17.6 Million People
are Currently Impacted by War and Conflict
Across East, West and Central Africa.
CHALLENGES AND CONCERNS
➤ PTSD May Heighten the Risk for Poverty Further Aggravating the Consequences of War and Conflict.
A recent study of traumatised Congolese refugees in Uganda confirmed previous studies indicating that trauma survivors present significant impairment in cognitive and psychosocial functions. Such impairments make it challenging for traumatized populations to attend school programs, keep jobs, and contribute to playing a role in emerging economies.
➤ Trauma Relief is Not a Humanitarian Priority
Humanitarian assistance is stretched thin, with few if any resources for psychosocial support and mental health. Under-resourced health systems have other priorities and there is still little appropriate support for people living with trauma, PTSD and extreme stress.
➤ Current Efforts are Expensive
The World Bank, Liberia and Japan have a psychological support project reaching approx. 18,000 beneficiaries with mental health and psychosocial support to alleviate the consequences of the Ebola epidemic in West Africa. While necessary, this and other trauma interventions rely on individual, one-on-one approaches that are costly and cannot be taken to adequate scale.
➤ No Evidence-Base is Available to Guide Treatment Choice
There are not enough trauma treatment studies with African groups. Systematic reviews [5, 6, 7, 8, 9] identified experiments that investigated the efficacy of trauma treatment models for refugees worldwide. Even with a handful of studies, researchers were unable to draw a firm conclusion of what treatment works and should be recommended for refugees, considering all studies were methodologically diverse, and involved different refugee populations. Among all studies identified, only two [10, 11] were conducted with Africans (Sudanese, Rwandan and Somali groups).
We urgently need more scientific research to develop best practices around trauma relief interventions in war-impacted communities.
➤ Post-Traumatic Stress Disorder (PTSD)/ Complex Trauma (cPTSD)/ Extreme Stress are Common Outcomes of War.
While categorizations and severity levels may vary, all expressions of traumatic stress are debilitating and shatter one's ability to function in society. PTSD is often associated with psychiatric comorbidity and chronic cognitive, behavioral, and physiological impairment.
➤ Trauma is a Silent Epidemic
A genetics study of refugees from the Rwanda genocide reported rates of PTSD diagnoses to approach 100% based on the nature and severity of a traumatic event. Alongside genocide, other common war crimes across Africa can be categorised among some of the most severe worldwide:
- The use of children in armed forces and groups
- Pervasive sexual violence as a weapon of war
- Physical mutilation
- Systematic torture
A national survey in Liberia also indicated that 44% of the total population reported PTSD symptoms 5 years after the end of the second war, but experts suggested the numbers were likely higher. Other post-conflict zones in Africa and worldwide have testified to similar statistics [1, 2].
➤ Time Doesn't Always Make it Better
PTSD typically follows a chronic, often lifelong, course. While we are still trying to understand the biological make-up that helps some people to heal naturally and others not, it's been well documented that trauma symptoms remain pervasive in refugee groups decades after traumatic exposure [3, 4]. PTSD has also been noted particularly predominant in individuals from specific geographical locations where violent conflicts took place, such as Nimba County in Liberia, even twenty years after the war.
➤ The Ebola Outbreak Worsened Existing War-Related PTSD
West Africa was declared Ebola-free, and the majority of mobilised humanitarian assistance have left, but the long-lasting impact of the endemic on mental health among communities that had already suffered so much is in most part unattended.
An Innovative Response
A Trauma Relief Tool for Humanitarian Emergencies
With the in-kind support of global partners, we have developed and are now finalizing preparations to field test an innovative clinical curriculum for trauma in a digitised mHealth prototype, that promotes research collaboration and large-scale dissemination of trauma relief in war-impacted communities.
- Short-term 10-hour program.
- Combined clinical models.
- Psychological safety.
- Manualized curriculum.
- Neurophysiological framework.
- Altruistic approach to scale.
- Audio tracks in local dialects for communities with high incidence of illiteracy.
- Open source with DHIS 2 interface for Ministries of Health (MoHs).
- Research version available for scientists to monitor clinical efficacy and improve content overtime.
- Free download.
mHEALTH/ software FEATURES
- FIELD VERSION
Designed as a tool for lay health workers to independently lead trauma relief groups in their own communities.
- Integrated health assessments to track improvement of each group member.
- Simple layout and easy-to-follow content.
- Encrypted digital database of beneficiaries and immediate impact evaluation for service providers.
