Nguvu - Reducing Partner Violence and Psychological Distress among Refugees in Tanzania
To develop and pilot an integrated mental health intervention for improving psychosocial health and reducing intimate partner violence (IPV) among Congolese refugee women in Tanzania.
Development and pilot evaluation of an integrated intervention that targets IPV and its psycho-social health consequences in a refugee camp within a low-income setting.
Intimate partner violence is a widespread and critical concern for human rights and public health globally1. There is strong evidence for links between intimate partner violence and a range of negative outcomes for health and wellbeing in women, including mental health2. Intimate partner violence is also an acute concern in populations affected by armed conflict and a systematic review of 10 studies found that rates of intimate partner violence were particularly high in conflict-affected populations in LMIC3.
Little is known about effective interventions for this population. IPV and psychological distress have a bi-directional relationship, indicating the potential benefit of a structured psychological component as part of efforts to reduce IPV for women currently in violent relationships4.
This project developed and pilot evaluated an 8-session integrated psychological and advocacy intervention named Nguvu with female adult survivors displaying moderate to severe psychological distress. The outcome of the pilot trial will provide information on the relevance, acceptability, and feasibility of a novel integrated group intervention aimed at secondary prevention of IPV that includes a structure psychological component to address psychological distress.
- 311 women from existing women’s support groups were recruited within villages in Nyarugusu refugee camp, Tanzania
The pilot evaluation was designed to assess the acceptability and feasibility of intervention and research protocols. We will examine psychometric properties of measures assessing:
- Recurrence of IPV
- Symptoms for anxiety, depression and post-traumatic stress
- Functional impairment
"The issues of thinking, again and again, someone has already figured out something. How can you remove it while she has put it in her head? And that is what we have been saying: remove the stagnant thoughts; do not keep them there like milk. Let them not stick in your brain. They got all that. And even if you get the people who we taught and ask them, can you tell me about stagnant thoughts? Ahh! At this moment, they will tell you, it is to take a breath.”
- Intervention facilitator
Intimate partner violence comprises physical, sexual, psychological, and/ or controlling behaviors, most commonly against women by their current or former male partners1. A recent synthesis of data from 141 studies in 81 countries found that globally 30.0% of women aged 15 years and older reported lifetime physical and/ or sexual intimate partner violence2. Practitioners and researchers in settings of armed conflict have increasingly emphasized considering the importance of ongoing stressors such as intimate partner violence as determinants of mental health and psychosocial wellbeing, in addition to conflict-related events in the past5-6. At the same time, researchers have been interested in the role of interpersonal violence as a social determinant of mental health in order to inform public mental health strategies7-8.
The aim of this pilot evaluation was to evaluate the feasibility and acceptability of an integrated mental health and advocacy intervention named Nguvu (Swahili for strength) for improving psychosocial health and reducing the recurrence of intimate partner violence among Congolese refugee women in Nyarugusu Refugee Camp, Tanzania. 311 women were recruited through local women’s groups which have on average 16-17 women per group. These women’s groups were organized in the camp by the United Nations High Commissioner for Refugees (UNHCR) implementing partners to provide skills training and an opportunity for women to strengthen their social networks.
This intervention included Cognitive Processing Therapy, a type of cognitive behavioral therapy with a trauma focus, as it was found to be highly effective in Congolese women residing in the DRC in reducing symptoms of depression, anxiety, and posttraumatic stress disorder, as well as in reducing functional impairment9. The intervention was adapted for the Congolese refugee population in Nyarugusu, Tanzania. The project team worked with the lead authors of the three intervention manuals (the 12- and 6-session Cognitive Processing Therapy manuals; the advocacy manual) to develop an 8-session intervention called Nguvu (KiSwahili for strength). The result was an 8-session intervention consisting of one individual initial session, followed by seven group sessions, delivered once per week over 8 weeks in total.
Ten Congolese refugees working as lay psychosocial workers in Nyarugusu camp for the International Rescue Committee (IRC) gender-based violence and women’s empowerment programs were selected as facilitators for the intervention. The facilitators received 9 days of training that covered basic counseling skills, the intervention manual and self-care strategies.
