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Mediation of daily stressors on mental health within a conflict context: a qualitative study in Gaza

Schafer, Alison; Masoud, Hajar; Sammour, Rania

doi: 10.1097/WTF.0000000000000031
Articles

The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support (IASC, 2007) promote the provision of basic needs and community/family supports as key approaches to improve the overall wellbeing of people affected by crises, including conflict. However, positive impacts and/or evidence base for these initiatives, seen through the lens of psychological theory and research, are limited. A World Vision AusAID livelihoods project in Gaza was qualitatively examined in order to explore this question of how psychosocial supports improve wellbeing for men, women and children. Results of the qualitative examination presented in this paper show that locally prescribed feelings of wellbeing improved through the reduction of daily stressors and supported the model of a mediating relationship between traumatic events and mental health, as suggested by Miller & Rasmussen (2010). The paper also demonstrates the benefits of a multidisciplinary and integrated psychosocial support approach for programmes delivered with a whole-of-family perspective, which has more broadly supported the psychosocial needs of this conflict affected community. The paper further reflects on the important need for effective measurement models in relation to ascertaining impacts of integrated psychosocial support approaches.

Alison Schafer is a World Vision International's Senior Program Advisor for Mental Health and Psychosocial Support. She is based with World Vision Australia's Humanitarian and Emergency Affairs team. email: alison.schafer@worldvision.com.au

Hajar Masoud is a Monitoring and Evaluation Officer with World Vision Jerusalem-West Bank-Gaza. She is based in Gaza and responsible for the impact and evaluation of the World Vision AusAID AMENCA2 program.

Rania Sammour is a Psychosocial Support Officer with World Vision Jerusalem-West Bank-Gaza. She is based in Gaza and manages the implementation of psychosocial support activities as part of the World Vision AusAID AMENCA2 program.

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Introduction

The importance of basic needs and social supports has become one of the cornerstones of the Inter-Agency Standing Committee Guidelines in Mental Health and Psychosocial Support in Emergency Settings (Inter-Agency Standing Committee [IASC], 2007). The guidelines maintain that the majority of people affected by crises will recover naturally over time, once basic safety and survival needs are met, and community/family supports are restored. Many humanitarian aid agencies subscribe to these guidelines and their premise, and strongly advocate for basic needs and community/family supports. However, the evidence base of how such interventions improve wellbeing and psychosocial health remains scant (Tol et al., 2011a) and the practical implementation of effective measurement models for such programmes is a persistent challenge. Despite general psychosocial approaches in the provision of basic needs and community/family supports being cited as some of the most common interventions in humanitarian organisations working in the mental health and psychosocial support (MHPSS) field, the impacts of these initiatives, their links to psychological health and psychological theory is lacking and sorely needed (Tol et al., 2011a, 2011b; Wessells & van Ommeren, 2008).

Miller & Rasmussen (2010) termed the dichotomy of perspectives between clinical and community based MHPSS work as trauma focused versus psychosocial approaches. They theoretically described the trauma focused model as consisting of a linear correlation between conflict/war exposure and mental health problems. Whereas the psychosocial approach and model was described as consisting of a wider range of stressful conditions, or daily stressors, that may mediate the relationship between war exposure and mental health. Miller & Rasmussen suggested that, despite the fact that the psychosocial model offers an explanation for the mental health concerns among war affected communities, the model also continues to focus largely on the impacts of conflict, rather than on both the impacts of conflict as well as the ordinary daily stressors of people living in poverty. Consequently, Miller & Rasmussen proposed an alternative mediation theory of mental health in conflict contexts, shown in Figure 1. This theoretical model incorporates both daily stressors incurred by the conflict, as well as ordinary daily stressors incurred as a result of poverty, both of which would be likely to mediate the relationship between exposure to armed conflict and mental health.

Figure 1

Figure 1

Support for this theoretical model was empirically demonstrated in a study by Jordans et al. (2012). This study assessed the perceived needs of displaced Iraqi people living in Jordan and Bhutanese refugees living in Nepal. In both groups, Jordans et al. confirmed a significant linear correlation between traumatic exposure to common conflict events and distress, as measured on the General Health Questionnaire (GHQ-12). However, when the study added perceived, unmet needs to the model, a significant mediation effect was found in the Iraqi group, to the point where the correlation between trauma exposure and distress was no longer significant. In the Bhutanese sample group, a small but significant effect of unmet needs mediating the relationship between trauma exposure and distress was also revealed. Also, the direct effect of trauma exposure and distress remained significant, but reduced its power; demonstrating that unmet needs were still contributing significantly to overall distress.

