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How do we build the foundations for more resilient social, economic, and political systems and link individual with collective resilience to sustain change across generations? These are pressing questions in the fields of resilience humanitarianism and peacebuilding, fields that seek transformative, sustainable changes to achieve ambitious goals affecting research, policy and practice. This chapter provides three examples of systems-level thinking on resilience that have structured the architecture of the humanitarian and peacebuilding agenda. These examples offer proof-of-concept approaches to synergistically foster wealth, health, and peace, in ways that link: resilience and peacebuilding to household wealth and food security; resilience and social cohesion to individual health and stress regulation; and cultures of peace to caregiving and early child development. They emphasize a theory of change that strives to strengthen the social compact between state, civil society, and families in contexts of fragility, conflict, or forced displacement. Resilience is an everyday practice for crisis-affected communities, one rooted in the political economy of social action and structural transformation. Efforts to build systems-level resilience require careful work with respect to conceptual clarity, meaningful measurement, and grounded intervention.

Purpose In situations of adversity, young people draw on individual, relational, and contextual (community and cultural) resources to foster their resilience. Recent literature defines resilience as a capacity that is underpinned by a network of interrelated resources. Although empirical studies show evidence of the value of a network approach, little is known regarding how different country contexts influence which resources are most critical within a resource network and how resources interact for adolescent resilience. Methods Network analysis was conducted with data from studies that had used the Child and Youth Resilience Measure. Regularized partial correlation networks of 17 resources were estimated for 14 countries (Botswana, Canada, China, Colombia, Equatorial Guinea, India, Indonesia, Italy, Jordan, New Zealand, the Philippines, Romania, South Africa, and Syrian refugees living in Jordan). The sample size was 18,914 (mean age = 15.70 years, 48.8% female). Results We observed mostly positive associations between the resources of interest. The salience and strength of associations between resources varied by country. The most central resource across countries was having supportive caregivers during stressful times because this resource had the most and strongest positive associations with other resources. Conclusions This study gives first empirical evidence from multiple countries that an interplay of social–ecological resources (such as individual skills, peer, caregiver and community support, and educational aspirations and opportunities) matter for adolescent resilience. Across countries, caregiver support appears to be most central for adolescent resilience. Future resilience interventions might apply this network approach to identify important, contextually relevant resources that likely foster additional resources.

OBJECTIVES: Oxidative stress is hypothesized to contribute to age-related somatic deterioration. Both reproductive and ecological context may necessitate tradeoffs that influence this outcome. We examined whether measures of lifetime reproductive effort were related to levels of oxidative stress biomarkers in peri- and post-menopausal women and whether associations were moderated by rural or urban residence. METHODS: We surveyed 263 healthy women (age 62.1 ± 10.0 SD) from rural (N=161) and urban Poland (N=102), collecting sociodemographic data and urine samples to analyze biomarkers of oxidative stress (8-oxo-2’-deoxyguanosine, 8-OHdG) and antioxidative defense (copper-zinc superoxide dismutase, Cu-Zn SOD). Linear regression models, adjusted for residence, were used to test for associations between reproductive effort and 8-OHdG and Cu-Zn SOD. RESULTS: Univariate models demonstrated significant associations between gravidity and the biomarkers of oxidative stress (8-OHdG: R(2) = 0.042, p =

Major knowledge gaps remain concerning the most effective ways to address mental health and psychosocial needs of populations affected by humanitarian crises. The Research for Health in Humanitarian Crisis (R2HC) program aims to strengthen humanitarian health practice and policy through research. As a significant portion of R2HC’s research has focused on mental health and psychosocial support interventions, the program has been interested in strengthening a community of practice in this field. Following a meeting between grantees, we set out to provide an overview of the R2HC portfolio, and draw lessons learned. In this paper, we discuss the mental health and psychosocial support-focused research projects funded by R2HC; review the implications of initial findings from this research portfolio; and highlight four remaining knowledge gaps in this field. Between 2014 and 2019, R2HC funded 18 academic-practitioner partnerships focused on mental health and psychosocial support, comprising 38% of the overall portfolio (18 of 48 projects) at a value of approximately 7.2 million GBP. All projects have focused on evaluating the impact of interventions. In line with consensus-based recommendations to consider a wide range of mental health and psychosocial needs in humanitarian settings, research projects have evaluated diverse interventions. Findings so far have both challenged and confirmed widely-held assumptions about the effectiveness of mental health and psychosocial interventions in humanitarian settings. They point to the importance of building effective, sustained, and diverse partnerships between scholars, humanitarian practitioners, and funders, to ensure long-term program improvements and appropriate evidence-informed decision making. Further research needs to fill knowledge gaps regarding how to: scale-up interventions that have been found to be effective (e.g., questions related to integration across sectors, adaptation of interventions across different contexts, and optimal care systems); address neglected mental health conditions and populations (e.g., elderly, people with disabilities, sexual minorities, people with severe, pre-existing mental disorders); build on available local resources and supports (e.g., how to build on traditional, religious healing and community-wide social support practices); and ensure equity, quality, fidelity, and sustainability for interventions in real-world contexts (e.g., answering questions about how interventions from controlled studies can be transferred to more representative humanitarian contexts).

