Phase 2: Rapid qualitative assessment
Through free listing, we identified 95 mental health problems. After categorization, the most frequently mentioned mental health problems and concerns associated with violence are described in Table 3 along with Smith’s Salience Index.
Table 3
Main mental health problems and concerns related to violence
Themes
|
Overall frequency (%)
|
Frequency (Female)
|
Frequency (Male)
|
Average rank
|
Salience
|
Mental health problems
|
Worry
|
54.8
|
61.8
|
46.4
|
3.09
|
0.434
|
Stress
|
40.3
|
50
|
28.6
|
3.24
|
0.318
|
Depression
|
37.1
|
32.4
|
42.9
|
4.04
|
0.275
|
Sadness
|
32.3
|
32.4
|
32.1
|
2.35
|
0.272
|
Shame
|
32.3
|
38.2
|
25
|
2.75
|
0.258
|
Fear
|
27.4
|
23.5
|
32.1
|
3.82
|
0.197
|
Anger
|
27.4
|
23.5
|
32.1
|
2.53
|
0.231
|
Dwelling over thoughts
|
24.2
|
23.5
|
25
|
4.47
|
0.162
|
Crying
|
21
|
26.4
|
14.3
|
3.46
|
0.169
|
Negative worldview & frustration
|
19.4
|
26.5
|
10.7
|
5.25
|
0.123
|
Experiences of violence
|
Physical punishment
|
43.5
|
41.2
|
46.4
|
7.44
|
0.186
|
Witnessing traumatic events
|
27.4
|
17.6
|
39.3
|
5.18
|
0.17
|
Rape and sexual violence
|
19.4
|
23.5
|
14.3
|
5.17
|
0.104
|
Mistreatment or abuse
|
14.5
|
11.8
|
17.9
|
8
|
0.051
|
Fighting in the community
|
12.9
|
8.8
|
17.9
|
6.75
|
0.046
|
Priority mental health concerns: ‘Worry’ was reported to be the most salient mental health problem (salience index 0.434) amongst adolescent girls and boys, reported by nearly 55% of the respondents as amongst the top three problems experienced by early adolescents. Further, 40% and 37% of the participants reported that ‘stress’ and ‘sadness’ respectively were amongst the main five problems experienced by adolescents. The frequency of report of ‘stress’ was higher for women and girls at 50 compared with frequency of report by men and boys at 28.6, and the frequency of report of ‘depression’ was higher amongst men and boys (frequency = 42.9) compared with women and girls (frequency = 32.4). A third of the participants shared that ‘sadness’ and ‘shame’ were amongst the top three problems of Burundian refugee adolescents in Tanzania, with a higher number of females reporting this.
While a large proportion of the adolescent participants reported sadness as a top problem (44%), only 18% of the adult participants recognised this as a concern in need of priority attention, whereas anxiety-related difficulties were recognised more frequently by caregivers. Other relevant psychosocial distress complaints were ‘fear’, ‘anger’, ‘dwelling over thoughts’ with each problem reported by a quarter of the participants and frequency of report being similar across youth and adults.
Main problems associated with violence: The top problem associated with violence was ‘physical punishment’ for both boys and girls, reported by 43.5% of the respondents. ‘Witnessing traumatic events’ as a top problem was highlighted by over a quarter of the participants with a significantly higher number of reports by boys and men (frequency = 39.3) as compared with girls and women (frequency = 17.6); however, narratives of sexual violence as traumatic experiences for young adolescents were common and amongst the top five problems faced by girls (frequency = 23.5) in this community.
Impact on daily activities: In order to better contextualize findings with regard to mental health of Burundian refugee adolescents, we aimed to learn more about how girls and boys spent their time in Mtendeli refugee camp, and which activities were most affected when they experienced mental health difficulties. Girls and boys reported their main activities as water collection, carrying firewood, cleaning, washing, cooking, praying, playing and studying. Water collection and carrying firewood were associated with risks of sexual violence for girls and boys. In addition, while girls were involved in household farming activities and were responsible for caring for their younger siblings, boys worked in brick-making and were expected to engage in household income generating activities. For boys, this implied leaving the camp for work (which may potentially expose them to a range of psychosocial and protection risks, including violence).
An ‘intelligent’, ‘polite’ and ‘obedient’ adolescent was described as a girl/boy doing well, and being good at studies, doing daily chores (e.g., cleaning), and being an effective communicator were important indicators of this. Caregivers’ responses indicated that they assessed boys’ well-being through outward indicators, such as playing, eating and smiling, but found it more difficult to identify characteristics of girls who were doing well. Therefore, it can be gathered that parents found it more challenging to identify signs of emotional problems and well-being of adolescent girls, who typically had fewer opportunities to play and interact with others.
