In this ‘In Conversation’ podcast, Dr. Janna Metzler discusses establishing an evidence-base for programmes used to support children and families impacted by conflict and forced displacement.
There is also a discussion on Janna’s recent JCPP paper ‘Improving adolescent mental health and protection in humanitarian settings: longitudinal findings from a multi-arm randomized controlled trial of child-friendly spaces among South Sudanese refugees in Uganda’ (https://doi.org/10.1111/jcpp.13746).
Discussion points include:
- The challenges of conducting research or trying to implement interventions in conditions of adversity.
- A definition of child-friendly spaces.
- An overview of the research described in the JCPP paper, including methodology and key findings.
- How and why the effectiveness of two interventions (Standard psychosocial intervention and a newly developed Toolkit for Child-Friendly Spaces in Humanitarian Settings) varied across different groups.
- Recommendations for building on the foundation of child-friendly spaces and other interventions that make a difference to refugee children and their families.
- Additional upcoming projects related to the trial.
- Suggestions for CAMH professionals and policy makers.
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Janna Metzler, DrPH, MPH, MSW, focusing on establishing an evidence base for programs used to support children and families impacted by conflict and forced displacement. Dr. Metzler has experience designing and leading mixed-methods research and evaluations in global health and humanitarian settings in Africa, Asia, the Americas, and the Middle East. Her research seeks to foster social, physical and economic well-being through the application of participatory methods and people-centered design principles that support communities develop and implement innovative and durable approaches to achieving health equity, eliminating disparities, and improving the lives of those impacted most by emergencies. Dr. Metzler is the new Director of Research for the World Trade Center Health Registry within the NYC Department of Health and Mental Hygiene and an adjunct Assistant Professor in the Heilbrunn Department of Population and Family Health within the Columbia University Mailman School of Public Health.
Other resources
- Featured paper ‘Improving adolescent mental health and protection in humanitarian settings: longitudinal findings from a multi-arm randomized controlled trial of child-friendly spaces among South Sudanese refugees in Uganda’, (2023). Janna Metzler, Terry Saw, Denis Nono, Agatha Kadondi, Yuan Zhang, Cheng-Shiun Leu, Aimyleen Gabriel, Kevin Savage, Cassie Landers
- World Vision, Humanitarian Research – Child Friendly Spaces
- World Vision, Child Mental Health & Protection in Emergencies
- ELRHA, An RCT of Enhanced Child Friendly Space Interventions for Children Affected by Conflict and Displacement
Transcript
[00:00:01.380] Jo Carlowe: Hello, welcome to the In Conversation Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in Psychology. Today, I’m interviewing Dr. Janna Metzler of Columbia University, Mailman School of Public Health in New York. Janna’s work focuses on establishing an evidence base for programmes used to support children and families impacted by conflict and forced displacement, and this will be the topic of today’s conversation.
If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.
Janna, welcome. Thank you for joining me. Can you start with an introduction about who you are and what you do?
[00:00:53.649] Dr. Janna Metzler: Thanks so much, Jo, I am delighted to join you today. I am Janna Metzler. I am a trained Social Worker and Public Health Researcher with experience leading community-based participatory research and mixed-methods evaluations of child and adolescent programming, primarily in global health and humanitarian settings.
[00:01:10.470] Jo Carlowe: Great, thank you, and what prompted your interest in researching adolescent mental health in humanitarian settings?
[00:01:17.860] Dr. Janna Metzler: I came to this work through a range of experiences, including as a High School Teacher in Ghana when I was working with peer educators and mentors to prevent the transmission of HIV and provide a central reproductive health information for adolescents. During my graduate training, my focus shifted to working with forcibly displaced children and adolescents, and this was after supporting a reproductive health needs assessment in Haiti, following the 2010 earthquake that absolutely decimated the health infrastructure.
I was struck by the shear strength of adolescents to not only identify what their needs were in addressing violence and sexual and reproductive health needs and – but also, solutions that would enable them to better connect to the social structures, the support structures that were there and to strengthen them, even in the midst of this growing political and environmental uncertainties, following the earthquake. And this ended up having, I think, a really profound effect on me and shifting my thinking from something that was outcome-based framing for mental health that tends to pathologise children who have experienced this extreme adversity. And it shifted towards a broader view of how mental health is a reflection of these adaptive processes and capacities of children and families within communities that lift the child up to thrive.