Deployment in a crisis zone is a perilous undertaking. Little is known right now about how humanitarian workers relate social and professional goals to lived experiences of high-risk environments. In South Sudan, ranked as the most dangerous country globally for aid workers, 20 international humanitarian staff were interviewed to examine their sense of place, well-being, and vocation, using thematic and interpretative phenomenological analysis. Subjectivities of humanitarian space hinged upon negotiating physical hardships and social relationships: Juba, the capital, was described as a 'prison' and a 'party hotspot'. For expatriate staff, making sense of spatial, social, and professional transience was sharply gendered and rooted in the subjectivities of risk-taking, crisis management, and career-building. Two policy measures are highlighted here to address the implications of transience for human well-being and organisational effectiveness. Efforts to support teams and structure work environments, altering the humanitarian and vocational bubble, will help to develop resilience at the heart of humanitarian systems.الانتشار في مناطق الأزمات هو عمل محفوف بالمخاطر. وحتى الآن، لا يُعرف سوى القليل عن كيفية ربط العاملين في المجال الإنساني بين الأهداف الاجتماعية والمهنية بالتجارب المعيشية في البيئات عالية الخطورة. ففي جنوب السودان، المصنف على أنه أخطر دولة بالنسبة لعمال الإغاثة على مستوى العالم، أجرينا مقابلات مع موظفين دوليين في المجال الإنساني (عددهم = 20) لفحص باستخدام التحليل الموضوعي والتفسيري للظواهر وإحساسهم بالمكان والرفاهية والوظيفة. توقفت السمات الشخصية للمساحات الإنسانية على التفاوض بشأن الصعوبات الجسدية والعلاقات الاجتماعية حيث وُصفت جوبا بكونها "سجن" و "بقعة ساخنة للحفلات." بالنسبة للموظفين المغتربين، كان فهم الزوال المكاني والاجتماعي والمهني مرتبطًا بشكل حاد بالنوع الاجتماعي ومتحدرا في السمات الذاتية للمخاطرة وإدارة الأزمات وبناء المسار الوظيفي. نسلط الضوء على اثنين من تدابير السياسة لمعالجة الآثار المترتبة على الزوال لكلا من رفاهية الإنسان والكفاءة التنظيمية. ستساعد الجهود المبذولة لدعم الفرق وهيكلة بيئات العمل، وتغيير الفقاعة الإنسانية والمهنية على بناء المرونة في قلب الأنظمة الإنسانية.在危机地区部署是件危险的事情。迄今为止，关于人道主义工作者如何将社会和职业目标与高风险环境的生活经验联系起来，我们知之甚少。南苏丹被评为全球援助工作者最危险的国家，我们采访了20名国际人道主义工作人员，利用主题和解释性现象学分析来考察他们的地点感、幸福感和职业感。人道主义空间的主观性取决于对物质困难和社会关系的谈判:朱巴被描述为“监狱”和“派对热点。” 对于外派员工来说，对空间、社会和职业短暂性的理解有明显的性别差异，根植于冒险、危机管理和职业生涯建设等主观活动。我们强调了两项政策措施以解决短暂性对人类福祉和组织效率的影响。努力支持团队和构建工作环境，改变人道主义和职业泡沫，将帮助 人道主义系统的核心建立弹性。.

