Youth FORWARD Hub Project Summary
DR. BETANCOURT: So we're here today to talk about Youth FORWARD, capacity-building in alternate delivery platforms and implementation models for bringing evidence-based behavioral interventions to scale for youth facing adversity in West Africa. I'm Theresa Betancourt of the Boston College School of Social Work and director of the Research Program on Children and Adversity, and I'm joined by my MPI colleague Nathan Hansen, Professor of Health Promotion and Behavior Change at the University of Georgia College of Public Health.
We're going to give you a little bit of background on the need for mental health and psychosocial evidence-based interventions in post-conflict settings, how our project has moved from longitudinal and intergenerational research to intervention development with the youth readiness intervention, and then how we have been in recent years working on the challenge of scale, how to integrate evidence-based mental health interventions into new delivery platforms, such as education and livelihoods and entrepreneurship programs as we did in youth forward, and how we address issues of quality and fidelity in so doing, and then we'll talk about the Youth FORWARD design and what we learned and next steps.
So here is a graphic overview of our partnerships. You see the admin core at Boston College, the capacity building core at University of Georgia, and the scale-up study that took place in Sierra Leone, but also a lot of work with the government of Sierra Leone and partners at the University of Sierra Leone University of Liberia on capacity building and implementation science research.
Here is our amazing team at all the institutions, including Caritas Freetown and Innovations for Poverty Action, who are also a part of the research, and Haja Wurie, our co-investigator at the University of Sierra Leone.
So to talk about post-conflict environments and conflict-affected settings, as we see in the news today, these are not side issues. These are central public health issues. We are facing the largest humanitarian crisis since World War II in our lifetimes, with over 452 million children living in active conflict zones. When you move to post-conflict settings and fragile countries that still have the vestiges of conflict like Sierra Leone and Liberia, we're talking about even greater numbers.
So one in six children living in conflict are massive public health issues, and they have developmental consequences across the life course.
If you're interested in adversity and child and youth development, Sierra Leone offers far too many opportunities. On the UN Human Development Index, it's ranking 182 out of 187 countries. The highest rate of maternal mortality on earth, very low rates of literacy in females, and low life expectancy and underemployment in young people.
This was all made possible by an 11-year civil war that raged from 1991 to 2002 and also decimated the health system, setting the groundwork for the 2014-2016 Ebola virus disease outbreak, which further set back opportunities for young people and contributed to distress, trauma, and loss. COVID-19, 14 percent of Sierra Leone is vaccinated, but its health system today continues to struggle, and opportunities for youth are limited.
We started a study at the end of the war in 2002, a longitudinal study of war-affected youth, following the lives of 529 young men and young women who were 10 to 17 when the war ended and really trying to understand what were the factors that shaped more risky or more resilient life trajectories over time.
From that, we developed the youth readiness intervention and then most recently in Youth FORWARD have been testing strategies for scaling. So just to tell you a little bit about results of the longitudinal study and the groundwork that was laid, we immediately saw that poorest outcomes when it came to mental health were amongst those who had an accumulation not just of war-related experiences, especially toxic stress exposures and trauma, but these were made much worse by the post-conflict environment when young people came back to poor community relationships, low guidance, and social support, multiple daily hardships, food insecurity, housing insecurity, and limited access to education and life opportunities.
And mental health got in the way of those life opportunities. For young people who had functional impairments, interpersonal deficits, emotion dysregulation problems, they might struggle to take up life opportunities like getting back into education or livelihoods and employment programs.
So the youth readiness intervention drew evidence-based common practice elements, transdiagnostically, that have been used for youth exposed to violence, drawing mainly from cognitive behavioral therapy, but also some components from group interpersonal therapy, and mindfulness based practices. It was designed as a group intervention model that could be delivered by non-specialists, and you see the flow from stabilization and skills to integration of those skills and then connection to others.
