Violence and War in Low-and Middle-Income Countries

Violence, whether self-directed, interpersonal, or collective, and disasters, can create disruption in social and public infrastructures (WHO 2002). Whether the tragedies occur in low-and middle-income countries (LMIC) or high-income countries (HIC) can influence trajectories of community rehabilitation. In low-income settings, the effects of war compound, with many post-conflict countries unable to rebound from the effects of poverty, fragmented families, destruction in public services, unstable political conflict, and possible military confrontation. Though high-income countries are three-times more affected by disasters than low-income countries, 81 % of casualties occur in the latter (cf. Index of Global Reports 2009–2010). Violence also impacts LMIC more severely, with ten times more collective violence in LMIC than HIC (WHO 2002). In 2007, 88 % of the 34 armed conflicts were in low-income countries (Harbom et al. 2008). LMIC struggle with interpersonal violence, war, and road traffic accidents (all leading causes of death), along with migration problems due to violence and disasters (WHO 2004). In 2009, of almost one billion refugees, 200 million went to another LMIC, with less than 8 % going to a HIC (cf. Index of Global Reports 2009–2010). To deal with these burdens, LMIC may use alternative interventions than those used in HIC due to the lack of highly trained professionals, variations in psychopathological expression, and spiritual explanations for mental health problems as opposed to medical or psychological ones (de Jong 2011).

Effects of Violence on Youth in LAMIC

The majority of those killed in modern warfare are civilian children (Singer 2006). Armed conflict and displacement from homes can lead to depression, suicide, post-trauma stress, substance abuse, and other problems in youth (WHO 2008). Violence due to war can negatively impact the physical and mental development of youth (Punamäki 2002) both in a clinical sense, including depression, posttraumatic stress and anxiety (Stichick 2001; Ward et al. 2001), and in normal reactions of aggression, withdrawal, and pre-occupation with negative thoughts (Jones et al. 2003). The impact of indirect exposure to violence, such as a “near miss” experience of being close to a traumatic event, can lead to similar posttraumatic distress as if there were direct exposure (Pat-Horenczyk et al. 2007). Therefore, more mental health interventions are needed for youth living in areas of political and community violence (Jordans et al. 2010), especially in perpetual violence (Barenbaum et al. 1994; Attanayake et al. 2009).

The Need for Research and Services for child/Adolescent Mental Health

Due to a need to understand and care for those in LMIC affected by violence, the WHO has called for a scale up in mental health services in these countries (WHO 2008), especially for children and adolescents (Chisholm et al. 2007; WHO 2001a, b; WHO 2008). LMIC have shortcomings in the scarcity, inequity, and inefficiency of mental health resources (Saraceno et al. 2007). There is a large gap in particular, between child and adolescent mental health needs and resources in LMIC (Patel et al. 2008). When LMIC undergo armed conflict and war, they are additionally affected by the lack of resources to meet the suffering community needs. Research can play a role in determining the culturally expected reactions to extra-ordinary events, and identifying youth with unidentified severe mental health needs. The majority of research on war-affected youth in LMIC focus on psychopathology and the association between war, PTSD, and depression (Attanayake et al. 2009). Robust studies on resilient variables are relatively lacking, despite the need for culture- and context-specific resilient factors incorporated into interventions (Tol et al. 2013). Resilient factors may be both empowering and a more effective use of existing resources in addressing the negative impact on individuals and communities. Oftentimes, resources in LMIC can hardly afford supporting basic psychosocial support programs. Clinical research and its programmatic implications can therefore pose a great challenge.

Ethical Considerations

This need for research on the effects of war and conflict on youth specifically in low-income countries highlights several ethical questions relevant to the field of child mental health: How are research questions prioritized, balancing the needs of the community versus a researcher’s needs? What are ethical considerations in conducting research in low-income countries affected by war? How is the process of research consent, at the institutional review board and participant levels managed? The prioritization of investigations should be discussed with the local community. In low-resource countries, the need for services in the short-term may outweigh the benefit of research to society in the longer-term. The justification of “therapeutic versus nontherapeutic research” in children has been debated (Ramsay 1976; McCormick 1976) and the National Commission REPORT (1977) allows studies that expose children to greater than minimal risk without intent to benefit if the children will be benefitted in the future. Sufficient evidence should be provided to show that: (1) research-induced pain or stress is not severe; (2) potential harms are reversible; (3) researchers are qualified; and (4) the setting is appropriate for the study (Fisher et al. 2002). The Mental Health and Psychosocial Support in Humanitarian Settings—Research Priority Setting (MH-SET), a consensus-based initiative, showed that “the most highly prioritized research questions favored practical initiatives with a strong potential for translation of knowledge into mental health and psychosocial support programming” (Tol et al. 2011).

Funding can influence the topic or type of research. For example, funds may be mandated for use on service, evaluation, clinical, or biological research, and demand quick results (Allden et al. 2009; Bolton and Betancourt 2004; Goodhand 2008; Yamout and Jabbour 2010). Since LMIC do not have the funding mechanisms to allow for their own research, many local governments become dependent on donors for research projects. These donors then may have predominant control over funding allocation, program development, and participants. With a dependence on external funding, researchers may exclude local academics or Ministries from the research discussion and implications.