Background Evidence of ‘what works’ in humanitarian programming is important for addressing the disruptive consequences of conflict and forced displacement. However, collecting robust scientific evidence, and ensuring contextual relevance, is challenging. We measured the biological, psychosocial, and cognitive impacts of a structured psychosocial intervention, implemented by Mercy Corps with Syrian refugees and Jordanian host-community youth. In this paper, we present a case analysis of this evaluation study and reflect on the scientific contributions of the work, the challenges experienced in its delivery, and the strategies deployed to address them. Discussion We identified challenges with respect to study design, methods, and dissemination: these included the logistics and acceptability of implementing a randomized controlled trial in a humanitarian context, the selection and refinement of culturally-relevant research tools and community-based practices, and the dissemination of results to multiple stakeholders. We demonstrated beneficial and sustained impacts on self-reports of insecurity, stress, and mental health; developed a reliable and culturally-relevant measure of resilience; experimentally tested cognitive skills; and showed that levels of cortisol, a biomarker of chronic stress, reduced by one third in response to intervention. Using stress biomarkers offered proof-of-concept evidence, beyond self-reported data: interventions targeting mental health and psychosocial wellbeing can regulate physiological stress in the body as well as improve self-reported mental health and wellbeing. We built constructive dialogue between local communities, scholars, humanitarian practitioners, and policy-makers. Conclusions Our work shows the value of rigorous research in humanitarian settings, emphasizing relevance for local communities and meaningful ways to build research ownership. Findings encourage the adoption of cognitive measures and stress biomarkers alongside self-report surveys in evaluating programme impacts. High-quality scientific research with youth can be feasible, useful, and ethical in humanitarian settings.

Temporal examinations of the biological signature of stress or trauma in war-affected populations are seldom undertaken. Moreover, few studies have examined whether stress biomarkers track biological sensitivity to brief interventions targeting the improvement of psychosocial wellbeing. Our study is the first to prospectively examine, in war-affected adolescents, the associations between hair cortisol concentrations (HCC) and self-reports of stress, insecurity, posttraumatic reactions, and lifetime trauma. We conducted a randomized controlled trial to test the impact of an 8-week intervention based on profound stress attunement. We collected data for a gender-balanced sample of 733 Syrian refugee ( n = 411) and Jordanian non-refugee ( n = 322) adolescents (12–18 years), at three time-points. We used growth mixture models to classify cortisol trajectories, and growth models to evaluate intervention impact on stress physiology. We observed three trajectories of HCC: hypersecretion, medium secretion, and hyposecretion (9.6%, 87.5% and 2.9% of the cohort, respectively). For every one percent increase in levels of insecurity, adolescents were 0.02 times more likely to have a trajectory of hypersecretion (95% CI: 1.00, 1.03, p = 0.01). For each additional symptom of posttraumatic stress reported, they were 0.07 times less likely to show hyposecretion (95% CI: 0.89, 0.98, p = 0.01). Indeed, stronger posttraumatic stress reactions were associated with a pattern of within-individual cortisol dysregulation and medium secretion. Overall, HCC decreased by a third in response to the intervention (95% CI: −0.19, −0.03, p = 0.01). While the intervention decreased HCC for youth with hypersecretion and medium secretion, it increased HCC for youth with hyposecretion (95% CI: 0.22, 1.16, p = 0.004), relative to controls. This suggests a beneficial regularization of cortisol levels, corroborating self-reports of improved psychosocial wellbeing. We did not find evidence to suggest that gender, resilience, or posttraumatic stress disorder influenced the strength or direction of responses to the intervention. This robust impact evaluation exemplifies the utility of biomarkers for tracking physiological changes in response to interventions over time. It enhances the understanding of trajectories of endocrine response in adverse environments and patterns of stress responsivity to ecological improvement.