The implications of the Miller & Rasmussen (2010) and Jordans et al. (2012) analyses have indicated that efforts to improve post conflict, or protracted conflict, environments by reducing resultant or aggravated stressors may contribute significantly to improved wellbeing of war affected communities and support psychological wellbeing and recovery. For many individuals, this may even be achieved without trauma focused interventions. Such ideas are consistent with Williamson & Robinson (2006) who have long supported the integration of psychosocial initiatives as being interlinked with material and biological aspects of wellbeing. As Jordans et al. described: ‘Multidisciplinary interventions that aim to reduce current stressful social and material conditions caused or worsened by humanitarian emergencies may potentially buffer against the negative impact of traumatic experiences on an individual's mental health’.

These theories on reducing daily stressors as an approach to reducing the psychosocial impacts of conflict are further supported within the foundations of the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Additionally, these guidelines offer justification for why humanitarian agencies might include broader multidisciplinary programmes as part of their humanitarian response to support improved wellbeing. However, further research has been called for (Jordans et al., 2012) in order to help demonstrate the ways in which these ideas can be effectively programmed and implemented by humanitarian organisations. The global MHPSS field would benefit from case studies and examples of how this might be seen within practical and operational terms, while donors would benefit from understanding more clearly how these relationships exist. It is, therefore, important to continue explaining, in qualitative terms, the considerable difference that programmes aiming to reduce individual, family or community stress can offer in enhancing existing programmes, or directly support, the mental health and psychosocial needs of war affected populations.

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Context and project background

Since 2009, World Vision has been a partner in the second AusAID-funded Australia Middle East NGO Cooperation Agreement (AMENCA2). As part of this programme, World Vision has been implementing a livelihoods project in Gaza (occupied Palestinian territories) with a focused integration of psychosocial support activities. The project aimed to improve the livelihoods and resilience of 15 communities (approximately 1200 households consisting of 8,250 individuals) in the northern and southern regions of Gaza. These communities had been impacted during the 2008/2009 Israeli incursions known as ‘Operation Cast Lead’, as well as more recently in November 2012 with the ‘Operation of Defence/Pillar of Cloud’ conflict. The Gaza Strip remains an extremely fragile context, blockaded from the rest of the Palestinian territories, and the world.

The 2008 Operation Cast Lead war resulted in a range of mental stressors and mental health concerns for Gaza's girls, boys, women and men (WHO, 2009). This was exacerbated by six years of a blockade (Save the Children & Medical Aid for Palestinians, 2012) followed by the 2012 Operation of Defence/Pillar of Cloud six day war (United Nations Office for the Coordination of Humanitarian Affairs [UNOCHA], 2012). Although the MHPSS working group was active in Gaza, following Operation Cast Lead, many responses to mental health needs have been viewed through a trauma lens, with treatment taking clinical or counselling approaches. With an estimated 50% of Gaza's 1.64 million people likely to require some form of psychosocial support [Consolidated Appeals Process (CAP), 2011; Palestinian Central Bureau of Statistics (PCBS), 2012], it is impractical that a direct service model will reach all those in need, particularly given the limited mental health services available. Additionally, direct mental health services are not geared towards helping individuals and families reduce daily or war induced stressors, recommended as a vital need for MHPSS according to Williamson & Robinson (2006), the IASC Guidelines (IASC, 2007), Miller & Rasmussen (2010), and Jordans et al. (2012). Loss of livelihoods was shown to be a significant stressor for men, while women are more commonly faced with the challenges of supporting children with difficult behaviours and trying to ensure family harmony in light of ongoing loss of property, livelihoods and community social networks.

World Vision's AMENCA2 project, implemented in partnership with the Union of Agricultural Works Committee (UAWC) has included a range of livelihoods initiatives as its primary focus. This has involved support to restore agricultural lands and greenhouses, rebuilding roads for market access, support to fishermen, and home gardens for female headed households. All agricultural works are supported through UAWC and their agricultural extension officers, who regularly visit project stakeholders to provide technical assistance, such as advice on watering, fertilising, harvesting and so on. Community based organisations (CBOs), including women's groups, are assisted in capacity building for self-management and sustainability, so they will be able to continue supporting themselves and other farmers at the close of the project. Youth livelihoods were also targeted and supported through entrepreneurial programmes that encourage young people to begin new and unique small businesses, with each entrepreneur selected for a start-up grant, and allocated a business mentor to guide their business plans, management and implementation.

One of the targeted psychosocial activities in the project included the implementation of two longer term children's programmes based on the child friendly spaces (CFS) model (as described by the Global Education Cluster et al., 2011), for children aged between 6 and 16 years. Additional CFS were established following the November 2012 six day war.

