Improving mental health and socioeconomic outcomes of women survivors of violence: Impact Evaluation of Narrative Exposure Therapy in Eastern DRC Alev Gürbüz Cuneo Léa Rouanet Moussa Sawadogo Julia Vaillant ICDE Clermont-Ferrand June 30th, 2022 Context ➢ High rates of Gender Based Violence in the DRC ▪ 27% of women experienced sexual violence at some point in their lives (2013-14 DHS) ▪ 57% of women experienced physical or sexual violence ➢ Persistent conflict and insecurity ▪ large-scale civilian deaths and displacements ▪ systematic violence against women and girls in Eastern DRC ▪ reports of atrocities committed by armed forces, including sexual violence 2 Motivation ➢ Survivors are at high risk of psychological distress and mental health disorders ➢ Limited services to support SGBV survivors ➢ Scarcity of adequately trained mental health service providers • Urgent need for low cost, effective mental health services in low- income and conflict/post-conflict settings • But very limited evidence on effective mental health interventions in such contexts 3 Narrative Exposure Therapy ➢ Narrative Exposure Therapy (NET): ▪ World Bank funded project – Great Lakes Emergency Sexual and Gender Based Violence and Women’s Health Project ▪ Implemented by the Government of the DRC ▪ Design, Training, and Supervision: vivo international ➢ Address trauma in survivors of sexual violence in North and South Kivu ▪ Short term intervention ▪ 8-12 individual sessions with a counselor of approximately 90 minutes each ▪ Trauma survivors undergo multiple distressing events within their lifetime • Focusing on the traumatic events, the patient constructs a chronological narrative of his or her life story and a coherent narrative is then structured with the assistance of the therapist. 4 Narrative Exposure Therapy ➢ Therapy delivered by counselors in the Center of excellence Heal Africa, in health centers, and in Community-Based Organizations (CBOs). ▪ Healthcare professionals ▪ Psychosocial assistants: non-professionals Heal Africa 8% N=89 N=142 Health Center 14% N=822 CBO 78% 5 Heal Africa Health Center CBO Research Questions ▪ What is the impact of the Narrative Exposure Therapy (NET) on female survivors’ mental health in Eastern DRC in the short term? ▪ Is this impact durable in the medium term? ▪ What is the impact of NET, through the improvement in mental health, on women’s economic empowerment, labor participation, and other psychosocial outcomes in the medium term? ▪ What is the differential impact of NET when delivered by healthcare professionals vs. laypeople? 6 This paper What we do ➢ Measures the causal impact of NET on three sets of outcomes: ▪ Mental health outcomes: PTSD (HTQ-16) and Depression and Anxiety (HCL-25) ▪ Economic empowerment outcomes: labor force participation, paid work, earnings, savings, decision-making, sharing of housework, childcare ▪ Psychosocial outcomes: self-esteem, local functioning, management of problems, social groups, networks, mobility ➢ Look at heterogeneity of impacts by mode of delivery Contribution ➢ First rigorous evaluation of NET in a conflict setting ➢ Large sample ➢ New outcomes: economic empowerment outcomes ➢ Studying several modes of delivery 7 NET IE Design and Data Collection ➢ Randomized Control Trial at the individual level ➢ Treatment group received NET – delivery of NET in cohorts by counselors ➢ Control group received standard of care provided in the Great Lakes project ▪ Waitlisted to receive NET until after endline ➢ Data collection in 3 different points in time. ▪ Baseline – between June 2017 and Oct 2019 ▪ Midline – 3 months after delivery of NET ▪ Endline – 12 months after delivery of NET 8 Preview of results ➢ Significant effects on mental health outcomes of NET beneficiaries both in short term and in medium term ▪ Decrease in Post-Traumatic Stress Disorder ▪ Decrease in depression and anxiety ➢ Significant increase in beneficiaries’ self-esteem and local functioning but no effects on other psychosocial outcomes ➢ Weak impacts in women’s economic empowerment improvements. ➢ NET has a significant impact only when delivered by laypeople through Community Based Organizations 9 Sample Characteristics at Baseline (1) (2) t-test Control Treatment Difference N Mean/SD N Mean/SD (1)-(2) Age of the respondent 528 36.063 525 34.907 1.156 [13.020] [12.790] Married or living with a partner 528 0.441 525 0.434 0.007 [0.497] [0.496] Respondent has been in school 528 0.563 525 0.543 0.020 [0.497] [0.499] Respondent is the household head 528 0.419 525 0.398 0.020 [0.494] [0.490] Years of education of the respondent 528 3.093 525 3.301 -0.208 [3.629] [4.031] Total household size 528 6.598 525 6.731 -0.133 [2.568] [2.570] 10 NET significantly improves mental health outcomes -0.14*** -0.1*** -0.13*** -0.12*** Also: • Significant negative impact on probable PTSD: 10% lower probability at Midline • Significant negative impact on probable depression and anxiety: 6.5% lower probability 11 Among psychosocial outcomes, NET improved self-esteem and local functioning 0.07*** 0.05* -0.07* ➢ No impact at midline or endline on other psychosocial outcomes: management of problems, self-care, social groups, networks, mobility. More 12 Impact of NET on economic empowerment variables -0.05* -0.055* -1.95* ➢ No impact on the respondent’s likelihood of working or having paid work in the last 7 days but decrease in the working hours at endline. 