Background Strengthening the evidence base for humanitarian interventions that provide psychosocial support to war‐affected youth is a key priority. We tested the impacts of an 8‐week programme of structured activities informed by a profound stress attunement (PSA) framework (Advancing Adolescents), delivered in group‐format to 12–18 year‐olds in communities heavily affected by the Syrian crisis. We included both Syrian refugee and Jordanian youth. Methods We followed an experimental design, comparing treatment youth and wait‐list controls over two programme implementation cycles, randomizing to study arm in cycle 2 (ClinicalTrials.gov ID: NCT03012451). We measured insecurity, distress, mental health difficulties, prosocial behaviour and post‐traumatic stress symptoms at three time‐points: baseline (n = 817 youth; 55% Syrian, 43% female), postintervention (n = 463; 54% Syrian, 47% female), and follow‐up (n = 212, 58% Syrian, 43% female). Regression models assessed: prospective intervention impacts, adjusting for baseline scores, trauma exposure, age, and gender; differential impacts across levels of trauma exposure and activity‐based modality; and sustained recovery 1 year later. We analysed cycle‐specific and cycle‐pooled data for youth exclusively engaged in Advancing Adolescents and for the intent‐to‐treat sample. Results We found medium to small effect sizes for all psychosocial outcomes, namely Human Insecurity (β = −7.04 (95% CI: −10.90, −3.17), Cohen's d = −0.4), Human Distress (β = −5.78 (−9.02, −2.54), d = −0.3), and Perceived Stress (β = −1.92 (−3.05, −0.79), d = −0.3); and two secondary mental health outcomes (AYMH: β = −3.35 (−4.68, −2.02), d = −0.4; SDQ: β = −1.46 (−2.42, −0.50), d = −0.2). We found no programme impacts for prosocial behaviour or post‐traumatic stress reactions. Beneficial impacts were stronger for youth with exposure to four trauma events or more. While symptoms alleviated for both intervention and control groups over time, there were sustained effects of the intervention on Human Insecurity. Conclusions Findings strengthen the evidence base for mental health and psychosocial programming for a generation affected by conflict and forced displacement. We discuss implications for programme implementation and evaluation research., Read the Commentary on this article at doi: 10.1111/jcpp.12870

The impacts of war and displacement on executive function (EF)-what we might call the cognitive signatures of minds under siege-are little known. We surveyed a gender-balanced sample of 12- to 18-year-old Syrian refugees (n = 240) and Jordanian non-refugees (n = 210) living in Jordan. We examined the relative contributions of poverty, trauma exposure, posttraumatic stress, and insecurity to variance in inhibitory control and working memory. We observed associations between poverty and WM, suggesting that, even in populations exposed to substantial violence and fear, poverty is a specific pathway to WM deficit. We did not, however, find associations between EFs and exposures to trauma. Careful distinction between childhood adversities may illuminate which neurocognitive pathways matter for measures of cognitive function. [ABSTRACT FROM AUTHOR]

The developmental origins of health and disease (DOHaD) hypothesis posits that early childhood stressors disproportionately impact adult health. Numerous studies have found adult mental health to be associated with childhood adversities and genetic variants, particularly in genes related to neurochemistry. However, few studies have examined the way interactive effects may manifest over time and fewer still include protective factors, like resilience. Our group has previously found associations between the monoamine oxidase A gene, MAOA, and a contextually-specific measure of resilience with a measure of perceived psychosocial stress over time in Syrian refugee youth. In this study, we work with the same sample of adolescents to test genetic variants in three additional candidate genes (FAAH, the 5-HTTLPR region of SLC6A4, and BDNF) for associations with six psychosocial stress and mental health outcomes. Using multi-level modeling, we find no association between variants in these candidate genes and psychosocial stress or mental health outcomes. Our analysis included tests for both direct genetic effects and interactions with lifetime trauma and resilience. Negative results, such as the lack of genetic associations with outcome measures, provides a more complete framework in which to better understand positive results and associations.

Early childhood trauma can have profound and lifelong effects on adult mental health and psychosocial wellbeing. Nevertheless, responses to trauma are highly variable. Genetic variants may help explain variation in responses to trauma by identifying alleles that associate with changes in mental health measures. Protective factors, such as resilience, likely also play an important role in responses to trauma. The effects of genetic variants, in combination with protective factors, on psychosocial health are not well understood, particularly in non-Western contexts. In this study, we test the relative influence of genetic variants of monoamine oxidase A (MAOA, a gene proposed to influence the impact of childhood trauma on adult violence and antisocial behavior), levels of resilience, and exposure to traumatic events on psychosocial stress and mental health trajectories over time. We use data from a cohort of 12-18-year-old Syrian refugees who were forcibly displaced to neighboring Jordan (n = 399). DNA samples and survey data on trauma exposure, resilience (CYRM-12), and psychosocial stress were collected at three time points: baseline, ~13 weeks, and ~48 weeks. Using multilevel models, we identified an association of MAOA variant, in males only, with symptom scores of psychosocial stress on the Perceived Stress Scale (PSS) over time (p = 8.1 x 10-4). We also found that resilience is strongly associated with PSS (p = 7.9 x 10-9), underscoring the importance of protective factors in influencing levels of psychosocial stress. Furthermore, there was an additive effect wherein the sharpest reductions in perceived psychosocial stress are seen in low-activity MAOA males with low trauma exposure or high resilience levels. Our results highlight the value of studies that integrate genetic and psychosocial factors to better understand complex phenotypes, such as responses to trauma in contexts of high trauma exposure.

