Psychosocial support for children in the Republic of South Sudan ...
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Eiling et al.Psychosocial support for children inthe Republic of South Sudan:an evaluation outcomeEllen Eiling, MarianneVan Diggele-Holtland,TomVanYperen &Frits BoerThis paper describes an exploratory outcome evalu-ation ofWar Child Hollands psychosocial supportintervention I DEAL, a life skills interventionaimed at improving the ability of children and youngpeople aected by armed conict in the Republic ofSouth Sudan to deal with their daily lives. Thespecic objectives were to assess whether I DEALis consistent with local perceptions of wellbeing,and to explore the outcomes, as well as the factorsthat inuence outcomes of this intervention. Theresearch was conducted using mixed methods,with a focus on qualitative and participatorymethods: group exercises, individual goal setting(N110)and interviews(N 62).Totriangulatendings from children, interviews were held withteachers (N 7), facilitators (N 5), and parents(N11). It was found that the content of the inter-vention was consistent with childrens perceptionsof wellbeing. Specic outcomes that were reportedby children and conrmed by facilitators, teachersand parents included decreased ghting andimproved relationshipswithpeers andparents. Find-ings suggest that I DEAL positively aectchildrens social coping skills and has the potentialto improve childrens emotional coping skills andclassroom performance.
Keywords: armed conict, children, parti-cipatory outcome evaluation, psychosocialsupport, Republic of South Sudan
IntroductionAn estimated one billion children andyoung people under the age of 18 live inareas aected by armed conict (Unitedht War Trauma Foundation. UnauthoNations Childrens Fund (UNICEF), 2009).Exposure to the disruption, loss andviolenceassociated with armed conict, and its after-math, negatively aects the psychosocialwellbeing of children (Jordans et al., 2010;Tol et al., 2011a; Attanayake et al., 2009).At the individual and interpersonal levelspsychosocial support can rebuild brokenrelationships and promote nonviolence(Wessels & Monteiro, 2006). This articlefocuses on the evaluation of a psychosocialsupport intervention that can contribute tononviolent behaviours and other peace-building processes at the interpersonal levelin the Republic of South Sudan.Thirty-eight years of civil war, between theSudan and South Sudan, has displaced 4.9million people and killed more than 2million. The vital infrastructure of theRepublic of South Sudanhasbeen essentiallydestroyed, and there is an almost completelack of basic social services. The populationis estimated at 9million, withmore than halfliving below the poverty line, especially inrural areas (World Bank, 2013). The popu-lation below the age of 18 is around 51%(Central Bureau of Statistics, 2009). Thecountry is highly rural, and is characterisedby isolated and inaccessible communities.The high costs of primary education, thenecessity for children to contribute to thefamily income, as well as long distances toschools, all contribute to severely low schoolenrolment levels. At 8%, South Sudansfemale literacy rate is the lowest in the world(World Bank, 2012).rized reproduction of this article is prohibited.61
Psychosocial support for children in the Republic of South Sudan: an evaluation outcomeIntervention 2014, Volume 12, Number 1, Page 61 - 75After South Sudans independence in 2011,ongoing conict in some border regions,intercommunal conicts, food insecurity,seasonal ooding and internal displacementcontinue to aect communities (UnitedNations, 2012). In addition, the presence ofseven armed groups, the recent outburst ofviolence, as well as more generalised vio-lence all continue to negatively impactthe psychosocial development of children.This is often demonstrated by violent beha-viour and weak social skills, as observedduring situation analyses and byWar Childssta.Eastern Equatoria State, where the evalu-ation of I DEAL was conducted, wasparticularly aected by the civil war from1983^2005. Until today, the region experi-ences insecurity caused by landmines, manycivilians owning weapons, and shatteredsocial and community relations. Cattlerustling, armed robbery, and banditry areendemic. In many areas of the state there islittle security presence.Violent conicts overcattle and land are common, which arefurther exacerbatedby the return of refugeesand the arrival of internally displaced civi-lians. In addition, Eastern Equatoria experi-ences chronic food insecurity, a lack ofbasic services, and few economic opportu-nities (United Nations Development Pro-gramme (UNDP), 2012). War Child hasworked in Eastern Equatoria since 2009,implementing child protection, educationand psychosocial support programming.The ongoing conicts, generalised violenceand the recent outburst of ethnic violence callfor continued support in all three areas, aswell as eective peacebuilding, to promotechildrens rights and their healthy develop-ment.War Child follows an ecological approach(Bronfenbrenner,1979) to improve childrensrights and healthy development, throughstrengthening protective factors at