The CFS initiatives worked with 2,000 children, within age and gender defined groups. Children aged 6–10 years attended within mixed gender groups, while those aged 11–16 years attended in gender segregated groups, according to cultural customs. Each session comprised between 30 and 40 children, who attended in shifts for 3 hour sessions before or after school, three days per week. Most children attend the programme for no more than 2 years, though this varies depending on individual circumstances. The CFS is located in small urban buildings, using a few child decorated rooms and small fenced outdoor spaces. These spaces were provided through existing CBOs. The children, all of whom are referred to the CFS through the livelihoods programme (e.g. children, neighbours, relatives of the direct livelihoods beneficiaries), participated in structured and facilitated activities, such as drama, crafts, art, music, life skills games and activities, English language and, if required, tutoring for specific educational needs. The children's programme was overseen by four facilitators per session.

Based on a survey of information needs of parents, 654 mothers of children attending the CFS also participated in educational sessions on various topics, including psychological first aid (PFA) for supporting family members when distressed, dealing with family conflict, managing difficult behaviours of children, bed wetting and how to identify children and adults that may need more specialised mental health care. Approximately 1,500 mothers have been directly involved with the CFS programme in some way, many of whom have also used this engagement as an opportunity for personal social support as well. Many fathers and farmers in the project have also been involved in psychosocial awareness and PFA training. In all, the project has delivered PFA training to more than 7,000 individuals, consisting of project staff, partners, CBOs, women's groups, youth, mothers and fathers.

World Vision and UAWC staff were, therefore, trained in how to implement a livelihoods project, with an overarching psychosocial approach, that cared for individuals they were working with and not only based on supporting their physical needs. The AMENCA2 project further integrated psychosocial support by building the capacity of all CFS facilitators, farmer and livelihoods extension officers and youth mentors. They received training in the IASC Guidelines (IASC, 2007), honing in on the key principles of working in participatory ways and emphasising the importance of upholding dignity and offering support to programme stakeholders. Training in PFA was provided with a focus on good communication skills, for example, agricultural extension officers were encouraged to support farmers with skills such as reflective listening and empathy, while also offering them practical assistance for their livelihoods work.

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Research aims and questions

From World Vision and AusAIDs perspective, the project needed (1) to be specific as to the benefits of this integration of psychosocial supports within a livelihoods programme; and (2) to be able to theoretically convey how and why these aspects of the project function achieve positive outcomes, as identified by the project participants. This perspective led to the following considerations. While improvements in overall wellbeing were included in the project evaluation, this was problematic because ‘wellbeing’ in the local language translated into ideals of affluence or wealth, which did not adequately reflect the changes that were observed. Additionally, the construct of wellbeing does not offer theoretical insights as to how or why changes are occurring in the communities involved. Research by Giacman et al. (2007) suggested the notion of wellbeing, as measured by quality of life for Gazan people, was broadly related to socio-economic status and the negative consequences on wellbeing, dignity and freedom, due to the Israeli occupation.

Miller and Rasmussen's (2010) mediation model was explored as a possible explanation for the positive effects observed in the AMENCA2 project. It was considered that the livelihoods and psychosocial support activities might jointly be contributing to reducing daily stressors for the project participants, and reducing the psychological consequences of living within a conflict, as well as highly political, context (Giacman et al., 2007; Mataria et al., 2009). Therefore, it was decided by project staff that a qualitative study might further test this hypothesis and offer an understanding of the process or theory of changes observed amongst AMENCA2 participants. It was hypothesised that the Miller and Rasmussen (2010) mediation model would be qualitatively supported. To explore this, this brief research investigated the following research questions:

  1. How do local people involved in the AMENCA2 project describe the construct of wellbeing?
  2. What were the benefits of integrating psychosocial supports into this livelihoods programme and how have the benefits been different for children, women and men?
  3. Have the benefits of integrated psychosocial supports in this programme influenced family and community supports?
  4. In what ways have the integrated psychosocial support elements of the programme contributed to livelihood improvements documented by the project?
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Methods

Participants

The participants were selected from a group of women and men who had previously met with World Vision to discuss what had been learnt from the project. At this event, participants shared their beliefs that the psychosocial components were a major factor in the success of AMENCA2. This was the impetus for the research initiative. Due to time and logistical constraints, the north Gaza project stakeholders were asked to participate in focus group discussions, to enable more in depth discussion. Nine women and six men, who had been part of the learning event, agreed to participate. Seven children (from the families of these women and men), all of whom were participants in the CFS programme, were also selected to participate in focus group discussions. Of these women (n = 9), men (n = 6) and children (n = 9), one woman, man and child, who comprised a family of their own, were interviewed separately (not as part of focus group discussions). This was approached differently because the father had more emphatically shared his positive beliefs about the psychosocial aspects of the project work, which was viewed as a possible risk to bias of others in the focus group forums. Despite these differences in data collection methodology, the data reported on the total group women, men and child participants, combining key themes from all those who engaged in discussion with the research team.