- RESEARCH VERSION
Designed for clinical research trials with advanced features. This version will become available to scientists interested in conducting independent investigations to (i) verify the efficacy of the intervention with new demographics, (ii) replicate studies, and (iii) continuously improve the curriculum. Both group and individual modes available. Features include:
- RSA encryption for digital data storage at SQLite application and MySQL server.
- Integration to biofeedback equipment to objective measure levels of subject stress during trials.
- Security settings such as restriction of data access to protect participant’s confidentiality.
- Text-to-speech software audio to control for pitch variables.
- A user-friendly interface developed to facilitate subject participation.
- Automated wellbeing, stress (SUDS scale) and temperature check-ins added during exercises.
- Lock-in feature: For studies examining individual and remote use of the intervention, the curriculum is programmed to unlock tasks every 24-hours, at the daily time stipulated by the participant during baseline. This feature prevents participants to attempt to complete the curriculum in less than seven days.
- A daily alarm has been set to remind participant to complete the tasks at 1 hour and at 15 minutes before starting time.
- Time-tracking features to register precise subject participation, e.g. when an exercise has been paused, skipped, or not played.
Our original intervention framework evolved from:
- Years of experience delivering and adapting western trauma care approaches to thousands of beneficiaries in West Africa since 2008.
- Emerging neuroscience studies delineating cross-cultural neurobiological markers of war-related trauma, further informing pathways of restoring systems disrupted by traumatic stress.
- Expert consultations to integrate our field experience and the latest scientific discoveries to practical, simple, and harmless exercises at community level.
Encouraging trauma survivors to share their stories is not recommended without supervision of qualified therapists due to the high likelihood of re-traumatization. But recent studies indicate that talking about what happened may not be a necessary step towards healing, which is very good news for humanitarian relief efforts. It allows us to choose safer approaches that we can take to scale in regions that lack qualified workforce. Our model does not directly address the traumatic narrative via techniques of exposure that could trigger distress.
COMBINED CLINICAL MODELS
We've seen it many times: when it comes to mental health treatment, one size doesn't fit all. We did the research and integrated safe elements of evidence-based methods that target the clinical objectives in each of our modules. Clinical approaches utilised include: IPT, CBT, EMDR, SE, yoga breath work, and MBCT.
For optimizing clinical consistency and dissemination.
SHORT-TERM 10-HOUR PROGRAM
There is no known cure for PTSD, and we are not suggesting, unless the data we will collect tell us otherwise - that trauma could be healed in 10 hours. What we do know is that various techniques can optimise brain circuitry to promote a sense of safety, reconnection and symptom relief. Such relief, as we have observed over the years in our clinical projects, is powerful to significantly improve quality of life. In some cases, beneficiaries never complain about trauma symptoms again. Take a look at our success stories.
We chose a neurophysiological framework because it is grounded on universal evolutionary processes of fear and survival systems, making it suitable for cross-cultural application. Relational tasks have been revised, edited, and approved by our African staff to assure for a culturally integrated curriculum. Moreover, our African leaders also named the tasks, and contributed with cultural metaphors and analogies. While minor revisions of local colloquialisms will be recommended between countries, it is a simple and feasible task during translation stages.
Approximately 20 million people are identified as people of concern by the UNHCR including 4.4 million refugees and 11 million internally displaced people (IDP’s). We will prioritize implementation in areas where relief is precarious and needed most urgently.
IDPs: 190, 591
In Phase 1 of the project, we developed a comprehensive clinical curriculum for trauma relief and built the first clinical and research prototypes.
We started Phase 2 in Liberia with individuals traumatized by the 14-year Liberian Civil War and Ebola. We plan to extend the project to nortern Uganda, due to the emerging crisis in South Sudan by January 2018.
Once we have tested and iterated a working version of the digital app, in Phase 3 we plan to conduct two randomized clinical trials (RCTs) to examine efficacy of the clinical curriculum in reducing symptomatology (pre, post and 6-month follow-up). We anticipate this step beginning in 2019, dependent on funding support and our network of implementing partners.
Total People of Concern
Source: UNHCR Global Appeal 2016-2017
Built to Scale
The Sankofa mobile app is designed to work in communities with limited access to electricity and low connectivity.
Falling connectivity and device prices mean we are seeing the rapid adoption of smartphones in Sub-Saharan Africa and in two years Africa will have more than half a billion smartphone users (GSMA).
Because smart phone ownership is growing but still limited, the app’s use case takes a one-to-many approach. This means that only one device is needed to run the protocol on the app for a group of many people. In terms of scale, one facilitator with one device can reach multiple groups at one time, and multiple groups over time.
