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Evidence-based mental health and psychosocial support in humanitarian settings: gaps and opportunities
  1. Wietse A Tol1,
  2. Mark van Ommeren2
  1. 1Global Health Initiative, Yale University (New Haven, CT) & HealthNet TPO, Amsterdam, The Netherlands
  2. 2Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
  1. Correspondence to Wietse A Tol, Global Health Initiative, Yale University (New Haven, CT) Hillhouse Avenue, New Haven, CT 06520-8206; wietse.tol{at}yale.edu

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Research in humanitarian settings – referred to here as areas affected by disasters and armed conflicts – has shown diverse impacts of such crises on the mental health and psychosocial well-being of populations. These consequences range from resilience (good mental health despite exposure to significant adversity), non-disordered psychological distress, to increased mental disorders, including anxiety (eg, post-traumatic stress disorder (PTSD)), depressive, and substance use disorders.1,,3 In addition, mental health practitioners in humanitarian settings frequently encounter people with severe pre-existing neuropsychiatric disorders (eg, psychotic disorders and epilepsy).4 Moreover, disasters and armed conflicts have been shown to impact the social conditions that shape mental health, through increased poverty, threats to human rights, domestic and community violence and changed social relations.5

To address negative impacts, mental health and psychosocial support (MHPSS) programmes are increasingly a standard component of humanitarian response. MHPSS has been defined as ‘any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder’.6 There appears to be increasing consensus on best practices, as indicated by the publication of two sets of international guidelines; the 2007 Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings6 and the 2011 Sphere Handbook.7

In this editorial, we discuss the emerging field of MHPSS from the perspective of evidence-based practice. We describe challenges to evidence-based MHPSS practice, and highlight areas where concerted action may either (A) improve the quality of MHPSS programming (by basing decision-making on research findings) and/or (B) improve MHPSS research efforts (by making the pursuit of reliable and valid knowledge more responsive to needs of affected populations). We structure the discussion in accordance with steps of the programme cycle where empirical evidence may support decision-making, that is needs assessment; programme design; implementation, monitoring and evaluation.

MHPSS needs assessment

A key principle of evidence-based medicine is that ‘the clinical problem – rather than habit or protocol – should determine what type of evidence is sought.’8 This principle puts the focus squarely on the process of who defines what the main problem is and how this is done. Research efforts in the MHPSS field aimed at defining the problem have traditionally mostly consisted of psychiatric epidemiological studies, in which PTSD has been studied as the most important mental health consequence of humanitarian crises. The focus in much of this research has been on correlating exposure to circumscribed crisis-related events to PTSD symptoms.

Significant controversy, however, has surrounded the question whether PTSD is the most crucial public health outcome in humanitarian settings. To illustrate, a recent research priority setting study requested an interdisciplinary group of researchers and practitioners broadly representative of regions affected by humanitarian settings (n=136) to name their top five research questions. Only 6% of the 733 generated research questions concerned traumatic stress. Furthermore, the final top 10 most highly prioritised research questions from this study – with over 80% agreement that these questions were ‘essential’ to address in the coming 10 years – included six questions relevant to problem analysis and assessment.9 ,10 In addition to a focus on a broader range of mental disorders and psychosocial issues, the resulting research agenda emphasises the inclusion of perspectives from affected populations and sensitivity to socio-cultural issues in defining mental health and psychosocial problems, needs and capacities in humanitarian settings. Promising developments that may be helpful in realising this consensus-based research agenda include mixed methods approaches to assess stressors and needs.11 ,12 The WHO and the United Nations High Commissioner of Refugees have recently developed a mixed methods toolkit for needs assessment.13

MHPSS programme design

In selecting MHPSS interventions to target identified problems, evidence-based practice prescribes that decisions are based on the best available evidence.8 The Inter-Agency Standing Committee MHPSS Guidelines and Sphere Handbook envision MHPSS services in a four-layered pyramid, in which services become more specialised and focused towards to the tip of the pyramid. From the bottom of the pyramid, MHPSS interventions include ‘social considerations in basic services and security’ (eg, advocating that water and sanitation services respect cultural norms), ‘strengthening community and family supports’ (eg, providing opportunities for locally appropriate mourning), ‘focused non-specialised supports’ (eg, mental health services delivered by community health workers), and ‘specialised services’ (eg, therapeutic services offered by trained professionals). Current research efforts, however, are heavily skewed towards the top two layers of the pyramid.