The nine women participants in the research were aged between 35 and 45 years (M = 38.88, SD = 2.85 years). They were all married, with at least one child attending the AMENCA2 north Gaza CFS. In addition, the women had all participated in PFA and education training at the CFS. The six male participants were aged between 30 and 55 years (M = 43.60, SD = 9.46 years) and were part of the farmers group in the AMENCA2 programme. As a result, they were all direct recipients of agricultural livelihoods inputs, such as land rehabilitation tools, irrigation networks, plant seedlings, and livestock. The men were all married and also had at least one of their children involved in the north Gaza CFS. They had received psychosocial support from the UAWC agricultural extension officers and participated in PFA training at the CFS.

Of the nine children who participated in the brief research initiative, six boys aged between 7 and 15 years were regular attendees of the north Gaza CFS, alongside three girls, all aged 14 years. The overall mean age of the children was 13 years (SD = 2.77).

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Interview schedules

The qualitative data was collected in two formats; (1) group discussions; and (2) an individual family interview. In total, three group discussions were held with women, male farmers and children. The group discussions utilised a simple interview schedule that posed the same questions to each group, these aimed to build on the ideas women and men had already alluded to at the World Vision AMENCA2 learning event. Participants were asked:

  • to think about and describe the behaviours of other people in their families before the project began (e.g. children were asked about their mothers and fathers, women were asked about their husbands and children, and men were asked about their wives and children);
  • to consider what was stressful for their families before they were involved in the AMENCA2 project;
  • to reflect on what was different about the behaviours of other people in their families after being involved in the project.

Following this, it was explained to the group that World Vision had noticed and believed that there was a link between the livelihoods initiatives with adults and the psychosocial activities with children in the AMENCA2 project, and wondered why they thought this approach had been so successful.

After the above discussion points had been addressed, the participants contributed to two additional activities. First, participants were asked to use only one or two words to describe the construct of wellbeing. Second, the participants engaged in an activity termed ‘the dartboard’ (mapping on a diagram, like a dartboard), the extent to which they felt psychosocial support issues were present in their lives. They used red stickers on the diagram to indicate their responses to the key statements before AMENCA2 and blue stickers to indicate their responses after AMENCA2. Stickers placed far away from the centre indicated that they felt they were not in agreement with the key statements; in contrast, stickers placed close to the centre, or the bullseye of the dartboard, indicated that they more strongly agreed with the key statements. The key statements about psychosocial support the participants reflected on were:

  1. I feel my family supports each other.
  2. I feel I have people I can turn to for emotional support.
  3. I feel confident to provide emotional support to others.
  4. I feel strong enough that I could cope in a positive way to crisis.

The family interview was unstructured, but sought to glean similar details to those of the discussion groups.

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Procedure and data analysis

The group discussions and family interview were held on a single day in March, 2013. The participants were selected by convenience based on minimum criteria that the families all had children involved with the CFS programme, and had been recipients of either CFS parent educational programmes and/or direct livelihoods inputs.

All group discussions and the family interview were facilitated by a local World Vision staff member in Arabic. The facilitator described the purpose of the research and sought permission from the participants for their information to be recorded. The three group discussions took approximately 80 minutes, with the facilitator ensuring each participant had the opportunity to respond to each question. The family interview took approximately 60 minutes. Some questions were asked directly to the mother, father or child, while other questions were directed to the family in general. In the latter case, for the most part, the father responded on behalf of the family.

Information from the group discussions and family interview was recorded in writing by two local World Vision staff members, in Arabic. As the research was unplanned and opportunistic (based on feedback from the learning event), there was inadequate time and budget for rigorous data collection approaches. Therefore, the two local World Vision staff documented key themes and comments presented by the participants. The noted transcripts were then translated into English, with the two note takers confirming the most accurate translation. It is a clear limitation of this study that the statements of the participants were not transcribed precisely and some nuance from the data were lost in translation. Regardless, the English data provided adequate information to enable a basic thematic analysis.

Given the closeness of the research team to the AMENCA2 project implementation, it was acknowledged that a systematic process of thematic analysis was essential to maintaining an accurate reflection of the findings (described as reflexivity by Multerud, 2001). Therefore, the analyses followed Braun & Clarke's (2006) six phases of thematic analysis, including: (1) familiarisation with the responses to each question; (2) generating initial thematic codes; (3) searching for emergent themes among those codes; (4) reviewing the themes; (5) defining the themes and giving each theme an overarching name; and (6) identifying exemplary, representative and descriptive extracts from the data to present for the results, which also involved slight grammatical changes to translated responses for ease of reading. Data from the dartboard activity was not thematically analysed, but summarised, based on the participants’ responses to the key statements.

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Results

Research question 1: How do local people, involved in the AMENCA2 project, describe the construct of wellbeing?

