization of CPT and advocacy counseling, as well as its use of a task-shifting approach while supporting local involvement in the intervention. These tools might be useful in other humanitarian settings.

For example, intervention implementers provided resources to locals, such as training Congolese refugees with some previous experience in mental health assessment as research assistants for recruitment and assessment procedures. I believe this inclusion ensures local involvement during the intervention, which is important for a contextual and local perspective during the implementation of an intervention.

This intervention also included a task-shifting approach with the utilization of lay refugee incentive workers which might be helpful in humanitarian settings where trained professionals are often lacking. However, as mentioned in the study, the inclusion of incentive workers also brought some inaccuracy in the data collection process. Therefore, thorough training might be necessary with a detailed explanation of the expectations from the researchers.

Lastly, although the outcomes shed light on the intersection of IPV and mental health issues in conflict-affected settings, they also revealed shortcomings that warrant further research, especially concerning approaches for ensuring consistent participation by the targeted population.

Photo credit: Jessica Scranton/FHI 360

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