Children and Global Adversity
The Research Program on Children and Global Adversity (RPCGA) works to close the global implementation gap between the realities facing children and families in adversity such as that due to communal violence/armed conflict and HIV/AIDS and the evidence base on promoting mental health and child development in low resource settings. Directed by Dr. Theresa S. Betancourt, Associate Professor of Child Health and Human Rights in the Department of Global Health and Population, the program operates at the crossroads between research, policy and program design, implementation and evaluation. The RPCGA is engaged in applied research to contribute to stronger and evidence-based interventions to serve children and families in adversity worldwide.
Projects pursued under the program banner include the following:
- The Family Strengthening Intervention – Rwanda
This portfolio of work is the result of close collaboration with Partners In Health /Inshuti Mu Buzima (PIH/IMB) and the Rwanda Ministry of Health, and is focused on the development of mental health screening tools and preventive mental health interventions for HIV-affected families in the country’s Eastern Province.
- The Longitudinal Study of War-Affected Youth – Sierra Leone
To date, one of the RPCGA’s major contributions to the global health field has been the application of (and advocacy for) longitudinal, culturally-informed research on children in adversity that is supported by communities and local collaborators. Dr. Betancourt’s Longitudinal Study of War-Affected Youth (LSWAY) has been ongoing in Sierra Leone since 2002, and is the first and only prospective longitudinal study of mental health and psychosocial adjustment in male and female former child soldiers to be performed in sub-Saharan Africa. Analyses of this unique cohort of over 500 youth continued in 2012 to examine, among other topics, how gender affects the long-term psychosocial trajectories of former child soldiers.
- The Somali Bantu Refugee Community Project
The RPCGA’s Boston-area research with Somali refugee parents and youth, as well as Bhutanese refugees has also grown. Analysis of data from recent collaborative qualitative research with Somali Bantu adults and children (an ethnic sub-group within the larger Somali resettlement population) and Bhutanese refugees is underway to identify services needs and preferences, as well as culturally relevant protective processes that deserve priority attention in intervention planning. Preliminary analyses highlight how family dynamics, including communication, values, and parenting, are influenced by acculturation stressors, including language barriers, limited access to services, and wide cultural gaps.
- The SAFE Project
The SAFE Model, developed by the RPCGA, is a holistic rights-based framework that examines the four fundamental and interrelated domains of children’s security: Safety and protection, access to health care and basic physiological needs, family and community relationships, and education and economic security. The model underscores the interdependence of children’s survival needs and accounts for both dangerous and adaptive survival strategies that children and families employ to cope with deficits in any of these four core security domains. The SAFE toolkit, an application of the SAFE model, has been developed to monitor and evaluate the effects of development and interventions on children across a range of settings. The toolkit is comprised of a qualitative component – the SAFE Child Impact Assessment (SCIA), and a quantitative component – the SAFE Checklist (under development).
Joint Learning Initiative on Children and HIV/AIDS
The Joint Learning Initiative on Children and HIV/AIDS (JLICA) was an interdisciplinary two-year initiative, launched in 2006, that engaged a network of policy-makers, practitioners, community leaders, activists, researchers, and people living with HIV, in research to refocus global responses to the needs of HIV-affected children, their families and communities. Learning groups (LGs) focused on four themes: strengthening family (LG1), community action (LG2), expanding access to services and protecting human rights (LG3), and social and economic policies (LG4). The FXB Center worked collaboratively with FXB International as Secretariat to the Initiative. The FXB Center also sponsored and co-directed the projects and related fieldwork of Learning Group 3.
The final report Home Truths: Facing the Facts on Children, AIDS, and Poverty, contains a comprehensive set of recommendations to reorient and improve services for the millions of families and children affected by HIV. Among the report’s key findings:
- Much of the current AIDS response overlooks fundamental realities of the daily lives and the impact of HIV on children and their families
- Families and communities provide the vast majority of care for HIV-affected children, with little or no support
- Extreme poverty in many of the most seriously affected regions is a critical barrier to the uptake of HIV programs and services
- Current program design and implementation means external funding frequently fails to reach local communities
- The underlying vulnerabilities that increase the impact of HIV/AIDS on women and girls are not being addressed sufficiently
- Targeting relief efforts to “AIDS orphans” is ineffective and may be counterproductive
Global Health Delivery Project
Medical treatments for the world’s worst diseases have multiplied rapidly, but the processes for delivering these medicines have not kept pace. This has slowed efforts to improve health in developing and developed countries. In 2007 the FXB Center launched the Global Health Delivery Project to help address this implementation bottleneck. The GHD project offers a library of over 30 Harvard Business School-style teaching cases with accompanying guides for instructors. These cases serve as the foundation for a range of health-care delivery courses. The project also hosts GHDonline, a platform for global health professionals to connect and exchange insights about their work. Launched in 2008, GHDonline now hosts 13,000 members representing more than 5,400 organizations in 182 countries. Additionally, GHD offers an annual three-week intensive summer program based at the Harvard School of Public Health. Now in its fifth year, the course offers trainees in global health a curriculum of epidemiology, management science, and health care delivery, featuring our case study collection. The GHD project is a collaboration between the FXB Center, Harvard Business School, Harvard Medical School, and the Brigham and Women’s Hospital. For more information on GHD, please visit http://www.globalhealthdelivery.org/.