When asked to describe the construct of wellbeing in Gazan terms, the participants identified three themes: ‘happiness’, ‘meeting needs’ and ‘good health’. Overall, the participants viewed wellbeing as both internal feelings and external conditions, described as follows:

  • Happiness’ incorporated feelings of being happy, comfortable, content and self-satisfied. ‘Wellbeing means to be happy’ (child, aged 13).
  • Meeting needs’ involved being able to meet individual and family needs, ranging from safety and stability, to having money to meet the daily demands of families (e.g., health care, electricity, gas, food, etc.). Employment was perceived as being a component of meeting needs. ‘My husband has psychologically changed, because he has an income now’ (woman, aged 38).
  • Good health’ was referred to as a complete state of physical and psychological health and included one's need for psychosocial support. ‘Wellbeing means physical and psychosocial health’ (child, aged 14).
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Research question 2: What were the benefits of integrated psychosocial supports in the livelihoods programme and how have the benefits been different for children, women and men?

The participants were cognisant of the direct benefits they were receiving from the AMENCA2 project. The children largely cited their involvement with the CFS programmes, the women with the CFS and PFA training activities and the men with the livelihoods inputs. However, participants were also aware that the project involved a ‘whole-of-family’ response, which was a theme throughout their comments about what support they and others had received from the project. For example, a man, aged 55 years said; ‘World Vision provided farmers with agriculture materials, house gardens, rehabilitation of lands, irrigation networks, goats and hens, PFA training, CFS, and awareness sessions [on psychosocial issues] through AMENCA project’. Another farmer, aged 40 years said; ‘World Vision has helped the whole family’.

When participants were asked to reflect on the behaviours of others in their families before their involvement with the project, an overall theme of families experiencing a range of stressors emerged. Specifically, three major concerns were identified:

  • Lack of play’ was commonly raised as a challenge for parents and children before the introduction of the CFS programmes. Children recalled that before the CFS programme in AMENCA2, they felt trapped in their homes and frustrated by the lack of play opportunities. A girl, aged 14 years said; ‘we were playing only with our relatives and there were no places to play. We couldn’t get out of our houses because we didn’t have places to go. I feel that I couldn’t speak and I feel that someone was choking me. Because I couldn’t play and I don’t have my freedom’.
  • Familial conflict’ emerged as a noticeable stressor for families. Conflict between children and their parents as a consequence of children being unable to play and the resultant poor behaviour. Sibling conflict and marital strain were also mentioned. ‘Before coming to the centre [the CFS] my father was shouting all the time... before coming to the centre we couldn’t go out from our house to play... but now there is more freedom’ (boy, aged 14). A 43 year old man noticed how lack of work created strain on his marriage; ‘.. when the land levelling by Israeli forces [happened], I sat in my house without any work; it was hard times and situations. I had a lot of problems with my wife because I sat at home without work’.
  • Preoccupation with war’ was another theme, particularly for children, before they had stimulation and distraction from the CFS programmes. A 14 year old girl said; ‘we were suffering a lot from the war and we needed something to let us forget all these things. People were dying and we were also waiting to die’.

As the participants commented on the changes they had observed for themselves and others in their families since the inception of AMENCA2 project activities, the following six themes emerged: (1) increased play for children; (2) improved child behaviour; (3) reduced familial conflict; (4) increased emotional support from parents to children; (5) less worry about children; and (6) increased personal/couple time, particularly for women. Overall, these themes suggested that the various activities of the AMNECA2 programme contributed to less family stress and greater family harmony.

