Table 4

Reported barriers to and facilitators of intervention delivery

Access and security
  •  “A continuous problem was the security situation, which impacted implementation of the programmes from the level of access to the target population, selection of staff and development of communication, to the identification of local support mechanisms”132

  •  “There are always security risks to staff members due to the presence of landmines and unexploded ordinances, in addition to general travel restrictions imposed by peace-keeping troops that directly affect the sample selection process”69

  •  “Time was another major constraint during these camps as, due to security concerns, travelling was not possible after dark”76

  •  “Another obstacle was that the program coordinators were not allowed to travel to Iraq due to the worsened security situation. They were therefore forced to organize and supervise the program via the Internet, Skype, and by telephone”152

  •  “Poor network coverage and phone charging facilities in the settlement makes community mobilisation processes difficult for the implementation team”103

  •  “The recent bombing and closure of the clinic resulted in a huge loss for the local communities’ leaving a gap in critical services for the health system of this war ravaged region”73

  •  “In these settings, the context is likely to change abruptly at any moment, and the research subjects who are participating out of goodwill alone may no longer be available. The sudden change in political circumstances meant that the original plan to measure postintervention outcomes at 4 months after admission to the nutrition program had to be modified”106

Language and culture
  •  “There was a huge language barrier as two-thirds of the patients could only communicate in Pashto. Even the Pashto speaking professionals had difficulty conducting interviews because of the dialect spoken by most IDPs”76

  •  “Throughout the intervention programme, it was observed that the majority of the children who participated in the study could not name or explain their emotions”149

Training lay staff
  •  “A limitation involves training teachers who had no mental health background and whose own mental state following the war trauma was a factor we could not control for completely (despite addressing it in their training)”84

  •  “It was a challenge to find refugees resident in the settlement with even basic education. Many had had their schooling interrupted by the conflicts from which they fled, and most of those with some education had already left the settlement in search of employment opportunities”117

Heterogeneity of study population
  •  “There was a broad age range, not all participants had been abducted and there was a broad range of reported psychopathology at pre-test assessment”113

  •  “Other limitations were: not investigating the process of the intervention, not involving parents, the large size and developmental heterogeneity of the intervention groups, and the different treatment requirements for PTSD and depression”143

Utilisation of local community members
  •  “These psychosocial outreach volunteers represent the foundation of the mental health and psychosocial support programme. This is, in part, due to the fact that Syrian and refugee outreach volunteers are able to access areas that UNHCR staff are currently not permitted to visit, including collective shelters and communities hosting displaced Syrians. The outreach volunteers and the mobile MHPSS case managers are therefore able to provide a crucial outreach function by helping to decentralise psychosocial support and to bring mental health services closer to vulnerable populations”70

  •  “The use of local volunteers and program graduates promotes community as well as enables the program more flexibility to reach out to a wider range of war-affected children in Kosovo”66

  •  “The intervention which can be easily delivered by trained community volunteers (CVs). The CVs in our study by virtue of residing in these camps had the advantage of sharing the same language and culture of the refugees, thereby enhancing their acceptability”151

Training of outreach volunteers for referrals
  •  “Community outreach in DRC was also an important source of referral. This outreach by MSF includes specific information on sexual violence services, which may be a reason for the high proportion of survivors of sexual violence, including children, presenting to the programme”96

  •  “Community-based activities allowed outreach to a wide range of people among those in need as well as those who were not in need. After defining the scope of the intervention, the coverage of the refugee population could be extended to districts other than the ones previously identified, according to the population needs”91

Integration of MHPPS interventions into existing PHC/referral networks
  •  “The main difference between the two projects resided in the network; in a center-based program, the creation of the referral system toward the center relied mostly on the pre-existing network of service providers (NGOs, community-based organizations, local institutions), while a community-based program created its own network, usually in collaboration with community leaders and key persons such as shopkeepers”91

  •  “In DRC, the integrated nature of the programme and links with community health workers is reflected in the fact that almost half of all patients were referred by primary healthcare services, whereas in Iraq the focus on links to secondary and tertiary health services meant they were of more importance than primary care providers. Specific provision of information on child mental health services, by providers of those services, to groups that come into contact with children appears to improve uptake”96

Adaptation of interventions
  •  “Using therapeutic consultations, mainly at the patient’s residence and often involving the family, more than three-quarters of patients had improved at the end of therapy. The importance of this adapted therapy, based on the psychodynamic approach and respecting the Palestinians’cultural characteristics, was possible and efficient”65

  •  “In the absence of trained professionals for emergency interventions, mobilizing teachers was the best alternative to reach the largest number of students”84

School-based approach
  •  “School-based intervention is the best way to reach a large number of children suffering from conflict-related distress and to target youth in their natural school environment by training professionals in the educational system. School-based programs allow youth to be trained and treated in a non-stigmatizing environment with little disruption to their daily schedules, which is important for mitigating posttraumatic stress“24

  •  “Underscoring program sustainability, the Federal Ministry incorporated implementing the program into the counselors’ job requirements and contracted local mental health professionals to provide supervision. The resulting professional network interlinked participating schools with local mental health clinics and the local university and allowed the program to run autonomously throughout the school year“90

  • DRC, Democratic Republic of Congo; IDP, internally displaced person; MHPSS, mental health and psychosocial support; MSF, Médecins Sans Frontières; NGO, non-governmental organisation; PHC, primary health centre; PTSD, post-traumatic stress disorder; UNHCR, United Nations High Commissioner for Refugees.