variouslevels in society (Betancourt & Kahn,2008). Therefore, War Child Hollandspsychosocial support intervention I DEAL1ht War Trauma Foundation. Unautho62is implemented in combination with inter-ventions promoting educationandchildpro-tection. I DEAL aims to support children(11^15 years of age) to deal better with theaftermath of armed conict, by strengthen-ing determinants of resilience and psycho-social wellbeing, such as self-condence andsocial andemotional coping skills. Importantdeterminants for resilience include havingan internal locus of control and a sense ofself-ecacy (Betancourt & Kahn, 2008). Toincrease childrens condence that they canmake a dierence (internal locus of control)and to achieve their goals (self-ecacy), theintervention uses participatory methods, tocreate opportunities for the children toexpress themselves and to reduce their fearof speaking within group situations.Other essential determinants of resilienceare social and emotional coping skills(Betancourt & Kahn, 2008), and supportivesocial relationships with peers, parents andother adults (Benzies & Mychasiuk, 2008).I DEALs aims of strengthening childrenssocial and emotional coping skills contrib-utes to improving social relationships,through group discussions and game basedactivities, focused on collaboration andconict solving.The themes addressed in the six modules ofI DEAL (each consisting of 3^4 sessions),are identity, dealing with emotions, peerrelations, relationships with adults, conictand peace, and the future. Participantsactively contribute to the intervention byselecting the themes to be addressed, andthrough participatory monitoring andevaluation exercises (Claessens et al., 2012).The intervention consists of a maximum of19 sessions of 1.5 hours each, implementedover a period of 4 to 6 months, dependingon local circumstances and modulesselected. Each session combines creativeand participatory techniques, such as roleplay, drawing, games and group discussionsto stimulate active learning (Kalksma-vanLith, 2007). The groups have a maximumof 25 participants and are facilitated byrized reproduction of this article is prohibited.
Eiling et al.community workers (hereafter facilitators)in schools, after school hours. Previouslypublished and non published evaluations inother countries have shown positive short-term outcomes of I DEAL; mitigating reac-tions to violence, such as aggression andimproving relations with adults and peers(Claessens et al., 2012).Despite growing evidence of the eective-ness of psychosocial interventions for child-ren and young people (Flament et al., 2007;Jordans et al., 2010), there is an urgent needfor a stronger evidence base on the eectiveapproaches for children aected by armedconict (Tol et al., 2011b). As complexpsychosocial interventions call for practicedriven research, process oriented and parti-cipatory approaches are required, beforemoving towards more rigorous researchdesigns (Claessens et al., 2012). Buildingon a pilot study conducted in Uganda(Claessens et al., 2012) in 2012, War ChildHolland, in collaboration with the Univer-sity of Amsterdam, the Netherlands YouthInstitute, and HealthNet TPO, conductedan exploratory outcome evaluation anda process evaluation of I DEAL in theRepublic of South Sudan.The primary purpose of this research isto further strengthen the intervention, inaddition to facilitating future eect evalu-ations, by exploring locally relevant out-come measures. The study also aims tocontribute to current knowledge gaps inthe eld of psychosocial support, throughaddressing three prioritised, internationalresearch areas for psychosocial supportinterventions (Tol et al., 2011b): eectivenessof school based psychosocial support; localperceptions of psychosocial problems; andthe extent to which current interventionsaddress these needs. This paper addressesthe following questions:1. Dht oes I DEAL t with participants per-ceptions of wellbeing?2. What are the outcomes of I DEALregarding: War Trauma Foundation. Unauthoriza. the achievement of participantspersonal goals, and;
b. social and emotional coping skillsed r3. What factors inuence the outcomes ofthe interventions?MethodsDesignThe exploratory evaluation followed amixed method, nonrandomised, pre andpost test design. As it was interventiondriven, the research included a conveniencesample in schools where the interventiontook place, and did not include a controlgroup. The pre test was conducted in April2012, the post test in November 2012. Theresearch is in line with international ethicalstandards and guidelines for the evaluationof psychosocial programming (UNICEF,2011; Inter-Agency Standing Committee(IASC), 2007). Respondents gave informedconsentverbally.Condentialitywasensuredto all respondents, and it was explained thatall identity information was collected foranalysis only.To ensure data quality, nine communityworkers received three days of trainingand conducted the interviews in local lang-uages (Juba Arabic and Lotuho), withstructured topic lists. In order to build trust,the teacher introduced the researchers andthe research purpose to the children, andresearchers used child friendly approachesand games.
