Review the following article (ATTACHED): Ager, A., Akesson, B., Stark, L., Flouri, E., Okot, B., McCollister, F., & Boothby, N. (2011). The impact of the school‐based Psychosocial Structured Activities (PSSA) program on conflict‐affected children in northern Uganda. Journal of child psychology and psychiatry, 52(11), 1124-1133.Answer the following questions: What were the original program goals for the intervention? Sketch out a bare-bones logic model summarizing the inputs, activities, and outcomes. For the purposes of this exercise, skip the outputs and impacts.How did the authors measure and operationalize their primary outcome? What were the indicators that were used?What is the study design used? What are the threats to internal validity common in this design? Read the case study:WVI Child-Friendly Spaces (CFS) Intervention at Buramino Camp, Dolo Ado, Ethiopia: Buramino refugee camp, located along the southern Somali-Ethiopian border, was selected in cooperation with World Vision Ethiopia as the first evaluation site. At the time of the evaluation, the Ethiopian Administration for Refugee and Returnee Affairs (ARRA), the main implementing partner of UNHCR, had organised five camps within two hours of the Dollo Ado transit centre to address the growing needs of Somali refugees who had migrated in response to drought and ongoing conflict in the region. In January 2012, World Vision Ethiopia’s first Child Learning Centre (subsequently referred to through this report as a CFS site) was established, offering a range of services to children aged six to 17 years. The second CFS site started activities later that year, in May 2012. Within the wide continuum of CFS programming approaches, these two sites emphasised functional literacy and numeracy skills. Based on discussions with ARRA and parents of children attending these centres, psychosocial activities, such as drawing, singing, and recreational play, were included, but to a modest degree. On-site counselling and a feeding programme were also offered. To help meet the overwhelming demand in the camp, each centre provided two three-hour sessions for children: a morning session for younger children aged six to 11 and an afternoon session for older children aged 12 to 17. The first CFS provided services for 784 children (500 aged between six and 11 and 284 aged between 12 and 17). The second CFS site provided services for 787 children (506 aged between six and 11 and 281 aged between 12 and 17).Source: http://www.cpcnetwork.org/wp-content/uploads/2015/04/WV-CU-CFS-Ethiopia-Field-Study-Summary-Report.pdfAnswer the following questions: Develop one evaluation questionConsider what study design would best answer your questionDecide what data you need to collect4.Recommend one random and one non-random sampling scheme. (circle your choices)Types of random samplingTypes of non-random samplingSimple random sampleSystematicProportionate stratifiedDisproportionate stratified (Cluster sampling)Quota samplingExtreme case samplingMaximum variation samplingHomogeneous samplingTypical case samplingSnowball samplingCriterion sampling5.Discuss the advantages and disadvantages of each scheme that you choose.6.Why did you choose the random sampling scheme you did?7.What aspect(s) of the evaluation question would this scheme help you answer?8.Why did you choose the non-random sampling scheme? 9.What aspect(s) of the evaluation question would this scheme help you answer?
ager2011_uganda_schoolchildren.pdf
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Journal of Child Psychology and Psychiatry 52:11 (2011), pp 1124–1133
doi:10.1111/j.1469-7610.2011.02407.x
The impact of the school-based Psychosocial
Structured Activities (PSSA) program on
conflict-affected children in northern Uganda
Alastair Ager,1 Bree Akesson,2 Lindsay Stark,3 Eirini Flouri,4 Braxton Okot,5
Faith McCollister,3 and Neil Boothby1
1
Mailman School of Public Health, Columbia University, USA; 2Care and Protection of Children in Crisis-Affected
Countries Initiative; 3Program on Forced Migration & Health, Mailman School of Public Health, Columbia University,
USA; 4Department of Psychology and Human Development, Institute of Education, University of London, UK; 5Child
Resilience Program, Save the Children in Uganda
Background: Children in northern Uganda have undergone significant psychosocial stress during the
region’s lengthy conflict. A Psychosocial Structured Activities (PSSA) program was implemented in 21
schools identified as amongst those most severely affected by conflict-induced displacement across
Gulu and Amuru Districts. The PSSA intervention comprised a series of 15 class sessions designed to
progressively increase children’s resilience through structured activities involving drama, movement,
music and art (with additional components addressing parental support and community involvement). Method: Eight schools were selected by random quota sampling from those schools receiving
the PSSA intervention. Two hundred and three children were identified in these schools as being
scheduled to receive intervention, and were followed up 12 months later following engagement with
PSSA activities. A comparison group comprised 200 children selected from schools that had met
inclusion criteria for receipt of intervention, but were not scheduled for intervention coverage until later.