A recent review compared currently popular practices (through grey literature review and analysis of funding) with the evidence for effective MHPSS practices (a systematic review and meta-analysis of controlled intervention studies). The most rigorous available evidence currently supports practices that are less likely to be implemented, that is specialised interventions for PTSD and depressive outcomes. Very little evidence (3 out of 32 controlled evaluation studies) exists for interventions at the bottom two layers, even though community-based supports, structured social activities and child-friendly spaces are among the most popularly implemented.14 An important area for future research, therefore, will be to strengthen evidence for the bottom two layers of the pyramid. Similarly, practices for which strong evidence exists should be implemented more widely where relevant based on identified needs. The above-cited research agenda also prioritises research that examines adaptation of existing MHPSS interventions across socio-cultural settings.9

This gap between research and practice raises the question on the role of the randomised controlled trial (RCT) – the gold standard in evidence-based practice – in research in humanitarian settings. RCTs require clearly defined outcome measures; reliable and valid measures; a manualised replicable and specific treatment programme; unbiased assignment to intervention; and adherence to treatment,15 all of which are more challenging when evaluating social interventions in real-life community setting.16 Although the RCT remains the gold standard also when evaluating social interventions, much more preparatory work and adaptation is required. For example, extensive mixed methods research may be required to strengthen formation of a theory of change and to prepare measures that capture intended outcomes in culturally sensitive, reliable and valid ways. Furthermore, RCTs in this area require multiple time-points in order to conduct multi-level analyses (eg, to assess if interventions have had intended effects on neighbourhood-level variables such as improved social cohesion), and to evaluate moderators and mediators of interventions (eg, to assess if a hypothesised improved social cohesion in turn is associated with improved individual well-being).

However, given both the significant resources these approaches require and the current glaring gap in evidence, meanwhile diverse, pragmatic evaluations should be implemented, including qualitative process evaluations and quasi-experimental research. It is here that collaborations between researchers and practitioners could provide a crucial window of opportunity, through strengthening the capacity of local, national and international organisations to systematically monitor and evaluate implementation of interventions.

Implementation, monitoring and evaluation

Research can make a valuable contribution to improving the implementation of MHPSS interventions, for example by determining how evidence-based MHPSS interventions can effectively be disseminated, by evaluating the effectiveness of capacity building, and by examining what factors determine uptake of interventions. Such ‘implementation science’, in the general health field is an emerging field of science.17

The area of programme monitoring and evaluation requires collaboration between researchers and practitioners in humanitarian crises. A key area of concern here are limitations with the mental health research capacity in low- and middle-income countries.18 Strategies to strengthen such capacity in the field of global mental health include research training programmes as integral part of intervention projects, longer-term secondments, mentorships, and joint projects between academic partners in high and low-resource settings.19 In humanitarian settings particularly, such capacity building should be directed also to organisations that respond to humanitarian crises. Collaboration between academic institutions and humanitarian responders could lead to expanded rigorous monitoring and evaluation of interventions in practice. Such improvement would partly depend on convincing humanitarian donors to fund evaluation of the longer-term outcomes of interventions (as opposed to immediate project outputs).

Previous such collaborations have, for instance, resulted in improved knowledge on therapist burden, costs associated with care, client satisfaction with interventions, knowledge increase after training, and client flow through programmes.20 Researchers have also focused on strengthening monitoring and evaluation measures (which was considered a key priority in aforementioned consensus-based MHPSS research agenda),21 culturally sensitive measurement of mental health22 ,23 and functioning.24 ,25

Conclusion

In summary, an evidence-based practice perspective strengthens MHPSS interventions in humanitarian settings by (A) improving assessment efforts to take a broader look at needs in humanitarian settings; (B) generating evidence about which design of programmes work best for whom and under what circumstances; and (C) strengthen the tools for monitoring, evaluation and implementation science. This will require closer collaboration between researchers and practitioners, in order for practitioners to make decisions based on the best evidence available, and for researchers to produce evidence that is maximally relevant to practice. We argue that marrying a commitment to principles of evidence-based practice on the one hand with a central focus on the relevance of research activities for MHPSS practices on the other hand is essential to benefit the quality and impact of interventions in humanitarian settings.

References

Footnotes

  • Competing interests None.