And so, soon after that, I joined a fantastic team and a decade-long pursuit to strengthen the evidence around, at the time, the most widely used psychosocial intervention to support children impacted by crisis globally. And that’s child-friendly spaces, which is what we’re talking about today.
[00:02:51.970] Jo Carlowe: Great, that’s really helpful background. You’ve designed and led research and evaluations in global health and humanitarian initiatives in almost every continent. What are the challenges you face when you conduct research or try to implement interventions in conditions of adversity, and how do you navigate the barriers that you encounter?
[00:03:11.620] Dr. Janna Metzler: To a certain extent, a lot of the challenges present are relatively typical to intervention research, but some can present quite challenging in humanitarian and displaced contexts. And common challenges include attrition, but the attrition, in this context, might be due to migration linked to employment opportunities. Individuals who participate in your baseline survey, they go back to other locations for work opportunities because they can’t work in the country that they have been displaced in.
Other challenges can be survey fatigue where there is survey-after-survey in these contexts, and participants end up feeling the sense that they’re being a laboratory experiment. We came into contact with restrictions put in place by COVID and that required methodological adaptations that, you know, have implications on your findings.
Another thing I would say is that I’ve worked in acute responses as well, such as the 2015 earthquake in Nepal, where you’re working to set up an evaluation with colleagues who are focused on getting an intervention up and running, while the ground is literally moving beneath your feet. So, I still remember the May 12th aftershock, what it felt like, like, it’s in my bones, and joining a team – my team in tents outside in the open air for most of our baseline, just being terrified and unsure of the world and the walls around you and the ground beneath your feet, it’s moving. And so, I think recognising that first responders and their families are impacted as well, in a diversity of ways, has to remain central to the work that we do. And it’s critical to be trained in advance to be able to respond to each other, even with a minimum of psychological first aid.
And if I can mention one more, one of the biggest challenges in my work is to ensure that research is useful, it’s not extractive and it’s grounded in real community pathways of social change. And to do this, we – in our work, we work in partnership with local research organisations, implementing agencies, communities, and children themselves, to conceptualise, to design the study that really meets the needs of children and their families that are invested in communities.
And in this particular study that we’re going to talk about today, you know, we use different tools and strategies, and we developed a Community Advisory Board to guide the ethical review process, and the overall implementation of the study.
[00:05:30.669] Jo Carlowe: Well, let’s look at the paper that you want to mention. So this is “Improving Adolescent Mental Health and Protection in Humanitarian Settings: Longitudinal Findings from a Multi-Arm Randomised Controlled Trial of Child-Friendly Spaces Among South Sudanese Refugees in Uganda.” This was recently published in the Journal of Child Psychology and Psychiatry, which is one of the three journals produced by ACAMH. Janna, what are child-friendly spaces? What do they entail?
[00:05:59.229] Dr. Janna Metzler: For over 25 years, if you can believe it, child-friendly spaces have been at the forefront of humanitarian response. The basic premise of how they work or create changes, that if you engage children in a safe and secure environment with structured activities that are led by trained and supported animators, then the children will feel and likely be more protected. They’ll have improvements to their psychosocial wellbeing, which includes the acquisition of skills and knowledge, and the community and carers around them will be motivated to support their care and protection. So, child-friendly spaces, they’re typically used to support children age six and up.
You’ll notice them in temporary structures, although they can be in more permanent structures, but the temporary structures such as tents, local materials, and they tend to operate as part of a short-to-medium term humanitarian response. You don’t typically see them in a more protracted context, although you can. The programming, the way they look and how they run are meant to be flexible in nature to be able to respond quickly to the contextually specific needs of children and their families, arising in this acute-response phase, and then really easy to scale up as needed, right? You could start one and if they’re in temporary structures, you can pop up ten in different areas.
[00:07:17.580] Jo Carlowe: Hmmm, can you give us an overview of the research described in the JCPP paper? What did you look at and why?
[00:07:24.130] Dr. Janna Metzler: My colleagues and I spent over a decade unpacking the effectiveness of these interventions, child-friendly spaces, to really evolve how and when and for whom these are most effective. And our earlier study series, of which this study is based upon, helped establish that there is a positive short-term impact of the intervention. So it’s really critical, in the early days following a traumatic event and circumstances of forced displacement.
These earlier studies also helped to identify how important quality implementation is to the likelihood and the magnitude of its impacts on mental health and psychosocial wellbeing, and really how this quality hinges on a relationship of the programme’s animators with the children and how they’re able to develop skills and support their needs through the intervention period.