Preliminary research used participatory focus group methodology to determine local indicators of child
well-being as viewed by parents, teachers, and children respectively. Pre- and post- assessments
focused on ratings for each child – by parents, teachers and children – with respect to these indicators. Results: Significant increases in ratings of child well-being were observed in both intervention and
comparison groups over a 12-month period. However, the well-being of children who had received the
PSSA intervention increased significantly more than for children in the comparison group, as judged by
child and parent (but not teacher) report. This effect was evident despite considerable loss-to-follow-up at
post-testing as a result of return of many households to communities of origin. Conclusion: General
improvement in child well-being over a 12-month period suggests that recovery and reconstruction efforts
in Northern Uganda following the onset of peace had a substantive impact on the lives of children. However,
exposure to the PSSA program had an additional positive impact on child well-being, suggesting its value
in post-conflict recovery contexts. Keywords: Psychosocial, structured activities, children, schools,
Northern Uganda, evaluation. Abbreviations: PSSA: Psychosocial Structured Activities.
Northern Uganda is in a state of transition after
20 years of conflict between the Lord’s Resistance
Army (LRA) and Ugandan government forces.
Despite continuing LRA activity in the region and
General Joseph Kony’s refusal to sign a Final Peace
Agreement in March 2008, the war drew to an
effective close in northern Uganda with an ‘Agreement on Cessation of Hostilities’ signed in 2006
between the Government of Uganda and the LRA
(Government of Uganda & Lord’s Resistance Army/
Movement, 2006; Machar, 2008). During the conflict
between 1.8 and 2 million people were displaced to
over 200 camps, located primarily in Gulu, Amuru,
Kitgum and Pader districts. These Internally Displaced Persons (IDP) camps were often cramped and
lacking in sanitation, and left most families unable
Conflict of interest statement: At the time of the study Braxton
Okot was serving as Program Manager of the Child Resilience
Program. Other authors declare no conflict of interest with
respect to the reported study.
to support themselves through traditional subsistence agricultural practices (Civil Society Organizations for Peace in Northern Uganda (CSOPNU),
2006). Excess mortality rates exceeded emergency
thresholds with estimates as high as 1,000 deaths
per week in 2005 among IDPs in the region (World
Health Organization, 2005). The conflict disrupted
the social and economic development of northern
Uganda for a generation.
Children were particularly harshly affected by this
conflict. One of the defining tactics of the LRA has
been its use of children as combatants, porters, and
sex slaves, often abducting them from their homes
and schools. While many of these formerly abducted
children eventually returned to their communities,
many returned with significant physical and emotional after-effects of their experience. Amongst
abducted youth in the region Annan, Blattman, and
Horton (2006) showed that ‘high levels of violence
committed and violence experienced are associated
2011 The Authors. Journal of Child Psychology and Psychiatry 2011 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
Psychosocial structured activities with conflict-affected children in northern Uganda
with substantial increases in emotional distress’
(p. 67). Those who were not abducted were also
found to have experienced significant violence, with
male youths between 14 and 30 typically reporting
having experienced nine traumatic events over their
lifetime.
The educational system – and thus children’s
schooling – has also been significantly affected by
the conflict. A 2006 survey indicated that 60% of
schools in the affected regions were not functioning,
depriving over 250,000 children of an education
(CSOPNU, 2006). The Uganda Ministry of Education,
in cooperation with a number of international nongovernmental agencies, responded to this situation
by expanding places at schools adjacent to IDP
camps (and deploying displaced teachers across
such schools). In Gulu and Amuru Districts, for
example, 40 schools were identified as having major
increases in student enrollment, and received
assistance in infrastructure development to assist
them to respond to such demands (Wilson, 2007).
Accommodating large numbers of displaced children, many of whom had been abducted or experienced other extreme conflict-related trauma and
virtually all of whom had experienced personal and
familial threat and loss linked to the conflict, was
acknowledged to have significant impact on the
learning environment of the schools. It was in this
context that Save the Children proposed to work in a
number of these schools with the ‘Child Resilience’
curriculum project, which involved deployment of
the Psychosocial Structured Activities (PSSA) intervention.
The PSSA intervention builds upon the work of
Robert Macy’s Classroom-Based Intervention (CBI)
Program, which has been used in a number of settings, including Palestine (Khamis, Macy, & Coignez,
2004) and Sri Lanka (Somasundaram, 2007).1 It is a
school-based, multi-phased approach designed to
use children’s natural resilience to help them recover
from trauma. Its core focus is 15 progressively
structured sessions leading from themes of safety
and control, through those of awareness and selfesteem, to personal narratives, coping skills, and
future planning. These sessions incorporate play
therapy, drama, art and movement in an effort to
enhance children’s resilience and feelings of stability
and security after trauma as they progress emotionally and cognitively over the course of the program. Each session opens with an activity designed
to prepare children for the session and then continues into a central activity and cooperative game
designed around the session’s theme. The PSSA
1
In some contexts the CBI program is designated as a CampBased or Community-Based Intervention. The CBI Manual was
adapted for use in the Uganda context by Susan Garland.