Core components include psychoeducation about trauma and its effects on yourself, your relationship with others, emotion regulation skills for when young people are in situations that are triggering, how to modulate those strong reactions, cognitive restructuring, challenging negative views of yourself and the world around you, behavioral activation, which has a tremendous evidence base for reducing depression, staying busy in the presence of others, and communication interpersonal skills. How to put your best self forward and using the group to set life goals and move towards them using sequential problem solving, step by step progress towards life goals.
This is all done in a group process with same gender groups. You have same gender facilitators, same gender group participants.
In the randomized control trial that we published in JAACAP in 2014, we saw pre- to post-intervention with the youth readiness intervention improvements significantly in emotion regulation improving, prosocial and interpersonal skills, improved functional impairments, and also improved perceptions of social support. But we also had evaluations of teachers who did not know who received the intervention and who hadn't, and we saw that teachers blind to status reported that young people who received the youth readiness intervention were six times more likely to persist in school and showed up better prepared and were better behaved in the classroom.
So that was really the genesis for thinking about Youth FORWARD. If this worked in education programs, what was possible within youth entrepreneurship and livelihoods programs? So we partnered in developing our U19 hub with the government of Sierra Leone and the District Youth Councils, as well as the German Development Agency, GIZ, that was looking to incorporate evidence-based mental health and psychosocial supports into its programming, and we were looking for platforms for scale. We found when we screened young people applying to these programs, 40 percent met criteria for emotion dysregulation and functional impairments.
To talk about our hybrid type II scale-up study, the first aim was to use a collaborative team approach to scale and sustain the youth readiness intervention and to conduct an impact evaluation of that integration, in particular to identify internal and external factors from the EPIS framework of implementation science developed by Greg Aarons that might be influencing successful integration of the youth readiness into the employment promotion program in Sierra Leone, using a process evaluation, understanding barriers and facilitators.
And then in our third aim, we were looking at clinical effectiveness, comparing the results when we delivered the youth readiness intervention through this platform of entrepreneurship programs run by the government and funded by GIZ, and looking specifically at mental health, emotion regulation, functional impairments, in high-risk youth, but also looking at their socioeconomic benefit and whether or not we saw economic self-sufficiency impacted over time, as well as behavior in those programs.
So we were using core elements of the collaborative team approach such as cross-site learning. We worked in three rural districts, Kono, Kailahun, and Koinadugu. They were sharing lessons learned on overcoming barriers as they used plan-do-study-act cycles to investigate barriers, come up with solutions, try them out, innovate, and then when those things worked to share that across the different districts so that people could learn from one another.
We had a common charter. We had routine collaborative team approach cross-site meetings, and we also spent a lot of time thinking about fidelity monitoring and quality improvement. So experts in the youth readiness intervention were based out in the rural districts, would do live sit-ins on some of the sessions and give live feedback, as well as tracking a fidelity checklist and feeding that back into the quality improvement process.
So now I'm going to turn it over to Nate to talk about the study design and findings.
DR. HANSEN: Thank you. As Theresa mentioned, we did this study in three rural districts. You can see them highlighted on the left side of the map on the screen. Youth were recruited through outreach conducted by GIZ as they were advertising their entrepreneurship program to youth. Our inclusion criteria included youth aged 18 to 30 who were not employed or in school fulltime, were not currently pregnant, and who showed elevated scores either on the WHODAS, the functional impairment, and on the Difficulties in Emotion Regulation Scale.
We aggregated the sample into 59 clusters, which were stratified by gender, and then they were divided into three conditions with 30 sites. So you can kind of see the flow across this screen here. We had a control condition, we had an entrepreneurship only condition, entrepreneurship program, and then we had the youth readiness intervention plus the entrepreneurship program. Youth were randomized by cluster, stratified by gender into these conditions. We had a baseline assessment. We did a post-assessment after the delivery of the YRI, youth readiness intervention, and then we had our end line assessment after the entrepreneurship program, three months later.
So this is a busy slide, lots going on, but basically what we did is we spent a lot of time trying to identify geographic clusters, geographic areas where we could collect a group of people, a group of youth, and that would be distinct. So there was not a chance of diffusion of intervention effects or spillover across the different sites.