So, this earlier study series, it also raised a number of questions that we had, right, including how can we do better? How can we strengthen our approach to ensure children, all children, are able to progress developmentally and thrive into adulthood? And so we launched the study in 2018 to better understand how a more structured psychosocial approach, when implemented within a CFS, child-friendly space, impacts children soon after participating in the programme, whether or not there are any lasting gains are secured through this exposure.
And then finally, we also wanted to look at this new toolkit or this new package of structured programming and whether or not this approach was more or less effective than existing interagency standards and no intervention.
[00:08:58.620] Jo Carlowe: Janna, can you share some of the key findings from this research?
[00:09:02.200] Dr. Janna Metzler: Right, this paper highlights the findings from our adolescent cohort, so those aged nine to 14 years who received no intervention, the standard intervention, which provided intermixed recreational and play-based activities or the toolkit intervention. And so this toolkit, the toolkit for child-friendly spaces in humanitarian settings, it was developed by World Vision and IFRC Reference Centre for Psychosocial Support and is a resource-synthesizing existing interagency standards for design and high quality implementation of child-friendly spaces. And it also expands these with a package of psychosocial activities that can be tailored to the local context or, sorry, circumstances, by trained facilitators and delivered in a sequential and structured manner, according to seven themes. So, these themes are related to the promotion of children’s wellbeing, safety, their recovery and management of stressful events, development of life skills, and so on.
So, we spoke with adolescents before the programme started, and this paper highlights findings from our follow-up period, roughly nine months after the programme ended. And we have a number of findings, so I’ll ju – I’ll highlight a few and the rest, please read in our paper.
One finding was that both the toolkit and the standard approaches were overall more effective in reducing psychological distress, in perceived protection risks, reported by adolescents compared to no intervention. So, when you think about adolescents, it’s this critical period where early intervention can support the acquisition of skills and knowledge they need to navigate to and negotiate for resources needed for their wellbeing. And intervening soon after displacement and early in the child’s development provides more opportunities to develop those foundational assets and adaptive capacities that lead to these lasting improvements in their health and wellbeing.
So, the structured approach laid out in the toolkit, it really did prove instrumental in reducing the risk environment, improving the psychological health and strengthening the resilience in adolescents over the longer-term. And during a period of extreme adversity brought on by the COVID-19 pandemic, which happened really right in the middle of the trial, to further build upon this positive trajectory, I think certain aspects of the activity catalogued within the toolkit can be further developed to build these skills and assets that support resource acquisition for adolescents, that support problem solving, that support positive risk mitigation strategies and also, positive engagement with caregivers.
On this last point, well, not included in the paper, but we are working on another paper that examines the relationship between the level of caregiver stress and the psychological health of the child in the care environment. And really how critical it is to include caregivers and other trusted adults, more explicitly to provide more opportunities for caregivers to engage in the development of social and emotional learning skills, enhanced communication with their children, and reduce and manage their own stress, right, the source of chronic stress and distress that – so they’re able to use these skills that they already have and the knowledge that they already have and know.
[00:12:10.649] Jo Carlowe: I’m just going to go and dig into the detail of the paper, ‘cause the paper suggests that certain groups responded differently to the two interventions explored, so this was the toolkit and the standard intervention. So, for example, the benefits of the toolkit did not fully extend to boys or those in middle adolescence or ethnic minorities. Can you elaborate about how and why the effectiveness of the approaches varied between different groups?
[00:12:36.740] Dr. Janna Metzler: A good question, let me start with the how. We found the toolkit particularly effective in supporting adolescent girls’ mental health. This signified a tremendous opportunity, sustained reductions in psychological distress and perceived risk, provide this opportunity for strengthening resources adolescent girls need to sustain their wellbeing and to seek out healthy pathways for development into adulthood.
We measured a number of dimensions of resilience: individual, relational, contextual, as well as other contributing factors, such as hopefulness, developmental assets, coping strategies, stresses related to caregiving and knowledge of resources available to promote positive psychological health and development for adolescents. So, one of the things we found was that those identifying with ethnic minority groups such as Baggara, Kakwa, Keliko, the toolkit worked better to bolster their overall resilience and relational capacities. When you looked at the standard approach, compared to nothing at all, there were notable declines, in each of these areas. So these two different programming approaches worked differently.