Copies of the CBI manual can be obtained by contacting Robert
Macy. http://www.traumacenter.org/initiatives/psychosocial.
php.
1125
program also seeks to incorporate a community
service component, and encourages parental
involvement through periodic meetings during which
issues related to the children’s experience and the
needs of the local community are discussed.
There is considerable value in determining a
robust methodology to establish the impact of
interventions such as PSSA. The PSSA program was
implemented by Save the Children in the United
States on the Gulf Coast after Hurricane Katrina and
in tsunami-affected areas of Indonesia. Few published, rigorous evaluations exist measuring the
impact of the program, though reports from the field
suggested that it was a popular intervention that
garnered the support of parents and school officials
(see Jaycox, Morse, Tanielian, & Stein, 2006; Lauten
& Lietz, 2008). Encouraged by such reports, Save the
Children in Uganda implemented the PSSA program
among children attending government schools in
northern Uganda beginning in the 2006/2007
school year. Positive anecdotal reports led to the
commissioning of an evaluation (Wilson, 2007) that
suggested that the program had indeed a positive
impact on the lives of children and their caregivers.
The intervention was reported to have had a positive
impact on attendance rates, student grades, and
teacher–student interactions in the classroom.
Increases in children’s resilience (defined through
consolidation of items elicited through a free-listing
exercise with participants in a fashion built upon in
the current study) were reported by both children
and parents. However, in the absence of baseline
measures, the study relied on retrospective judgments of changes since receiving the intervention. It
also had no form of control condition, only collecting
data from individuals exposed to the intervention.
The current study represents an attempt to establish
a more rigorous evaluation of the impact of the PSSA
program on children’s well-being in this context.
In general, there have been few rigorous studies of
the implementation of school-based psychosocial
activities in conflict and post-conflict environments.
An evaluation of a secondary-school-based mental
health intervention for children exposed to political
violence in Indonesia found some improvement in
post-traumatic stress disorder symptoms and hope
but did not reduce a variety of other traumatic-stress
symptoms (Tol et al., 2008). A study of structured
activities in child-focused interventions in Palestine
designed to increase children’s resilience found
improved emotional and behavioral well-being and
parental support, but no increase in hopefulness
(Loughry et al., 2006). A cluster randomized trial of a
version of the CBI program in Nepal found no main
effect of the intervention on mental health but significant impact on social well-being indicators
among sub-groups (such as girls’ prosocial behavior
and hope amongst older children; Jordans et al.,
2010). A recent literature review by Peltonen and
Punamaki (2010) analyzed the effectiveness and
2011 The Authors. Journal of Child Psychology and Psychiatry 2011 Association for Child and Adolescent Mental Health.
1126
Alastair Ager et al.
theoretical basis of 16 interventions for children
exposed to trauma associated with armed conflict, a
number of which involved school-based programming on conflict or post-conflict settings (Berger,
Pat-Horenczyk, & Gelkopf, 2007; Chase et al., 1999;
Layne et al., 2001, 2008; Woodside, Santa Barbara,
& Benner, 1999). The studies by Berger et al. (2007)
and Layne et al. (2008) were two of only four studies
identified as meeting formal criteria for meta-analysis of intervention effectiveness (an analysis that was
suggestive of the effectiveness of cognitive-behavioural and resilience-enhancing approaches on relief
of post-traumatic symptoms). Otherwise, although
reporting some promising findings, Peltonen and
Punamaki (2010) suggest that little can be concluded overall from these studies in terms of intervention effectiveness as a result of methodological
weaknesses, including the lack of randomization
and control conditions.
It is clear that implementation in conflict and postconflict settings means that such studies have had to
deal with significant methodological challenges in
relation to design and inference. For example,
although the validity of deploying psychometric
measures of well-being developed in other cultures
and circumstances is frequently questioned, there
are clear challenges for developing rigorous measures de novo in such settings (Ager, Stark, Akesson,
& Boothby, 2010a). Promising approaches appear to
be characterized by robust specification of replicable
data collection and analytical methods which,
through effective fieldwork engagement, nonetheless
flexibly accommodate to local construction of
concepts (e.g., Annan et al., 2006; Bolton et al.,
2007). Study designs that provide some form of
control or comparison condition – generally utilizing
a population ‘waited listed’ for receipt of an intervention as a result of resource constraints – are also
now increasingly seen as both feasible and appropriate in such settings (Ager, Ager, Stavrou, &
Boothby, 2011). The study reported here sought to
build upon such principles in constructing a rigorous methodology for evaluating the impact of the
PSSA intervention as its implementation was scaled
up in Gulu and Amuru Districts through 2007 to
2009.
