Innovation summary

Refugees are susceptible to increased rates of mental health difficulties including depression and post-traumatic stress disorder1-2 as they face a wide range of daily stressors (e.g. lack of access to basic resources, lack of safety and security, risk of family violence) that impact negatively on mental health3. Guidelines exist for delivering psychosocial support in emergency situations, but contention remains about which approaches are most effective, and whether these interventions can be delivered at sufficient scale. Community-based approaches offer promise for treating common mental disorders, are socially acceptable, and can decrease pressure on primary healthcare.

The World Health Organization4 described Community-based Socio-therapy (CBS) as an approach that uses 'the interactions between individuals and their social environment to facilitate the re-establishment of values, norms, and relationships and at the same time provide the opportunity for debate, the sharing of experiences and coping mechanisms’. CBS is delivered by lay-facilitators over fifteen weekly 3-hour group sessions. The sessions explore six phases: safety, trust, care, respect, new life orientations and memory. The social space of the group is governed by key principles including democracy, equality and confidentiality. 

Impact summary

Impacts are pending as the project is ongoing (due to complete 30th June 2021):

  • Coverage: 720 Congolese refugees (360 per study arm)
  • Outcome: Depressive symptomatology score as measured on the PHQ-9 at 16-weeks (primary endpoint) and 32-weeks (secondary endpoint)
  • Cost-effectiveness: A within-trial cost consequence analysis will be carried out to estimate mean resource utilisation, costs and total DALYs averted in each group, together with relevant measures of sampling uncertainty

“The project aims to culturally and linguistically adapt Community-based Sociotherapy (CBS) for use with Congolese refugees and evaluate its efficacy and cost-effectiveness for addressing the elevated levels of mental health difficulties experienced by populations that have been subject to conflict and displacement. If the intervention is shown to be effective, the project team will work in conjunction with CBS Rwanda and the United Nations High Commissioner for Refugees to disseminate the approach into diverse humanitarian settings”

  - Dr Ross White, Principal Investigator, COSTAR Project.

Innovation details

CBS has been delivered to over 20,000 people in Rwanda since 2005 to promote community connections and individual wellbeing after the genocide of 19945. Compared with usual care, CBS has been associated with significantly increased civic participation and significantly decreased distress in conflict-affected people in Rwanda at 8 months follow-up6.

  • It is practised in groups of between ten to fifteen people who meet weekly for approximately three hours over fifteen weeks in a community space that is safe and convenient for group members to access.
  • Over the course of the intervention the following six principles are applied: interest, equality, democracy, participation, responsibility, and learning-by-doing, and using actual and current situations
    • The CBS groups facilitate community members to identify, acknowledge, share, and manage together their everyday psychosocial problems related to their experiences of upheaval, displacement and/or conflict.
    • The focus during the first weeks is on actual daily life problems - including, for instance, poverty issues, family conflicts, health issues, drug abuse, and mistrust between neighbours
    • As a sense of safety and trust builds, the CBS sessions also provide opportunities to share about their experience of past distress and trauma
  • Two trained facilitators (drawn from the community) guide the groups through the CBS phases of safety, trust, care, respect, new rules, and memories.
    • The role of the facilitators is to facilitate shared learning and to help group members manage strong emotions related to past experiences and present-day suffering

To date CBS has not been adapted and evaluated for use with refugee populations. The ‘Community-based Sociotherapy Adapted for Refugees’ (COSTAR) project is conducting research aimed at adapting CBS for use with Congolese refugees in Rwanda and Uganda, and to this effect is undertaking a large cluster randomised controlled trial of CBS in both countries.

The evaluation will also explore the effectiveness and cost-effectiveness of the approach for reducing depressive symptomatology. A range of knowledge exchange materials relating to specific aspects of this research activity will be developed and shared with the scientific community.

Key drivers

The following key drivers helped Community-based Socio-therapy (CBS) to be successfully implemented in supporting communities in post-genocide Rwanda, which we hope will also help to support the wellbeing and functioning of refugees in both Rwanda and Uganda:

Grass-roots approach:

  • The CBS approach is designed to facilitate and link psychosocial healing and peacebuilding processes at the grassroots level. The approach recognizes a restored social fabric as an important contribution to making people feeling mentally healthy again.

Group-based dynamic:

  • CBS uses the group as a therapeutic medium for the establishment of trust, the creation of an open environment for discussion and the formation of peer-support structures. The dynamic in the group provides opportunities for participants to learn from one another and to regain vitality and trust to introduce positive changes in their personal, family and community life. 