  • Increased play for children’ was cited by children, as well as their parents. The children were particularly happy at having time and space to play and parents seemed more at ease in allowing their children to participate in the structured activities offered by the CFS. As told by a 13 year old boy; ‘My father allows me now to get out of the house and go to the centre to play with my friends’.
  • Improved child behaviour’ was noted by both children and mothers, which benefited the whole family, as children seemed more relaxed, less demanding and better behaved. A mother, aged 38 years said; ‘my daughter [has] become active, friendly, self-confident, expresses her opinions freely and is always happy and smiling’. Another mother noticed that her son had improved in his individual self-care; ‘CFS taught my child how to be healthy and everything about personal hygiene; he now has good behaviour in wearing clothes and brushes his teeth and hair. I am so happy and comfortable’.
  • Reduced familial conflict’ was shown to be another benefit for families. The children were happier because they were playing, their mothers were more content because they were able to engage with others in their communities and the fathers’ stress was reduced through having access to work; all factors that seemed to contribute to improved familial relations and reduced conflict in homes. A 14 year old girl said: ‘My two brothers were fighting all the time, but now their relationship has become more quiet, and they are playing in CFS with each other’. A 40 year old mother expressed that her involvement with CFS and the community had emotional benefits for her as well; ‘I suffer from the daily routine of the housewife and my husband didn’t allow me to leave the house. But when my children joined the CFS I had the chance to visit them and attend PFA training and awareness sessions. So CFS is my way to freedom’. A 53 year old farmer reiterated the reduced familial conflict (as well as improved child behaviour), saying: ‘before my grandson joined CFS he was always playing with sharp objects, such as a knife and razor, because he was a brat, aggressive and noisy, and he also hated his sister. But after joining the CFS he became calm and polite and has good behaviour’. For the men, they fully appreciated the important psychosocial link between their wellbeing and work, as the same 53 year farmer observed; ‘There is a correlation between work and psychological health. If I work, I will enjoy good psychological health, and if I don’t work, I won’t enjoy good psychological health’.
  • Increased emotional support from parents to children’ was seen as a benefit to all. Children noticed that their parents had become more trusting and proud of them, while mothers and fathers spoke of having greater awareness of how to care for their children when they were experiencing distress. For example, a 14 year old boy noticed changes in his parents; ‘my parents now participate in the workshops. They care about us more and they [have] become more knowledgeable, especially my Mum’. A 38 year old mother told of how she now supports her son when he is distressed; ‘ According to shock, he has difficulty sleeping, he heard the voice of rockets and bombing, so he woke up shouting. Now, when he hears the voice of bombing, we talk to our children, to calm them down and not to cry; we play together and talk. We are all cooperating together on all occasions, sad or happy’.
  • Less worry about children’ was a common theme for mothers and fathers, who noticed a difference in their children's psychosocial wellbeing. A 40 year old mother said; ‘There was a big bomb at night near my house. My daughter woke up crying and frightened. The next day she refused to go to school and attached to me all day... she became introverted and sensitive and kept crying. But when she joined the CFS she learned self-confidence again and expresses her opinions freely without any fear’. A 14 year old boy noted that his parents worried less about him when he became involved in the CFS; ‘... and they [his parents] trust me all the time. And they allow me to go to the CFS each day. Because of the structured activities’.
  • Increased personal/couple time’ was another benefit for women in particular, who noted that the CFS and work for the men offered them more opportunities for personal time and family time. A 38 year old mother said; ‘I have more time now to have a rest, and caring for my [other] children. Sometimes I go for a walk. We [she and her husband] spend time together. We never did this before’. This sentiment was echoed by another mother, aged 45 years; ‘Now I have time to take care of my husband and my little baby boy. We [the family] sit with each other for a long time’.

The direct benefits for women, men and children differed across the AMENCA2 programme. Women experienced support through their children being assisted, involvement in the parenting and PFA training, while work opportunities for men supported their whole families in practical ways. The combination of these activities clearly contributed to overall benefits at the family level, which appeared to be positively impacting all age groups and genders. The children were less demanding and better behaved, their parents were less concerned for their children's psychological health, families supported each other emotionally and greater personal time was enjoyed by the women; all of which reflected greater familial harmony.

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Research question 3: Have the benefits of integrated psychosocial supports in the livelihoods programme influenced family and community supports?

To answer this third research question, the dartboard activity was analysed for the three groups of children, women and male farmers. Before AMENCA2, the children had indicated their families did not support each other well, however, this had increased considerably since the project's inception. Nonetheless, the children still felt that there was room for improvement in this area. In response as to whether children felt they had people they could turn to for emotional support, whether they felt confident to provide emotional support to others, and if they felt they were strong enough to positively cope in a crisis, all children indicated their belief that they were far away from the centre of the dartboard in these areas before the AMENCA2 project, but that this had improved substantially since the project had been implemented.

In response to the key statement ‘I feel my family supports each other’, the women were divided in their opinions to this before the AMENCA2 project work, with some women suggesting poor family support, others moderate and a few women who felt that there had always been family support. However, on reflection of the same statement post AMENCA2 activities, the women were united in depicting their feelings that their family supported each other. In believing the women felt they had people they could turn to for emotional support, some women showed having minimal supports before the project, but much stronger supports afterwards. There was a similar pattern in response to the question of whether or not the women felt strong enough to cope positively in a crisis. In response to the statement that they felt comfortable to provide emotional support to others, most women reported minimal to moderate confidence before the project, and although all women showed an improvement to this provision of support to others after the project, two women felt they still needed more confidence in this area.

The men showed a similar pattern to feeling their family supported each other, feeling they had people they could turn to for emotional support and believed they could cope positively in a crisis, whereas they had indicated minimal feelings or beliefs before AMENCA2 and strong ‘bullseye’ views of these areas after the project. Interestingly, all the men indicated that before the project, they were confident in being able to provide emotional support to others. Although their views did not change considerably in the ‘after the project’ reflection, they still indicated that they felt this had been strengthened since the implementation of AMENCA2 activities.