SampleThe evaluation took place in Eastern Equa-toria State, where a total of 11 groups (152boys and 105 girls) participated in I DEAL.Out of the 11 groups, ve (from dierentvillages) were selected to participate in theresearch. Teachers selected children fromgrades 3 and 4, and in some cases theyincludedgirls fromanother grade to improvegender balance. Consequently, the age ofparticipants ranged from 8 to 16 years old(see Table 1 for demographic information).eproduction of this article is prohibited.63
Table 1. Demographic characteristics of participating children
School Mean age (SD) FemaleN MaleN TotalN
1 12.38 (1.69) 11 10 212 12.17 (1.09) 13 11 243 11.32 (1.72) 8 20 284 10.33 (1.04) 11 16 275 11.91 (1.44) 6 16 22
Psychosocial support for children in the Republic of South Sudan: an evaluation outcomeIntervention 2014, Volume 12, Number 1, Page 61 - 75The selection of the research groups wasbased on the security and accessibility ofthe area, and the starting dates of the inter-vention. The ve groups included a total of122 children: 73 boys and 49 girls.The total dropout rate of the interventionwas 32%, resulting in a smaller researchsample at the post test stage. SeeTable 2 foran overview of the sample sizes used for nalanalysis, per research instrument. For eachinstrument, the selection of respondentswas based on presence during data collec-tion, age and gender. Each child (N122)participated in at least one of the researchmethods. From each location, at least oneteacher from grade three or four was inter-viewed. It was an aim to include parentsfrom each location through snowballht War Trauma Foundation. Unautho
Table 2. Overview of sample per research
Baseline Wellbeing exercise 5 groupsof 8
Personal goalsPost test Personal goals
Evaluation interviewGroup discussions 5 groups
of 11Interview parents 2 locationInterview teachers 5 locationInterview facilitators
Two researchers had been facilitators in the past and also p
64sampling. However, due to practical con-straints, this resulted in a sample of 11parents from two locations.
Research instrumentsLocal perceptions of wellbeingThe participatory research tool, WellbeingExercise (Stark et al., 2012; Hart et al.,2007), was used as described by Stark et al.(2012) to compare the content of I DEALwith local perceptions of wellbeing, as wellas its relevance and cultural t. Duringgroup exercises, childrens local perceptionsof wellbeing were explored through reec-tion of what determines the wellbeing of achild within their community, and whatbehaviours they associated with peers whoare doing well.rized reproduction of this article is prohibited.
12 (1.65) 15 26 41
11.6 (1.56) 44 66 11011.4 (1.59) 30 44 74
^ 26 36 62^ ^ ^ 56
s ^ 8 3 11s ^ 1 5 6
^ 1 2 3rovided input.
Eiling et al.Personal goalsChildren set individual goals at thebeginning of the intervention, which isincluded as the Personal Goal exercise in theinterventions monitoring and evaluation2.Formulating child led and participatoryindicators of success supports facilitators toaddress the needs specied by the childrenthemselves. Further, childrens participationin planning, monitoring and evaluationcan, in itself, facilitate psychosocial growth(Karki, Kohrt & Jordans, 2009). To formu-late realistic and achievable goals, thepersonal goals were based on self-identiedstrengths and diculties, and set withinthe themes of the intervention; personaltraits and relationships with peers andadults. Progress towards reaching personalgoals was measured on a visual analogueline of 10 cm, a continuous line withoutnumbers, using a smiling and a sad face toindicate the positive and negative ends,respectively (Baker & Hall,1994). In clinicalsettings, similar types of Goal AttainmentScoring have shown positive therapeuticvalue in encouraging patients to reach theirgoals (Durrant et al., 2007). There is grow-ing evidence that this way of measuringhas greater sensitivity over standardmeasures, potentially avoiding oor andceiling eects (Turner-Stokes et al., 2006).These eects occur when respondentschoose the most positive or negative answeroption, which inhibits the measurement ofindividual dierences.
Evaluation interviewsBased on a client satisfaction questionnaire(Healthnet TPO & Centre for TraumaPsychology,2010), structured interviewswereheld at the end of the intervention to assesschildrens satisfaction with the intervention.Usingboth closed and open ended questions,the interviews assessed motivation to parti-cipate, reasons for missing one or moresessions, level of enjoyment and childrensperceptions of the benets of the interven-tion. To explore outcomes, children wer...