Ways of coping: Nearly three fourths of the participants described two main ways of coping: a) praying and other religious practices to deal with stressors of camp life, and b) seeking support from camp-based health and protection services provided by humanitarian organisations. Over two thirds of the adolescents reported seeking advice from elders in the community, demonstrating the key role of respected community members in providing support. Additionally, over 40% described their preferred way of coping with psychosocial difficulties as working towards meeting their basic needs (e.g., food and school materials such as books, pencils, bag etc.), and 40% also described spending time with friends and family as a way of coping. Other coping strategies were thinking of a better future, being encouraging of each other, going to school, forgiving others, staying away from ‘bad’ company, and being patient. A potentially unhelpful or maladaptive coping strategy which was commonly reported was ‘not talking about one’s problems’.
Preferences: A preliminary exploration was conducted on the preferences for provider characteristics and delivery of the intervention. In summary, preferences were for the provider to take on a training and advisory function and be able to collaborate with community leaders. It was important that they were perceived as trustworthy by the community and that sessions be held at a convenient and safe place that was easy to access. Examples are discussed below.
First, the provider was seen as a trainer for adolescents and caregivers. For example, a mother shared, ‘The facilitator would be someone who trains parents on how they can help their children with their problems, and also trains children on how to behave during a time of difficulties’. It was important for parents that the intervention involved teaching adolescents the value of obedience and respect towards elders and community leaders, which was congruent with the characteristics of adolescents doing well. In a community affected by political and community violence, hatred was a common theme and both young people and caregivers suggested that improved social relationships were a desirable outcome of a psychosocial intervention.
Preferred provider characteristics included ‘being merciful’, ‘loving towards children’ and being ‘trusted by everyone’. Familiarity with community members and engagement with local leaders (e.g., block leaders, zone leaders, religious leaders) whose role was to ‘advise, instruct, and assist’ was reported to be crucial by caregivers. Religious leaders suggested that the team of facilitators include people from diverse backgrounds, such as those with teaching experience, those with experience in child protection and other community members with leadership experience.
As mental health services for young people were limited at the camps at the time of this study, when asked about where adolescents would like to receive support, there was a diversity of responses based either on where child protection services were provided or where services for adults experiencing distress were available. A majority suggested that sessions be held at the IRC Wellness Centre, which provides psychological support for adults; others suggested that sessions be at child friendly spaces or schools or in the community. With regard to the timing of sessions, there was a preference for weekend sessions for school-going adolescents and caregivers.
Phase 3: Group cognitive interviews
Adaptations arising from the cognitive interviews were associated with (a) visual appearance of characters in the storybook and presentation of the camp context, (b) understanding of problem management activities for adolescents described in the EASE intervention materials, (c) cultural acceptance of content from the caregiver sessions.
Group cognitive interviews indicated that boys found the main character easier to identify with as compared to girls. It was advised that the name of the main character be changed, and the character strengthened to look Burundian. Recommendations were sought from Burundian incentive workers and the CAG on character revisions for adaptation (for example, vaccination marks, hairstyles and clothing in the storybook).
Cognitive interviews demonstrated that adolescents were able to understand Kian’s (renamed Niyo- a gender neutral and shortened Burundian name) story easily and found family and peer relationships relatable as described in the intervention materials. We also assessed comprehension of potentially complex exercises (such as the ‘feelings pot’ for emotion identification) and found that while these were novel activities, adolescents were interested in learning their use, however, needed more support. The problem-solving strategies were considered more complex, and an important recommendation for adaptation was simplifying these to ensure understanding. The EASE slow breathing activity was comprehensible. Finally, adolescents had difficulty relating to bird spotting as a leisure activity and this narrative was often misunderstood as bird hunting instead. For example, a young boy shared, ‘What he (Kian) does is not what we do; he goes to hunt in the bush, but we go to school’. This implied that there was a need for such activities to be more relatable in the cultural reality of the camp setting.
From the group cognitive interviews with caregivers, it was clear that caregiver sessions needed cultural adaptation to enhance acceptability of content. There were strongly held views about suicide in the community (for example, regarding supernatural powers causing suicide), which required additional training of facilitators and data collectors both to provide education about suicide and to increase knowledge of how facilitators could support participants in understanding suicide and its prevention. The use of physical punishment for disciplining was common (also reported as a top concern in the previous phase) and it was suggested that the session for caregivers on alternatives to physical punishment include specific examples of culturally acceptable alternatives (for e.g., prevention and monitoring strategies currently used by Burundian parents).