Why do humans heal one another? Evolutionary psychology has advanced our understanding of why humans suffer psychological distress and mental illness. However, to date, the evolutionary origins of what drives humans to alleviate the suffering of others has received limited attention. Therefore, we draw upon evolutionary theory to assess why humans psychologically support one another, focusing on the interpersonal regulation of emotions that shapes how humans heal and console one another when in psychosocial distress. To understand why we engage in psychological healing, we review the evolution of cooperation among social species and the roles of emotional contagion, empathy, and self-regulation. We discuss key aspects of human biocultural evolution that have contributed to healing behaviors: symbolic logic including language, complex social networks, and the long period of childhood that necessitates identifying and responding to others in distress. However, both biological and cultural evolution also have led to social context when empathy and consoling are impeded. Ultimately, by understanding the evolutionary processes shaping why humans psychologically do or do not heal one another, we can improve our current approaches in global mental health and uncover new opportunities to improve the treatment of mental illness across cultures and context around the world.

Conceptually and methodologically, medical anthropology is well-positioned to support a "big-tent" research agenda on health and society. It fosters approaches to social and structural models of health and wellbeing in ways that are critically reflective, cross-cultural, people-centered, and transdisciplinary. In this review article, we showcase these four main characteristics of the field, as featured in Social Science & Medicine over the last fifty years, highlighting their relevance for an international and interdisciplinary readership. First, the practice of critical inquiry in ethnographies of health offers a deep appreciation of sociocultural viewpoints when recording and interpreting lived experiences and contested social worlds. Second, medical anthropology champions cross-cultural breadth: it makes explicit local understandings of health experiences across different settings, using a fine-grained, comparative approach to develop a stronger global platform for the analysis of health-related concerns. Third, in offering people-centered views of the world, anthropology extends the reach of critical enquiry to the lived experiences of hard-to-reach population groups, their structural vulnerabilities, and social agency. Finally, in developing research at the nexus of cultures, societies, biologies, and health, medical anthropologists generate new, transdisciplinary conversations on the body, mind, person, community, environment, prevention, and therapy. As featured in this journal, scholarly contributions in medical anthropology seek to debate human health and wellbeing from many angles, pushing forward methodology, social theory, and health-related practice.

Validated measures are needed for assessing resilience in conflict settings. An Arabic version of the Child and Youth Resilience Measure (CYRM) was developed and tested in Jordan. Following qualitative work, surveys were implemented with male/female, refugee/nonrefugee samples (N = 603, 11–18 years). Confirmatory factor analyses tested three-factor structures for 28- and 12-item CYRMs and measurement equivalence across groups. CYRM-12 showed measurement reliability and face, content, construct (comparative fit index = .92–.98), and convergent validity. Gender-differentiated item loadings reflected resource access and social responsibilities. Resilience scores were inversely associated with mental health symptoms, and for Syrian refugees were unrelated to lifetime trauma exposure. In assessing individual, family, and community-level dimensions of resilience, the CYRM is a useful measure for research and practice with refugee and host-community youth.

Anthropology brings nuance and innovation to the field of Global Mental Health. It offers depth and breadth of knowledge regarding the drivers of mental health and psychosocial wellness, championing a fine-grained approach to culture, and insisting on critical analyses of social and moral contexts relevant to wellbeing. It offers insights that are relevant for the design of effective and sustainable interventions, helping us understand what can be transformative in health promotion and lasting in terms of intergenerational change. This chapter presents critical reflections on culture, resilience, and mental health from previously published work in Afghanistan. One of the important lessons drawn from this research is that a sense of trajectory—a sense of coherence and hope—is fundamental to the struggle to be well. In the context of coping with violence, poverty, and inequality, gaining a deep understanding of mental health becomes a matter of understanding local narratives of resilience, as well as identifying the cultural goals and material resources that feed hope and help weather everyday stressors. Cultural insights on risk and resilience in mental health are worth scholarly investment and best advanced with a collaborative agenda, one that integrates approaches from medical anthropology and cross-cultural psychiatry.