But the why is much harder to answer and, as an evaluator, we tend to dig deeper into the qualitative data that may signal these areas of programming that need to be expanded or better adapted to meet local circumstances. And so, I think similar to our earlier study series, we note there are differential impacts across group. Given the flexible nature of the child‑friendly spaces, the adaptation and the implantation of the activity package is critical to its success. Using gender-responsive and age-sensitive approaches recognises that girls and boys face different challenges at different life stages and have different needs, that’s fairly intuitive.
However, from a programming standpoint, in a situation where you are rapidly setting these up as a first touchstone for kids, as the first exposure they have, after coming to this new place, after who knows what kind of horrific things they’ve seen, they’ve experienced, that’s incredibly challenging. And when you think about the seeds of gender, racial and ethnic inequality, they’re sown even before birth, and reinforced over and over and over again throughout childhood. So, efforts to actively examine, challenge, transform these roots of these inequalities is a tremendous and also necessary integration for programming for something that you may not see its results after one year or even after one 12-week programme.
[00:14:56.579] Jo Carlowe: Janna, from your research, what recommendations do you have, going forwards, to build on the foundation of child-friendly spaces and other interventions that make a difference to refugee children and their families?
[00:15:09.970] Dr. Janna Metzler: There are many, many, many, many, but let me highlight three. And the first is that we need to mainstream quality and contextualisation in the implementation of CFS as a mechanism for emergency response. We’ve seen child-friendly spaces used as a first‑line response, across diverse range of circumstances, addressing a wide range of needs, from the 2015 Nepal earthquake to addressing the needs of those displaced from the Syrian crisis, and in response to planned settlement of refugees, in context of protracted crises, such as Uganda, which is described further in this paper.
Child-friendly spaces have provided the gamut of services, which is a potential strength, but a one-size-fits-all mentality is likely to undermine achieving its targeted outcomes. So, there has to be strong quality of provision, and that is very much reflected in the staff training and supervision. And there needs to be better contextualisation of the programming itself, right? Shaping the activities, in response to assessment of need, age, gender, ethnicity, disability status.
Second, I think the evidence, over the past many years, is suggesting a shift in our implementation strategy. One where it may be better to frame child-friendly spaces as a component of a phased intervention approach. One that works over time to strengthen community mechanisms needed to support children. So, during an initial acute, I have this in quotes, acute period of programming, child-friendly spaces should focus attention on the prompt provision of basic needs and protection. So, that includes initiating and supporting existing efforts to identify separate and unaccompanied children.
This initial phase of child‑friendly spaces would typically provide a programme of basic recreational activities, working to establish healthy attachment between children and facilitators. And with safety routine and relationships established, the intervention should move towards the second phase of operation. And this would be marked by a strong engagement with communities, focused on identifying both needs and local resources, which will inform the development of the programming to come.
So, as CFS moves from predetermined, generalised, rapidly‑implemented activities to ones that are grounded in community, right? Then you have this final phase, and planned closure of these spaces that, on the basis that other safe spaces have been identified, right, within schools, health facilities, sports facilities, places of worship, and they’ve been identified along with a network of systems to support, care and protect children.
The last recommendation I would say is that child-friendly spaces – that for child-friendly spaces to be effective as a high-quality phased interventional model, further resources need to be developed to support implementors in tailoring the phased approach to the local context and circumstances of the emergency. And that includes the diversity of the population. So, resources to harness sectoral guidance available in emergencies, of which there is a lot, and to harmonise this under one framework of child being, will be critical in the next six years.
[00:18:21.270] Jo Carlowe: Great, that was really comprehensive, thank you. You mentioned earlier that you were working on some other research, and I’m wondering what other projects you’ve been working on that you would like to share with us?
[00:18:28.830] Dr. Janna Metzler: Sure, we have been working on a few subanalyses related to the trial currently and have been in discussions with operational agencies about this phased interventional model, which I hope to say more on in the coming months.
A colleague of mine and I have also – we’ve been working a number of years on child‑friendly spaces, and we do, a shameless plug, have a new book chapter out in Migration and Health, that was just released this past year, examining the unique health considerations, during forced displacement, and that’s across the migration journey. And what I enjoyed most about this particular writing project was that so often it’s easy to point the finger at what’s going wrong or what we should do better, right? And in this chapter we delve into evidence-formed solutions that can be harnessed to improve population health for everyone affected by migration.
[00:19:12.840] Jo Carlowe: Can you name the book again, the title?
[00:19:15.240] Dr. Janna Metzler: Oh, Migration and Health.