Discussion about priorities and the implementation of studies is of extreme importance with local communities, since foreign researchers may not be familiar with the culture and priorities in humanitarian settings (Schenk and Williamson 2005). A local ethics review committee has been recommended as part of ethical guidelines in the conduct of community-based research (Ellis et al. 2007) and may be of use in low-income countries that do not have ethics review boards. A community-based participatory research approach can enhance our knowledge of social impacts such as war on youth, can allow for innovative programming and policy, and can address the concerns of community residents—especially for health care disparities and those in vulnerable populations (Gebbie et al. 2002). By forming relationships before the start of programs, researchers can receive practical and theoretical guidance about the development of relevant questions, implementation of the study, and culturally relevant dissemination of the data. This will add to the sustainability of system-oriented programs that empower individual, community, and organizational resources.

Cultural and Needs Assessments Prior to Starting Studies

Before entering a country, researchers and providers should understand the context and derive questions that are of priority and relevant to the setting since assuming answers without understanding the context may end up being detrimental. A needs assessment can assist in the identification of community priorities and needs. However, since needs assessments may take time—time that could be used serving the community with unmet basic needs—tension may arise between quickly providing services, and knowing what services to provide. Considerations can therefore be taken prior to a needs assessment for communities with severe, acute needs, such as low-income countries in current armed conflict.

A cultural assessment can be started prior to entry, before a needs assessment. Cultural assessments would include development of a knowledge base of the historical and political climates of the country, and the identification of local partners to assist in teaching researchers about their communities and culture. Ideally countries, study populations, and research questions should be chosen and developed in partnership with a local community. This will assist in ensuring the utility of the study and cultural appropriateness. Local partners should be identified in advance and engaged from the design of research questions to implementation and dissemination of results. Researchers from HIC should also have appropriate expertise, as they would if working in their home environment. The World Health Organization (WHO) recommends the implementation of some of following interventions before a mental health assessment is done: basic mental health skills training to humanitarian aid workers, providing recreational space in refugee camps, establishing communication among communities, involving the community in activities, starting school and recreational activities for children, supporting existing services, creating self-help groups, and reestablishing cultural and religious events (WHO 2001a, b). Kletter et al. (2013) indicate that effective assessment of children exposed to chronic or acute stress secondary to war or violence includes an understanding of the child’s cultural context.

A needs assessment is a preliminary survey of available community resources, as well as the mental health and psychosocial needs of the community, and was requested to be more systematically used in the design of mental health programs (Marsden and Strang 2006; Tol et al. 2011). To aid in the assessment of mental health systems, the WHO developed a comprehensive tool to gather information about mental health systems specifically for LMIC, since the scope and objectives may be different in HIC (Saxena et al. 2007). Called the WHO-Assessment Instrument for Mental Health Systems 2.2, this instrument has six domains: policy framework, mental health services, mental health in primary care, human resources, public information and links with sectors, and monitoring and research (WHO 2005). In addition to an assessment of available services, the WHO developed a Rapid Assessment of Mental Health Needs of Refugees, Displaced and Other Populations Affected by Conflict and Post-Conflict Situations (RAMH). This community-oriented assessment provides a rapid needs assessment for those who have limited time before starting research, with a population in urgent need of services. The RAMH provides an overview of how to conduct a needs assessment, which should include (WHO 2001a, b):

  1. 1.

    Description of the past/present conflict, how it affected the population

  2. 2.

    Identification of an appropriate research population (taking into account effects on non-researched populations)

  3. 3.

    Identification of mental health services available in the country (mental health policy and mental health personnel, paraprofessionals, social workers, traditional healer, women’s associations, community leaders, etc.)

  4. 4.

    Identification of local means of healing

  5. 5.

    Identification of traumatic events experienced by the population

  6. 6.

    Identification of the main characteristics in culture, religion, and socio-political organization

  7. 7.

    Description of how people deal with the consequences of violence and trauma at various levels (individual, family, and community) and how the coping mechanisms are affected by the current situation.

As much as possible, this framework should be adapted to the local context by involving various stakeholders, local and international grassroots organizations involved in relief and social programs, and policy makers.

Logistical Considerations in Conducting Research in Low-Income Countries

Working in low-resource countries poses logistical (broken public infrastructure), safety (continued armed conflict), and personal challenges (for example, the role between clinician and researcher). Additional challenges in low-resourced countries include the difficulty in sampling from roaming populations, climate and environmental factors (rainy season), limited workforce capacity in research and evaluation, and security problems (check points, working with former child soldiers, etc.) Personal well-being, safety, training, and data collection are important components to consider when performing research in LMIC. Often during the conflict or post-conflict periods, local people may be suspicious of foreign researchers who may produce work that can be highly politicized (Song 2012).