Haiti and Child Protection
Haiti’s 4.25 million children faced a bleak future following the earthquake of January 12, 2010. Not only did the earthquake create new challenges to child protection, it also exacerbated pre-existing vulnerabilities that limited the fulfillment of children’s rights. The FXB Center’s Literature Review, entitled Protecting Haiti’s Children: Risk Factors and Outcomes Before and Since the January 2010 Earthquake, assessed the available body of knowledge of child protection in Haiti and highlighted areas where this knowledge should be expanded, deepened, or re-oriented. The exhaustive review examined the types of child protection, security, and developmental threats that Haitian children faced before and after the earthquake and how children and their families responded to these threats. The overall goal of the project was to improve UNICEF’s and child protection actors’ understandings of child protection in Haiti, build a full picture of the child protection risks that Haitian children have historically faced, and the current needs that children and families now experience. The project aimed to bring renewed attention to the protection and promotion of children in Haiti and serve as a foundation for evidence-based policy and programs by Haitian and international organizations advancing the rights and well-being of Haitian children.
The Learning Collaborative on Child Health in Rwanda
In 2007 the FXB Center, in collaboration with the Rwandan Ministry of Health (MOH), launched a Learning Collaborative (LC) to promote the rapid dissemination and implementation of effective strategies for community-based PMTCT service delivery, and to increase the number of women receiving comprehensive prevention of mother-to-child transmission of HIV (PMTCT) services at 17 health centers in the Eastern Province of Rwanda. The LC was part of the Joint Learning Initiative on Children and HIV/AIDS (JLICA)’s Learning Group 3, focused on expanding access to services and protecting human rights. The LC model is based on the Institute for Healthcare Improvement’s “Breakthrough Series” and the Series’ “Plan-Do-Study-Act” cycles (PDSAs), in which problems are identified, solutions tested, results analyzed, and improvements incorporated into standard working procedures.
During four learning sessions, health center participants examined proven and recommended strategies for improving care for children affected by HIV/AIDS, developed plans for incorporating such strategies within their organizations, shared outcomes with health center staff, outlined policy implications for national PMTCT service delivery, and prepared for scale up of successful interventions. Between sessions, members tested changes within the current system and shared learning across teams in order to increase successful strategy implementation. Health center staff trained in the PDSA methodology; small teams visited each health center monthly to assist with PDSAs and other improvements toward meeting collaborative objectives.
Successful interventions addressed 1) early childhood development (ECD) as essential in comprehensive PMTCT care, and 2) persistent loss to follow-up of women after initial antenatal visit, which prevented appropriate PMTCT care from starting at 28 weeks of pregnancy. An ECD tool was designed using the WHO Integrated Management for Childhood Illness (IMCI) module on Care for Development, for use by Community Health Workers (CHWs) during home visits. Nurses at all participating health centers completed an activity-based training module on ECD, then used the module to train CHWs, who monitor for linguistic, social and physical development and counsel mothers on how to play and communicate with children to encourage healthy growth and development. By applying the PDSA approach to loss to follow-up issues, all health centers documented increased numbers of women receiving PMTCT services and antenatal services, and children receiving follow up care, including immunizations and bed nets for malaria prevention. Preliminary results demonstrate that the Breakthrough Series model may be applicable for addressing service delivery problems in low-resource settings. Final results can identify the most effective procedures that may be mainstreamed at a national level, as tools for governments facing similar challenges.
Lesotho Rural Initiative
The Lesotho Rural Initiative has enjoyed a collaborative partnership with the FXB Center, Partners In Health (PIH) and Brigham and Women’s Hospital to strengthen the health care system in southern Africa by providing quality care to address issues of HIV/AIDS, multi-drug-resistant tuberculosis (MDR-TB) and hunger for thousands in Lesotho, a country with one of the highest prevalence rates of HIV/AIDS and MDR-TB in the world. By 2009, the Initiative had opened seven new clinics to provide comprehensive health services in four rural districts, with two additional clinics in the planning stage by 2009. In its first two years at the Lebakeng clinic alone, the project tested more than 12,000 men, women, and children for HIV and started anti-retroviral (ARV) treatment for more than 1,900 patients, and diagnosed over 700 with TB. The clinics have trained more than 750 village health workers for these rural clinics and provided dozens of new nurses and a full time physician in each.
The Initiative includes a focus on children at risk. Lesotho has the highest per capita orphan rate in the world, with an estimated 25% of the country’s children having lost one or both parents to HIV. The Initiative is one of the leading implementers of the Mountain Orphans and Vulnerable Children Empowerment (MOVE) project. Each rural site also provides a comprehensive PMTCT (prevention of mother-to-child transmission) program, and clinic days for children under age 5 that include vaccinations, weight monitoring, and nutritional information. The Initiative has also responded to a recent dramatic increase in childhood malnutrition. Clinic staff who once saw a few malnourished children a week (usually with pellagra, caused by lack of niacin (vitamin B3) and protein), saw many more after a severe regional drought, with manifestations of both kwashiorkor (malnutrition caused by inadequate protein intake) and marasmus (a severe form of malnutrition caused by inadequate intake of both protein and calories). Staff have responded by initiating food programs, identifying food sources, and training village health workers to assess childhood growth.
The Lesotho team launched the country’s first community-based treatment program for multi-drug resistant tuberculosis (MDR-TB). Based at Botsabelo MDR-TB Hospital in Maseru, with funding from the Open Society Institute, and in partnership with the Lesotho Ministry of Health, the project is one of the most ambitious MDR-TB programs in any high-HIV-prevalence community. At Maseru, the team renovated the TB clinic to improve infection control, and PIH supported renovation of the TB laboratory, adding a new pharmacy to effectively manage daily medication distribution to patients co-infected with MDR-TB and HIV/AIDS, and to treat related side effects. Most MDR-TB treatment takes place at the community level, supported by paid and trained community health workers who make twice-daily home visits
The Lesotho Rural Initiative acts in partnership with the Lesotho Ministry of Health and Social Welfare. More information on the Initiative is available at http://www.pih.org/where/Lesotho/Lesotho.html.
Photo: Angela Duger/FXB