For children, women and men, the overall pattern was that prior to AMENCA2 project activities, most did not feel supported in their families or communities, did not feel they were resilient to crises, or had confidence to offer emotional support to others. However, after project activities had been implemented, children, women and men all reported marked improvements in their perceptions of family and community supports. For a pictorial demonstration of these findings, refer to Annex I.

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Research question 4: In what ways have the integrated psychosocial support elements of the programme contributed to the livelihood improvements documented by the project?

To answer this research question, the participants were directly presented with the following statement and question: ‘We [World Vision] believe that there has been a link between our livelihood work with adults and the psychosocial support activities with women and children. Why do you think this has been so effective?’. The participants reflected that this had occurred because various activities had reduced stress, increased community engagement and that all of those involved had received holistic support. The notion of a ‘whole-of-family’ approach, the praise the participants had for the facilitators and farmer extension workers, and the perspective of the livelihoods programme taking a psychosocial approach were viewed as being fundamental to the success of the programme. For example, the following quotes show how this whole-of-family and psychosocial approach of AMENCA2 was received and perceived by the participants:

  • Male farmer, aged 37 years: ‘What makes this project different is that it looks to us as humans and deals with us in this way. A human's needs cannot be covered only with money, but money and wellbeing is what is needed for a good man to live’.
  • Male farmer, aged 40 years, indicated that in terms of the farmer extension workers, CFS facilitators and World Vision staff that they seemed to offer more than just inputs: ‘AMENCA is a different project because it gives us a project [as opposed to a ‘hand-out’] and there is follow up from the staff.... When they are monitoring they do it with looking for all your problems [not just farming problems] and help to solve it... It's not important what is doing but how it is done’.
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Discussion

The participants described their ideas of wellbeing to be related to meeting their needs, experiencing good physical and psychological health and feelings of happiness. This is consistent with Giacman et al. (2007) findings that Gazans viewed their quality of life as being inherently linked with their socio-economic status and their capacity to experience some happiness in an otherwise suppressive environment. This finding is also consistent with reports from The World Happiness Report (Helliwell, Layard & Sachs, 2012), where economists have equated subjective wellbeing to happiness which, in turn, is influenced by income, work, community, mental and physical health, as well as positive family experiences. Furthermore, it adds weight to Williamson & Robinson's (2006) and Galappatti's (2003) positions that psychosocial initiatives are likely to be served best when they are integrated with other programmes, and there is a mutual focus on how programmes are implemented, in addition to the project inputs.

Throughout the research, participants did not explicitly use the term ‘daily stressors’, however, their feedback did imply that there had been a positive outcome, in terms of the project's ability to reduce such stressors. Specifically, daily stressors that had been reduced for men included restoration of livelihoods and their ability to appreciate improvements in their psychological wellbeing. Daily stressors that had been reduced for women included being less worried about their children, having personal time to themselves or with their partners, and being able to participate in social activities through the project activities. Daily stressors, such as lack of opportunities for play, family conflict and feeling preoccupied by the war, had been reduced for children who benefited from having a structured programme approved by their parents, in order to play, learn and socialise.

From a family perspective, children, women and men all reported that before the project, family stress was problematic, but project interventions had helped to reduce those stressors and contributed to greater familial harmony. Children, women and men all reported increased feelings of support within their families and communities, and parents in particular, improved in their confidence and capacity to provide emotional care and support for their children. Based on these findings, this study broadly supports in a qualitative way, the model and hypothesis of daily stressors mediating the relationship between traumatic events and mental health put forward by Miller & Rasmussen (2010) and Jordans et al. (2012). This study has also illustrated one example of how to apply this mediation theory of supporting mental health and wellbeing within a humanitarian response and programme.

Based on emerging literature on MHPSS programmes in humanitarian and conflict contexts, it is clear that there is a range of programmatic options for supporting the wellbeing of affected communities. Clinical interventions for severe mental disorders, whether pre dating or in relation to traumatic exposure and events, will always be a necessary aspect of mental health and psychosocial support within humanitarian responses (IASC, 2007; Miller & Rasmussen, 2010). However, it is also now apparent that broader programmes, aiming to reduce environmental and/or conflict related stressors for affected communities could also play a key role. In doing so, it is possible to improve wellbeing, capacity for coping and resilience for communities, families and individuals from a family and community supports perspective. While this has long been advocated by key thinkers in the global mental health field (Galappatti, 2003; Jordans et al., 2012; Miller & Rasmussen, 2010; Williamson & Robinson, 2006) and in the IASC Guidelines on Mental Health and Psychosocial Support, the literature is now gaining ground on the dearth of evidence that has previously struggled to demonstrate its process and effectiveness (Tol et al., 2011a, 2011b; Wessells & van Ommeren, 2008).