13 Impact of NET on economic empowerment variables 0.05** 0.10*** -0.06* ➢ Increase in saving probabilities and in the respondent’s decision power index in the household at endline 14 Heterogeneity analysis by delivery mode - 0.14*** - 0.15*** - 0.11 - 0.02 The impact of NET on mental health is significant only when delivered in CBOs: NET counselors who are not healthcare professionals No significant impact of NET when delivered in health centers or Heal Africa Caution with interpretation: the differences between modes of delivery is not significant 15 Conclusion ▪ Psychotherapy that works in low income, low literacy conflict affected setting, with high levels of trauma ▪ Mental health impacts are significant and sustained over time ▪ Smaller compared to other studies ▪ Control group not “pure” : might have benefited in priority for alternative treatments or supports → lower bound of the impact ▪ Small impacts on economic empowerment, but if anything women are better off ▪ Is it too soon to be transformative? ▪ Significant impact in CBOs but not Health Centers/Hospitals ▪ It works when non-professionals deliver it ▪ Implementation in CBOs makes more sense in that context ▪ Barriers to implementation by healthcare professionals ▪ CBOs more accessible and treatment more acceptable ▪ CBOs offer complementary services that could be key ▪ No causal inference: mode of delivery not randomized ▪ Another implementation lesson: ▪ Works better when there is proximity between the counsellor and the survivor (same language) 16 Thank you! Léa Rouanet (lrouanet@worldbank.org) 17 Delivery mode: what does this mean? Discussion on the heterogeneous impacts by delivery mode ➢ Suggestive evidence that the CBO delivery mode is more impactful ▪ NET has a significant impact on mental health outcomes, self-esteem and # hours worked only when delivered in CBOs. ▪ Caveat: differences between delivery mode are not significant. ➢ What is happening in CBOs? ▪ Counsellors: closer to the survivors - geography, language, socio- economic status ▪ Counsellors: fewer competing activities ▪ Women get a lot of additional complimentary services in CBOs ▪ Institutional differences → Heterogeneity by counsellors’ characteristics 18 Balance checks – Mental health and psychosocial outcomes (1) (2) t-test Control Treatment Difference N Mean/SD N Mean/SD (1)-(2) PTSD checklist score 528 1.953 525 1.964 -0.011 [0.565] [0.596] Probable PTSD 528 0.701 525 0.703 -0.002 [0.458] [0.457] HSCL-25 score for combined depression and anxiety 528 2.138 525 2.141 -0.003 [0.541] [0.549] Probable depression or anxiety 528 0.794 525 0.792 0.001 [0.405] [0.406] Self-esteem perception index (ave) 528 1.303 525 1.310 -0.007 [0.467] [0.479] Local functioning impairment index 528 1.436 525 1.377 0.060 [0.691] [0.682] Corrected index of strategies (ave) 528 0.708 525 0.730 -0.022 [0.540] [0.525] Number of social groups the respondent participates in 528 1.290 525 1.166 0.124* [1.151] [1.160] Respondent is not prevented from visiting family/friends or working outside in last 12 months 528 0.623 525 0.661 -0.038 [0.485] [0.474] Respondent has people to talk with in her network 528 0.833 525 0.813 0.020 19 [0.373] [0.390] NET IE Design Screening of survivors by nurse Eligible, most Eligible Non eligible severe cases NE Receive immediate Treatment Control Waiting list treatment or NT = 6 NC = 6 NW = NE – 12 referral to other Baseline survey Baseline survey Not in survey mental services Eligible for next round of Receive psychosocial randomization. Receive NET in support now. Receive NET if survivors in next 1-3 months Receive NET after 15 treatment group declines to months (after endline) participate. 