In recent years, anthropologists have become increasingly present in medical humanitarian situations as scholars, consultants, and humanitarian practitioners and have acquired insight into medical humanitarian policy and practice. In 2012, we implemented a poll on anthropology, health, and humanitarian practice in which 75 anthropologists discussed their experiences in medical humanitarianism. Our goal was to move beyond the existing anarchy of individual voices in anthropological writing and gain an aggregate view of the perspective of anthropologists working in medical humanitarian contexts. Responses lead to six inductively derived thematic priorities. The findings illustrate how anthropologists perceive medical humanitarian practice; which aspects of medical humanitarianism should be seen as priorities for anthropological research; and how anthropologists use ethnography in humanitarian contexts.

Risk and resilience research articulates major explanatory frameworks regarding the persistence of health disparities. Specifically, scholars have advocated a sophisticated knowledge of risk, a more grounded understanding of resilience, and comprehensive and meaningful measurements of risk and resilience pathways across cultures. The goal is to operationalize research issues into sustainable health practice and equity-focused policy. This article synthesizes current understandings on risk and resilience from the lens of medical anthropology: It reviews key insights gained from the standpoint of cultural narratives, political economy, and life history theory, as well as current shortcomings. The emergent literature on health-related risk and resilience is breathing new life into collaboration and dialogue across diverse fields of research and policy.

Grandparents are often a key source of care provision for their grandchildren, yet they are sidelined in caregiving research and policy decisions. We conducted a global, systematic review of the literature to examine the scope and quality of studies to date (PROSPERO database CRD42019133894). We screened 12,699 abstracts across 7 databases, and identified 206 studies that examined how grandparents influence child health and development. Indicators of grandparent involvement were contact, caregiving behaviors, and financial support. Our review focused on two research questions: how do grandparents influence child health and development outcomes, and what range of child outcomes is reported globally? We examined study design, sample characteristics, key findings, and outcomes pertaining to grandchildren’s physical health, socio-emotional and behavioral health, and cognitive and educational development. Our search captured studies featuring grandparent custodial care (n = 35), multigenerational care (n = 154), and both types of care (n = 17). We found substantial heterogeneity in the data provided on co-residence, caregiving roles, resources invested, outcomes, and mechanisms through which “grandparent effects” are manifested. We identified two important issues, related to operationalizing indicators of grandparent involvement and conceptualizing potential mechanisms, leading to gaps in the evidence base. Currently, our understanding of the pathways through which grandparents exert their influence is constrained by limited data on what grandparents actually do and insufficient attention given to interpersonal and structural contexts. We present a conceptual framework to explicitly measure and theorize pathways of care, with a view to inform research design and policy implementation. We underscore the need for more robust data on three indicators of caregiver involvement—contact, behavior, and support—and for careful description of structural and interpersonal contexts in caregiving research.

The general themes of early childhood and peacebuilding barely intersect, whether in scientific research, policy or practice. Yet recent studies emerging from different disciplines such as neurobio...

BACKGROUND: In humanitarian settings, family-level drivers of mental health are insufficiently documented; we examined the strength of caregiver-child associations with two-wave, family-level Afghan data. METHODS: We recruited a gender-balanced sample of 681 caregiver-child dyads (n = 1,362 respondents) using stratified random-sampling in government schools in Kabul (364 dyads) and refugee schools in Peshawar (317 dyads). One year after baseline, we re-interviewed 64% of Kabul and 31% of Peshawar cohorts (n = 331 dyads, 662 respondents), retaining fewer Peshawar families due to refugee repatriation. In multivariable analyses adjusted for baseline, we assessed the extent to which caregiver mental health (Self-Report Questionnaire, SRQ-20) was associated with child symptom scores of post-traumatic stress (Child Revised Impact of Events Scale, CRIES), depression (Depression Self-Rating Scale, DSRS), psychiatric difficulties, impact, and prosocial strength (Strength and Difficulties Questionnaire, SDQ). RESULTS: Caregiver mental health was prospectively associated with all eight measures of child mental health at follow-up, adjusted for baseline. For post-traumatic stress, caregiver mental health had a predictive impact comparable to the child experiencing one or two lifetime trauma events. For depression, caregiver mental health approached the predictive impact of female gender. Thus a one SD change in caregiver SRQ-20 was associated with a 1.04 point change on CRIES and a 0.65 point change in DSRS. For multi-informant SDQ data, caregiver-child associations were strongest for caregiver ratings. For child-rated outcomes, associations were moderated by maternal literacy, a marker of family-level dynamics. Both adults and children identified domestic violence and quality of home life as independent risk and protective factors. CONCLUSIONS: In the context of violence and displacement, efforts to improve child mental health require a thoughtful consideration of the mental health cascade across generations and the cluster of adversities that impact family wellbeing. We identify culturally meaningful leverage points for building family-level resilience, relevant to the prevention and intervention agenda in global mental health. Language: en