Methods
Participants and setting
As noted earlier, education authorities in Gulu and
Amuru districts, in collaboration with Save the Children, had identified 40 schools significantly impacted
by displacement of children following the conflict as
eligible for physical infrastructure upgrading and
potential curriculum support through programs such
as PSSA. All 40 schools were physically upgraded, but
funding and logistical concerns limited initial implementation of PSSA to 21 schools located across Gulu
and Amuru’s four sub-districts. Eight intervention
schools were selected for inclusion in the study – with a
quota of two schools per sub-district – by toss of a coin.
Comparison schools were selected from the remaining
19 schools meeting eligibility criteria for support (for all
of which PSSA implementation was provisionally
scheduled for the following year). Comparison schools
were selected and matched with intervention schools on
the basis of geographical location, which was seen as
appropriate proxy for both exposure to conflict and local
resource conditions. On this basis, one school was
selected to serve as a comparison for two intervention
schools (though different grades were drawn upon, see
below). School names are not reported in this article to
ensure confidentiality of study participants.
From each of the eight intervention schools, the first
group of 25 students selected to undergo the PSSA
program in the school year 2007/08 was the focus of
the evaluation. The program was targeted toward all
children who had grown up in the context of stress and
conflict, not only formerly abducted children or those
with identified psychological difficulties. At each school
a ‘rolling program’ of implementation by successive
‘batches’ of student groups was conceived, with all
students potentially benefiting. However, in selecting
the initial grade level for intervention, teachers were
encouraged to consider the number of children in that
year group who met certain criteria, such as those who
isolated themselves, were frequently absent, seemed
particularly stressed, had low self-esteem and/or a
violent family background. These criteria were additionally used by teachers to select from the chosen
grade the first ‘batch’ of students to receive the intervention. In the matched schools, children from the
same grades were chosen for the comparison group,
with similar criteria adopted to select specific
participants (i.e., following intervention group selection
criteria).
In total, 403 primary school students took part in the
study, 202 girls and 201 boys, with 203 in the intervention group and 200 in the comparison group. At
baseline children ranged in age from 7 to 12 years with
a mean age of 10.23 (sd = 1.61). Students from primary
school year groups 1, 3, 4, 5, and 6 had been selected
by schools to receive the intervention, which contributed to the wide range in ages participating in the
evaluation.
Intervention
The intervention was structured according to the three
PSSA components noted in the introduction. The
classroom component involved 15 highly structured
one-hour sessions delivered over the course of five
weeks by two regular school teachers trained in the
methodology in a residential workshop before the start
of the school year. Sessions followed a regular structure
of opening, thematic and closing activities, with thematic activities addressing issues of safety and control,
self-esteem, thoughts and reactions during danger,
resource identification and coping skills. Methods
included didactic presentations, reflective exercises,
drama and games. The community service component
was facilitated by the same teachers, and included
helping the sick and elderly, digging boreholes and
planting trees. The parental engagement component
2011 The Authors. Journal of Child Psychology and Psychiatry 2011 Association for Child and Adolescent Mental Health.
Psychosocial structured activities with conflict-affected children in northern Uganda
was principally implemented through periodic discussion meetings with parents facilitated by Save the
Children in Uganda (SCiUg) Child Resilience Project
staff who made regular supervisory visits to implementation schools.
In original program documentation these components had related to distinct program goals of
‘enhancing school performance’, ‘increasing participation in social activities and self-help community initiatives’ and ‘improving care and emotional support
received in families’. However, through inception the
program elements were increasingly seen as connected
to the core goal of enhancing child well-being and
‘resilience’. With this construct the central focus of
change, the study focused on operationalization of this
concept.
Measures
Researchers adopted a modified form of brief ethnographic interviewing (Hubbard, 2008) to determine
local understandings of child-well-being and resilience.
Prior to the evaluation, each of the eight intervention
schools was visited, and discussions held with children,
parents (and other main caregivers) and teachers. In
each school, children who had engaged in the first
‘batch’ of PSSA activities at the school (in academic year
2006/7) engaged in a ‘free-listing’ exercise, identifying
characteristics of a resilient child who demonstrated
good well-being (after the methodology outlined in Ager
et al., 2011). Responses from the 120 children engaged
in this manner were pooled and independently grouped
by seven raters with local language and cultural
knowledge. The preliminary categories of response were
then, through discussion, consolidated into the six
indicators listed in Table 1. An analogous procedure
was followed with 136 parents from across the eight
schools – and with 42 teachers during the course of
their training and supervision in implementation of
PSSA – to yield the list of indicators listed in Table 1.
Data collection
1127
day for data collection at each school, the research team
gathered the selected children outside or in an empty
classroom. The purpose of the evaluation was discussed and the meaning of each of the indicators
reviewed in Acholi. Chi …
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