Group Facilitators Using the Sankofa App
The app provides a training resource and job aide to Sankofa facilitators and others, including non-profits and community health workers, who would be using the app in their programs.
Because it collects real-time data on groups and group members, the app also functions as a management information system (MIS) for group facilitators. We follow best practices to safeguard the privacy and security of group member data.
IT WILL ALWAYS BE FREE
Our project and our diverse team of Second Chance Africa facilitators and mental health advocates, app developers, ICT4D experts and researchers are guided by the Digital Development Principles (http://digitalprinciples.org/).
Our implementation partners will have unrestricted access to the Sankofa platform, which will be free and open source.
Our Vision to Bring Mental Health Care to War-Impacted Communities
We see the Sankofa app as one piece of a larger plan to scale our Second Chance Africa protocol for trauma relief across war-impacted communities.
An Altruistic Approach to Scale:
Second Chance Africa's Model
The Survivor Mission
Among every group of trauma survivors, there are individuals who come to recognize their own victimization, seek to understand it, and transform it as the motivational basis to create wider societal change. They understand that whilst ‘there is no way to compensate for the atrocity, there is a way to transcend it by making it a gift to others’. These individuals are able to harness and transform their own personal trauma into a period of Post-Traumatic Growth (PTG). Those who adopt a survivor mission, primarily practice it out of a place of compassion and altruism: they have a desire to enable and empower others, while also recognizing that they need it for their own personal recovery. Their own recovery becomes inextricably linked with their commitment to social action, and their mission to create change becomes an inherent part of who they are.
We are maximizing on both therapeutic and scalable qualities of post-traumatic growth to enhance recovery and dissemination.
We integrated in the curriculum practical tasks that encourage participants to engage in acts of altruism between sessions, from planning to execution (if they choose to, when they decide they are ready to), also screening graduating participants to become new community health workers.
The clinical rationale behind many tasks in our intervention were based on Dr. Stephen Porges' work, which delineates the role of a cranial nerve throughout mammalian evolution in social and survival systems, both heavily impacted by traumatic exposure. His discoveries indicate that social engagement can play a critical role in restoring such impairments.
of Altruistic Action
- It builds interpersonal skills to cultivate secure attachments.
- It enhances sense of environmental safety.
- It drives proactive behavior reducing learned helplessness.
- It increases social empathy.
- It promotes interpersonal connectedness by initiating healthy social engagement.
- It engages executive function capacities such as planning and decision making for purposeful engagement.
We are utilizing three tools during evaluation phases to perform a comprehensive health assessment of all participants the day before the intervention (day 1), immediately after the last session (day 8), and at follow-up (6 months post-intervention):
- World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).
- The PTSD Checklist for DSM-5 with Criterion A (PCL-5).
- Patient Health Questionnaire (PHQ-9).
All questionnaires are integrated on our software for digital administration by our African team members, eliminating costs of paper, printing, and data entry. Data will be available to our researchers in real-time, enhancing time-efficacy and fast reporting to our funders and sponsors.
- Raw data and a comprehensive report will be made available for independent statistical analyses upon each project phase completion.
- Clinical curriculum development.
- Cross-cultural adaptations.
- App prototype research rv1.0
- App prototype field fv1.0
- Research designs.
- 1. Proof of Concept Implementation with App fv1.0
We will conduct two field implementations with 1,000 individuals for baseline curriculum evaluation:
Field Implementation 1
Location: Liberia, West Africa
Start date: June 2017
Intervention Group IDs: 1-50.
Participants: 500 individuals impacted by Liberia's 14-
year Civil War and Ebola endemic.
Field Implementation 2
Location: Northern Uganda
Start date: January 2018
Intervention Group IDs: 51-100.
Participants: 500 South Sudanese refugees.
2. App Prototype v2.0
We will test and improve v1.0 based on local feedback and functionality during field implementations, and build fv2.0 with DHIS 2 interface.
- 3. 6-month follow-up (n=1000).
- Two Randomized clinical trials (RCTs) with fv2.0 to examine efficacy of the clinical curriculum in reducing symptomatology (pre, post and 6-month follow-up).
- Publication of clinical rationale.
- Scientific publications.
- Researcher manual.
- Regional implementation partnerships.
Once we document satisfactory effectiveness and efficacy of the clinical curriculum, and enhance our software for scalability during phases 2 and 3, we will focus on translating the tool to new languages, local dialects and equipping our partners in target regions. Please note, additional RCTs and adaptations may be necessary prior to scaling.