[00:19:16.460] Jo Carlowe: Great, thank you. What is your message to CAMH professionals who work with refugee and immigrant youth, what would be helpful for them to take from your experience?
[00:19:25.300] Dr. Janna Metzler: I would say don’t just intervene to support kids. Support families. Think about whole-family approaches and supporting the needs of parents and their wellbeing as well. It’s critical, I think also, to amplify the voices of refugee and displaced children and adolescents, in both the framing of interventional research and its measurement, so that it is useful in improving communities and decision-making processes for parents and their children.
[00:19:52.559] Jo Carlowe: And what is your message to policymakers?
[00:19:55.010] Dr. Janna Metzler: The first is that child-friendly spaces work. There’s often some confusion around this, but they do. I think the confusion stems from our desire to make them better or being more than what they were initially intended to do, which was to create a safe place for children to go and begin to rebuild a sense of normalcy. And for parents to be able to leave their children in a safe place while they do what they need to do to take care of their family.
We do need stronger equality and more dedicated time and resources to communities to strengthen facilitation, supervisory skills, and contextualisation of programming. We also need to think of child-friendly spaces as a critical touchstone in the progress of recovery. It’s a window into the community that can be grown, if done well, into an opportunity to strengthen existing communal structures and resources that support children throughout their development. And we know that preventative interventions are cost effective. We know that these interventions, to be effective, we need dedicated resources for training and supporting community members to identify, link to, and integrate local resources to ensure children are supported, they’re cared for, they’re safe.
Lastly, if we want to end the trauma of war for children or displacement associated with climate change, we need policymakers to make changes now. Tackle it head-on, taking into consideration also the unique impacts on children and adolescents. We know that women and girls have been at the forefront of our changing environments as first responders and survivors of some of the most severe consequences of war and natural disaster. It is time to emphasise not only the gendered impacts of the climate crisis and these ongoing conflicts, but strategies that position women and girls, position children as leaders in the development, right? Development of national and regional policies that govern decision-making and response in emergencies.
[00:21:50.650] Jo Carlowe: How optimistic are you that healing is possible for children and young people who are displaced or at the centre of unrest?
[00:21:58.470] Dr. Janna Metzler: I would say I’m incredibly optimistic that children can and do thrive into adulthood.
[00:22:04.050] Jo Carlowe: Where can listeners go for more information on the issues we’ve talked about today?
[00:22:09.679] Dr. Janna Metzler: If you are keen to learn more, our partners in this research, World Vision, have an entire page dedicated to our earlier study series, and I’ll give you a link for that. This page will take you to our individual field reports, across five different humanitarian contexts, our tools for guidance, for monitoring and evaluation of child-friendly spaces. And we also have a video series, we completed in partnership with World Vision, Nepal, Save the Children [inaudible – 22:33] that brings that guidance to life.
And for more information on the latest trial, the summary of findings can be found on another World Vision webpage, with links to the toolkit understudy, and a snapshot that was developed with our funder, Elrha.
If you’re interested in broader resources, related to mental health and psychosocial wellbeing or child protection in emergencies, you could visit the World Health Organization, the Alliance for Child Protection in Humanitarian Action and the MHPSS Collaborative, they’re all excellent resources.
[00:23:01.799] Jo Carlowe: Janna, is there anything else in the pipeline that you would like to mention?
[00:23:05.600] Dr. Janna Metzler: There’s always a few things in the pipeline. This past year, I formalised a vision and an operational process that I’ve been working on for many, many years. A global research centre dedicated to advancing gender, racial and social justice and improving population health, through evidence generation driven by and with communities here in the United States and also globally.
[00:23:25.200] Jo Carlowe: Finally, what is your take home message to our listeners?
[00:23:29.080] Dr. Janna Metzler: There’s a lot that can and should be done for and with children in emergencies, but it’s not a one-size-fits-all solution, context matters. First responders need the flexibility and the skills to design programmes that holistically meet the unique and diverse needs of children after trauma and displacement. And partnerships towards that purist of evidence generation and capacity development will be critical in the coming years.
[00:23:54.860] Jo Carlowe: Thank you ever so much. For more details on Dr. Janna Metzler, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or review, and do share with friends and colleagues.
ENDS
ACAMH response to the conflict in the Middle East
The Association for Child and Adolescent Mental Health (ACAMH) is deeply concerned about the escalating conflict in the Middle East, particularly those who have lost loved ones or been displaced.