Facilitators were expected to deliver 1–5 sessions of the intervention per week depending on the number of active groups (1 session per group per week). A single facilitator delivered individual sessions (Session #1), while a pair of facilitators delivered the group sessions (Sessions #2–8). The facilitators received ongoing support from a psychologist (both remote and on-site supervision). During supervision, complex cases were discussed and the facilitators, together with their supervisors used clinical judgment to determine if certain cases should discontinue participation and whether a referral to other services may be needed.
Investing time to develop strong partnerships with clear roles, responsibilities and ownership was necessary to implement the research and intervention activities.
Formative and pilot research
Prior to implementing intervention activities, we conducted qualitative research to characterize the needs of the target population and gain insight into the refugee camp context. Furthermore, piloting our measurement tools, intervention manual and other procedures was necessary for successful implementation.
- A lack of trained human resources
- High demands on staff in non-specialized settings
- Scheduling difficulties, competing priorities and communication difficulties
We are currently reviewing the qualitative and quantitative data to develop plans for further adaptation of the intervention and research protocols. We hope to evaluate the effectiveness of the Nguvu intervention in a randomized controlled trial.
- United Nations High Commissioner for Refugees
- Muhimbili University of Health and Allied Sciences
- International Rescue Committee.
- University of New South Wales
- Research for Health in Humanitarian Crises (R2HC) - A program co-funded by United Kingdom Department for International Development (DFID) and Wellcome Trust.
This study employed a randomized pilot trial of two groups with randomization occurring at the cluster (i.e. women’s group) level and analyses occurring at the individual (i.e. participant) level.
Analysis of the primary and secondary outcomes will be evaluated using linear mixed-effects models and included:
- Symptoms of depression, anxiety and post-traumatic stress (Tools used included the 25-item Hopkins Symptom Checklist - HSCL-25 and Part 4 of the Harvard Trauma Questionnaire HTQ)
- Intimate partner violence (measured through the Demographic and Health Survey Domestic Violence Module)
- Functional impairment (measured using items developed through qualitative formative research)
Cost of implementation
A cost-analysis was not conducted as part of this research study.
Results from this randomized pilot trial provide evidence of reliability and validity for the measures used to assess our primary and secondary outcome measures for Congolese women in Nyarugusu refugee camp. Through a qualitative process evaluation of participants, staff and partners we found that the Nguvu intervention aligns with local needs and priorities, is accepted by women affected by partner violence and mental health problems, is valued by participants and is a service that women would like to be ongoing in Nyarugusu refugee camp.
- Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002.
- Devries KM, Mak JY, Garcia-Moreno C, Petzold M, Child JC, Falder G, Lim S, Bacchus LJ, Engell RE, Rosenfeld L, et al. The global prevalence of intimate partner violence against women. Science. 2013;340(6140):1527–8.
- Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse. 2011;12(3):127–34.
- Tol, Wietse A., et al. "An integrated intervention to reduce intimate partner violence and psychological distress with refugees in low-resource settings: study protocol for the Nguvu cluster randomized trial." BMC psychiatry 17.1 (2017): 186.
- Miller KE, Rasmussen A. War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med. 2010;70:7–16.
- Tol WA, Rees SJ, Silove DM. Broadening the scope of epidemiology in conflict-affected settings: opportunities for mental health prevention and promotion. Epidemiol Psychiatr Sci. 2013;22(3):197–203.
- Allen J, Balfour R, Bell R, Marmot M. Social determinants of mental health. Int Rev Psychiatry. 2014;26(4):392–407.
- Tol WA. Stemming the tide: promoting mental health and preventing mental disorders in low- and middle-income countries. Glob Ment Health. 2015;2:e11.
- Bass JK, Annan J, McIvor Murray S, Kaysen D, Griffiths S, Cetinoglu T, Wachter K, Murray LK, Bolton PA. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med. 2013;368(23):2182–91.