Personal Well-being

Though engaging in studies involves a role as a researcher and not clinician, team members should be aware of potential stress incurred from discussion of trauma experiences, in addition to the often times difficult living conditions that accompany working in a low-income country. Secondary traumatic stress has been well-documented and can often lead to burn-out (Baird and Jenkins 2003). We have found it helpful to have daily gatherings for team members to discuss the events of the day, current and anticipated problems and solutions, and support for a cohesive team. This extends not only during the duration of the data collection, but also after the return back home. Prior to involvement on the study, consideration should be given to the psychological well-being and capacity of local researchers who will work with those exposed to traumatic events. Research should also include a follow-up and monitoring of field researchers for signs of stress or discomfort.

Safety

Prior to even deciding the country of study, proper concern should be given to countries currently in conflict or with active security problems. Even when a war is officially declared over, there may be continued times of instability. The safety of researchers and local team members should be of priority. Even having a foreigner in certain areas can place the entire community in danger, in addition to the individual risk to the researcher. “If an experienced researcher gets killed in a particular area, aide can be shut down and the level of armed conflict can increase” (Allden et al. 2009). Special care is warranted for local people working with foreigners. For example, if a foreign researcher hires a local interviewer to evaluate human rights abuses, that local interviewer may be at higher risk of harm than a foreigner. Researchers should be aware of the security of the country, study location and surrounding areas, transportation conditions, availability of emergent medical treatment, and potential conflicts between the study populations and local inhabitants who may perceive the lack of research participation as a lack of aide.

Training

Data collection can be chaotic, trying to find participants, managing transportation, ensuring appropriate space with privacy for participants, and developing a working relationship with interpreters. Research assistants may feel overwhelmed, many of whom have experienced traumatic events themselves, or are unaccustomed to hearing about trauma. Protocols should be clearly defined so team members are clear about their roles prior to gathering data. Local team members should be treated equally with those from HIC, by including all staff in meals and transportation, while also being aware that interaction with a foreigner may put a local team member at risk. As an example, during a study with former child soldiers in a remote province in Burundi, local villagers began harassing one interpreter and imprisoned him for the night in order to collect a bribe, believing he was “rich” since working for Americans. Having a larger pool of team members to train may be helpful since unpredictable difficulties can emerge (such as team members with difficulty engaging in research protocols and difficulty with transport to the research site during rainy season).

Data

There is a need for studies that use validated and culturally appropriate mental health measures (Betancourt et al. 2008). Qualitative data is often a necessary first step before engaging in quantitative studies in low-income countries that do not have validated scales or prior studies to build upon. Through qualitative data, researchers can begin to understand the community. However, subjective biases may limit the accuracy of responses, allowing for the need of triangulation of data from multiple sources (WHO 2001a, b). Triangulation may include collecting data on the same themes from different primary stakeholders (such as local experts, mental health providers and policy makers). Proper screening should be followed by providing resources to those children in need (Kletter et al. 2013). Multiple raters offer the advantage of combining subjective and objective data points. Of course, cultural and linguistic competence needs to be achieved within all assessments. Moreover, if interviews are conducted by foreigners using interpreters, care should be taken to ensure elements do not get lost in translation. Researchers should ensure that the collection, storage, and analysis of interviews or data are secured so participants can be reassured that their information (such as status as a former child soldier) will not be released to the government or rebel forces which could lead to further stigma and discrimination.

Clinical Considerations

When considering studies with youth, working with a clinician can provide valuable information to guiding study questions and priorities. Many children living in poverty may overwhelm foreigners with their smiles, which does not inherently mean children are without distress. While being careful not to over pathologize, researchers should also acknowledge children’s distress when present. A clinician experienced in working with similar populations can more efficiently determine which youth are potentially at risk. Children may not feel comfortable telling foreigners or adults about their experiences, especially in areas of political instability and revelations may place children at increased risk. Researchers should be clear at the start of the study, about their roles, type of data collected, how it will be used, and confidentiality. Special care should be taken to speaking at a child’s developmental level. Young children may respond to survey questions better with a pictures than verbal questions. Developmental stage can also guide appropriate research questions, for example, risk-taking adolescent behavior may prioritize questioning on substance abuse, which would not be as useful in younger school-aged populations. Schools may be of great benefit to the researcher, as schools can help children return to a routine schedule and can serve as a central resource for information. Moreover, schools may have access to community resources and have a better understanding of each child’s “ecology”—individual, family, and community strengths and difficulties.

Conclusion

More research is needed to understand the multitude effects of war on youth, specifically in low- and middle-income countries that may not have the resource capacity or funding to conduct research. Foreign researchers can collaborate with local teams to determine priorities of studies, approaches, and cultural feasibility. The first step for foreign researchers prior to designing a study is to perform a cultural assessment, including the identification of local partners to collaborate with. The WHO has developed guidelines for the implementation of a needs assessment, which can assist in the prioritization of research questions. With an ethical lens, community partners and expert clinicians, researchers can provide an integral role in advocating for the development and well-being of youth without the appropriate resources to flourish.