20 Timeline for Data Collection Baseline Midline Midline End of Baseline in the in the in the End of Midline at HA HCs HCs CBO Baseline May June Feb Aug Feb Oct 2019 2020 2017 2018 2018 2019 (N=1053) (N=989) Midline Baseline Endline Endline Midline End of at HA in the at HA in the HC phone Endline Jan CBOs Nov May survey Feb 2018 July 2018 2019 April 2021 2018 2020 (N=979) 21 Measuring PTSD using HTQ-16 PTSD Checklist (HTQ-16) Posttraumatic Stress items 1. Recurrent thoughts or memories of the most hurtful or terrifying events 2. Feeling as though the hurtful or terrifying event is happening again 3. Recurrent nightmares (about the event) 4. Feeling detached or withdrawn from others 5. Unable to feel emotions 6. Feeling jumpy, easily startled 7. Difficulty concentrating 8. Feeling on guard 9. Feeling irritable or having outbursts of anger 10. Avoiding activities that remind of the traumatic or hurtful events 11. Feeling as if you don’t have a future 12. Avoiding thoughts or feelings associated with the traumatic or hurtful events 13. Sudden emotional or physical reaction when reminded of the most hurtful/traumatic events 14. Inability to remember parts of the most traumatic or hurtful events 15. Feeling no interest in things/less interest in daily activities 16. Having trouble falling asleep/staying asleep ➢ Participants rate how often they experienced each symptom in the prior four weeks using a 4- point Likert scale (0=not at all, 1=little bit, 2=moderate amount, 3= a lot). ➢ Average per-item scores with a range [0-3] where higher scores indicate greater severity. Back 22 Measuring Depression & Anxiety using HSCL-25 Hopkins Symptom Checklist 25 (HSCL-25) Depression/Anxiety items 1. Feeling low in energy, slowed down 16. Suddenly scared for no reason 2. Blaming self for things 17. Feeling fearful 3. Crying easily 18. Faintness, dizziness or weakness 4. Loss of sexual interest or pleasure 19. Nervousness or shakiness inside 5. Poor appetite 20. Heart pounding or racing 6. Difficulty falling asleep, staying asleep 21. Trembling 7. Feeling hopeless about the future 22. Feeling tense or keyed up 8. Feeling sad 23. Headaches 9. Feeling lonely 24. Spells of terror or panic 10. Thoughts of ending your life 25. Feeling restless, can’t sit still 11. Feelings of being trapped or caught 12. Worrying too much about things 13. Feeling no interest in things/less interest in daily activities 14. Feeling everything is effort 15. Feelings of worthlessness- no value ➢ Participants rate how often they experienced each symptom in the prior four weeks using a 4- point Likert scale (0=not at all, 1=little bit, 2=moderate amount, 3= a lot). ➢ Average per-item scores with a range [0-3] where higher scores indicate greater severity. Back 23 Local Functioning Impairment (LFI) Index In the last 4 weeks, how difficult was it to: 1. cultivate, fill your farming activities, raise animals? 2. trade or carry out your business/income generating activities? 3. cook? 4. take care of children? 5. socialize with your family members (advice to family members, unify your family members to do beneficial tasks to your family, take part in family activities and events)? 6. socialize with members of your community (give advice to members of your community (non-family), unify members of your community for doing beneficial tasks for your community, socialize with members of your community, take part in activities in your community and events organized by your community)? 7. exchange ideas? 8. do any type of manual work? 9. ask for or receive help from people or organizations when you need them? 10. make important decisions about your everyday life? 11. learn new skills? 12. focus on your tasks and responsibilities? 13. interact with people you do not know? 14. go to church or mosque as usual? ➢ LFI index is created by taking the average of 14 item scores rated on a 5-point Likert scale with values ranging from “0=No difficulty” to “4=So difficult that she couldn’t do it”. Higher scores indicate more difficulty in local functioning. 24 Counselor Characteristics N Mean SD Counselor is female 45 0.93 0.25 Counselor's age 45 39.02 10.64 Counselor is married or cohabiting 45 0.80 0.40 Counselor has children 45 0.93 0.25 Average number of children counselor has 42 5.07 2.43 Counselor's years of education 45 13.16 2.70 Has been in school 45 1.00 0.00 Highest level of education: some secondary 45 0.62 0.49 Highest level of education: some post-secondary 45 0.29 0.46 Highest level of education: some univ 45 0.09 0.29 Counselor's main activity is agriculture 45 0.40 0.50 Counselor is in health sector 45 0.24 0.43 Counselor's language is Swahili 45 0.71 0.46 Counselor's language is Kinyarwanda 45 0.13 0.34 Counselor's language is Mashi 45 0.09 0.29 Counselor's language is French 45 0.07 0.25 Average # of NET sessions to complete a case of NET 45 6.58 1.51 Min # of NET sessions to complete a case of NET 45 6.09 1.35 Max # of NET sessions to complete a case of NET 45 10.69 2.10 Counselor has experience in other therapies 45 0.89 0.32 Counselor's birthplace is same with treatment territory 45 0.64 0.48 25