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Limitations, challenges and lessons learnt

There are limitations to the methodology and findings of this study, many of which are typical of real time, field based, work. First, the recording and translation of material from the participants was not completed in its entirety, with only key points recorded and analysed. The flow of the group discussions varied according to participants’ responses, with some groups honing in on certain aspects of the research questions more than others. Another limitation of the study is the lack of a control group in which to make direct comparisons of the findings with people who had not been part of the integrated AMENCA2 programmed. Finally, it is vital that the findings are considered with an understanding of the methodological challenges associated with the research implementation (Malterud, 2001).

The research sample was one of convenience, and should not be deemed to be representative of all Gazan people, or even all individuals involved in the AMENCA2 programme. As those interviewed for this study had also participated in the AMENCA2 learning event, they were likely to already partially believe that the psychosocial aspects of the project were complementary to its success. Also, the research team comprised World Vision staff involved in the AMENCA2 project design and implementation, which may have led to bias in the key themes identified from the data.

Based on recommendations by Malterud (2001), this study did not constitute a rigorous, valid or reliably independent process, and findings should be used with caution. Regardless, the research remained useful for World Vision, and potentially for others working within community based MHPSS areas.

The research team believe that increasing time, budget and conventional research processes will be essential in order to formally demonstrate the findings. Although the learning event and donor needs afforded an opportunity for further exploration of these issues, in simplistic and expedient ways, this cannot replace the need for greater planning, management and independent analyses of research findings. The team were also challenged to analyse the findings systematically, not just based on their own viewpoints. They remain committed to the ongoing examination of the links between integrated psychosocial supports with livelihoods, and will pursue this through consideration of wider social impacts and the study of comparative groups who, have received livelihoods support with other organisations, without the psychosocial components. It is hoped that the team will develop such research designs in the next two years, with greater consideration of objectivity, preparation, sample group representativeness and data validity.

Despite the limitations of this imperfect study design and methodology, the key statements and meanings provided by the participants were substantial enough to draw out prominent ideas and thematic suppositions. These could be used as a starting point to continue exploration into how the impacts of less clinical approaches to psychosocial support programmes, including those integrated within various sectoral programs (e.g., livelihoods), can assist the field in both theory and humanitarian practice.

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Conclusions

This research emphasised that people in Gaza view their political situation and the military occupation as pertinent contributors to their overall physical, psychological, social and environmental wellbeing. Giacman et al. suggested that the impact of these factors were so great that the World Health Organization Quality of Life Brief version (WHOQOL-BREF) needed to include an additional ‘political context’ domain in the occupied Palestinian territories (and potentially other conflict environments). This is justified as the political context influences perceived causes of daily problems, stressors, familial impacts (due to lack of employment and access to services), as well as psychosocial wellbeing. This finding was further supported in a later study by Mataria et al. (2009), which connected the negative associations of the political and military context with higher levels of distress, fear and reduced financial and freedom status for men, women and their children.

World Vision staff, community members and AusAID observed that this project, with its psychosocial support components, has led to considerable change in the communities and families where the project was implemented. The psychosocial support activities appear to have enhanced the impacts of the livelihoods work, and AMENCA2 stakeholders also reported this at a learning event held in February 2013. Positive feedback was anecdotally received from men, women and youth, all of whom seemed to be experiencing broader and more enhanced quality of life since the project began.

This study has offered a practical example of how a project can effectively deliver a multidisciplinary and integrated psychosocial approach to its activities. All parties, notably the direct beneficiaries of the project, have perceived how this has supported their reduction in daily stressors and increased their sense of wellbeing. Predominantly, it appears from this study, that one of the best ways to successfully integrate psychosocial support within a multidisciplinary programme (in this instance, a livelihoods programme) is to take a ‘whole-of-family’ approach, and to ensure the management of the project is implemented with respectful, holistic and genuine care for all beneficiary needs, not just their material needs. It appears that ‘how it is done’ is perhaps as vital to project success and psychosocial supports as ‘what is done’.

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Acknowledgements

Thanks to Mark van Ommeren for his editorial support, and to Ola Mahmoud Masoud and Suzan Alwahedi for their excellent work on the transcripts for this research.

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Annex 1: Original ‘dartboard’ results from children, women and men

Light stickers indicate belief of the statement before project activities. Dark stickers indicate belief of the statement after project activities. Key statements were: (1) I feel my family supports each other; (2) I feel I have people I can turn to for emotional support; (3) I feel confident to provide emotional support to others; (4) I feel strong enough that I could cope in a positive way to a crisis.

Figure

Figure

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      Keywords:

      conflict; daily stressors; psychosocial; wellbeing

      © 2014 War Trauma Foundation, Diemen, The Netherlands