Challenges

The project is ongoing but the following potential challenges may be encountered:

  • Attrition of group members: As Community-based Sociotherapy (CBS) consists of 15 weekly sessions there is a possibility of drop out among group members.
  • Gender dynamics: There might be gender power dynamics in the group which can potentially impact on the quality of the sessions.
  • Environmental factors: Changes in weather (sudden rain/ heat) at the sites of the refugee camps/settlements may impede the CBS facilitators and research team members from undertaking their roles and responsibilities.
  • Transport: Because of large geographical catchment area, transportation could be a challenge for research team members.

Continuation

We plan to develop Implementation Guidance for adapting, delivering and evaluating Community-based Socio-therapy in different humanitarian contexts.

Partners

Funders

This study is funded by ESRC (Economic & Social research Council) under the ‘GCRF New Social and Cultural Insights into Mental, Neurological and Substance Use Disorders in Developing Countries’ funding call. Grant No. (ES/S000976/1). The University of Liverpool is acting as the sponsor of the COSTAR project.

Evaluation methods

Research activity in the COSTAR project will be conducted over 2 key phases which will consist of various workstreams:

Phase 1

  • Workstream 1 – Evidence Synthesis: A systematic review of relevant research evidence
  • Workstream 2a/b – Using the ‘Design, Implementation, Monitoring and Evaluating’ (DIME) approach to adapt Community-based Sociotherapy (CBS) and relevant instruments. This includes rapid qualitative methods

Phase 2

  • Workstream 3a – Cluster randomised controlled trial of CBS for Congolese refugees
  • Workstream 3b – Health economic evaluation of CBS delivery
  • Workstream 4 – Process evaluation to enhance replicability and generalisability of COSTAR
  • Workstream 5 – Implementation guidance for adapting, delivering and evaluating CBS in different humanitarian settings
  • Workstream 6 – Mentorship for clinical trial management at University of Rwanda
  • Workstream 7 – Knowledge exchange resources for evaluating interventions for refugees

Cost of implementation

A within-trial cost consequence analysis will be carried out to estimate mean resource utilization, costs and total DALYs averted in each group, together with relevant measures of sampling uncertainty. The economic evaluation will take the form of a cost-effectiveness analysis, to calculate the cost per DALY averted. Base case analyses will be conducted from a health sector perspective, with additional analyses from the societal perspective.

Impact details

The COSTAR project is ongoing at present and aims to implement impact through the following outcomes:

  1. Adapt assessment measures, and the content of CBS to address the needs of refugee populations in Uganda and Rwanda
  2. Assess the efficacy, fidelity and cost-effectiveness of adapted CBS (aCBS) to reduce the depressive symptomatology of Congolese refugees
  3. Analyse the mediating role of daily stressors and social capital upon these changes
  4. Develop implementation guidance for adapting, delivering, supervising and monitoring aCBS for refugees across diverse settings
  5. Build research capacity for evaluating complex interventions in Rwanda and Uganda
  6. Enhancing knowledge about a scalable and inclusive form of intervention aimed at supporting the mental and wellbeing of refugees – a group at high risk of experiencing mental disorders who are markedly underserved in terms of services and support at both the local and global level. 

References

  1. Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. The Lancet, 365(9467), 1309-1314.​
  2. Turrini, G., Purgato, M., Ballette, F., Nosè, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. International journal of mental health systems, 11, 51. doi:10.1186/s13033-017-0156-0
  3. Miller, K. E., & Rasmussen, A. (2014). War experiences, daily stressors and mental health five years on: elaborations and future directions. Intervention, 12, 33-42.​
  4. WHO (2014). Social Determinants of Mental Health. World Health Organization, Geneva.
  5. Richters, A., Rutayisire, T. Sewimfura, T., Ngendahayo, E. (2010). Psychotrauma, healing and reconciliation in Rwanda: The contribution of community-based sociotherapy. African Journal of Traumatic Stress 1(2):55-64.
  6. Verduin, F., Smid, G. E., Wind, T. R., & Scholte, W. F. (2014). In search of links between social capital, mental health and sociotherapy: A longitudinal study in Rwanda. Social Science & Medicine, 121, 1-9.

Research

Tools

Multimedia

Reports

Associates

Ross White Primary Investigator
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Country

Uganda, Rwanda

Affiliated organizations

University of Liverpool

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