Once we'd identified these clusters, we then matched them on 11 different variables to look for size and distance to travel to the sites and so on, and then we would divide those within groups of three. So we had triads of clusters that were similar to each other, and then we would randomize those into our three different conditions.
We analyzed our data using a linear mixed models approach, which allows us to take advantage of all data collected across all timepoints, our baseline, our post YRI, and our post entrepreneurship times. We're looking at change across time as well as difference by condition.
As I mentioned in the last slide, we actually used the variables that we used to aggregate our clusters and define our clusters as covariates in this model, as well.
Here you can see our consort diagram. We assessed or screened almost 3,500 youth. Of those, 2,255 youth were eligible for the program, although with our clustering we weren't able to include all of them, because we had them in distinct clusters geographically. We had 1,192 youth who were enrolled and completed consent, and then you can see how our flow kind of goes through our three conditions down each column.
The total sample that we analyzed was 1,151 youth. The average age was around 25 years old. You can see that we had similar numbers of men and women, which we attempted to have equal numbers, which is why we stratified by gender. We had a few more, 52 percent female, 47 percent male, and then as far as school attendance, almost 75 percent had attended school, but a sizeable number, over 25 percent of the sample, had never attended school before.
So here's a slide for our mental health results. You can see our table here shows our findings. I'll go over just the highlights here for time. So immediately after the YRI delivery, so sort of the middle column in the table, we found that youth who were both in the YRI plus entrepreneurship program reported reductions in emotion regulation -- difficulties in emotion regulation -- as well as improvements in overall anxiety and depression symptoms, and at the endline after the entrepreneurship program, youth who were in the combined YRI plus entrepreneurship program still reported reductions in the mental health outcomes depression and anxiety, compared to our controls.
Overall, across time, we did see that youth who were in the YRI plus entrepreneurship program reported and maintained reductions in depression and anxiety.
One point to make just on this mental health outcomes, and I think also applies to the SES outcomes, this was a very much carried by the males in the study. In our post hoc analyses and what we're kind of looking at now as we're diving deeper into the data, a lot of the findings were driven by males. The females actually did not do as well with this, and our qualitative data is suggesting that this is because of a lot of barriers that women experience with childcare, with partner violence. This is an area we are starting to look at more deeply with our data as we're going into our follow-up analyses.
Our SES results, again, here we have tables showing these, but I'll just hit the highlights. What we found was that participants who were in the entrepreneurship program and the YRI plus entrepreneurship program all increased their hours worked for self-employment. So their self-employment hours went up, in comparison to the control condition, and while the overall net income didn't increase, the amount of money that youth were making from self-employment actually went up for the entrepreneurship plus YRI. So we saw improvements in youth moving into self-employment in the outcomes of the study.
Theresa, I'll turn it back to you.
DR. BETANCOURT: Great, thank you. So just to wrap up and talk about the bigger picture implications and next steps, we did find in Youth FORWARD that integration of the youth readiness intervention into existing delivery platforms such as youth entrepreneurship and livelihoods programs was an important innovation that was both feasible and acceptable, and effectiveness is also evidenced from the data we just shared.
We think that in post-conflict and fragile settings like Sierra Leone, Liberia, and other war-affected countries, using such alternate delivery platforms could help increase access to limited evidence-based mental health services for young people. We do see that YRI participation appears to also have augmented the employment program benefits and occupational functioning, which is very exciting. We're currently, in addition to the gender analyses, looking at a return on investment analysis so that we can help governments and investment communities make these arguments about return on investment for such important mental health programs for violence-exposed youth.
And we're also continuing to explore other platforms where we can bake in the cross-site learning, the collaborative team approach, and the fidelity monitoring and quality improvement as we go and continue to scale using collaborative team approaches. We now have an adaptation of this intervention going on for war-affected youth in Colombia, a new project funded in South Sudan, and are looking for other ways to continue to work with government of Sierra Leone and partners there to continue to increase access.
So we're grateful for this opportunity, and with that, we'll wrap up and thank you.