Health interventions increasingly rely on formative qualitative research and social marketing techniques to effect behavioural change. Few studies, however, incorporate qualitative research into the process of program evaluation to understand both impact and reach: namely, to what extent behaviour change interventions work, for whom, in what contexts, and why. We reflect on the success of a community-based hygiene intervention conducted in the slums of Kathmandu, Nepal, evaluating both maternal behaviour and infant health. We recruited all available mother–infant pairs (n = 88), and allocated them to control and intervention groups. Formative qualitative research on hand-washing practices included structured observations of 75 mothers, 3 focus groups, and 26 in-depth interviews. Our intervention was led by Community Motivators, intensively promoting hand-washing-with-soap at key junctures of food and faeces contamination. The 6-month evaluation period included hand-washing and morbidity rates, participant observation, systematic records of fortnightly community meetings, and follow-up interviews with 12 mothers. While quantitative measures demonstrated improvement in hand-washing rates and a 40% reduction in child diarrhoea, the qualitative data highlighted important equity issues in reaching the ultra-poor. We argue that a social marketing approach is inherently limited: focussing on individual agency, rather than structural conditions constraining behaviour, can unwittingly exacerbate health inequity. This contributes to a prevention paradox whereby those with the greatest need of a health intervention are least likely to benefit, finding hand-washing in the slums to be irrelevant or futile. Thus social marketing is best deployed within a range of interventions that address the structural as well as the behavioural and cognitive drivers of behaviour change. We conclude that critiques of social marketing have not paid sufficient attention to issues of health equity, and demonstrate how this can be addressed with qualitative data, embedded in both the formative and evaluative phases of a health intervention.

Background: Humanitarian crises are associated with an increase in mental disorders and psychological distress. Despite the emerging consensus on intervention strategies in humanitarian settings, the field of mental health and psychosocial support (MHPSS) in humanitarian settings lacks a consensus-based research agenda. Methods: From August 2009 to February 2010, we contacted policymakers, academic researchers, and humanitarian aid workers, and conducted nine semistructured focus group discussions with 114 participants in three locations (Peru, Uganda, and Nepal), in both the capitals and remote humanitarian settings. Local stakeholders representing a range of academic expertise (psychiatry, psychology, social work, child protection, and medical anthropology) and organizations (governments, universities, nongovernmental organizations, and UN agencies) were asked to identify priority questions for MHPSS research in humanitarian settings, and to discuss factors that hamper and facilitate research. Results: Thematic analyses of transcripts show that participants broadly agreed on prioritized research themes in the following order: (1) the prevalence and burden of mental health and psychosocial difficulties in humanitarian settings, (2) how MHPSS implementation can be improved, (3) evaluation of specific MHPSS interventions, (4) the determinants of mental health and psychological distress, and (5) improved research methods and processes. Rather than differences in research themes across countries, what emerged was a disconnect between different groups of stakeholders regarding research processes: the perceived lack of translation of research findings into actual policy and programs; misunderstanding of research methods by aid workers; different appreciation of the time needed to conduct research; and disputed universality of research constructs. Conclusions: To advance a collaborative research agenda, actors in this field need to bridge the perceived disconnect between the goals of “relevance” and “excellence.” Research needs to be more sensitive to questions and concerns arising from humanitarian interventions, and practitioners need to take research findings into account in designing interventions. (Harv Rev Psychiatry 2012;20:25–36.)

We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive eff ect on the child’s psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identifi ed as aff ecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the eff ective integration of internally displaced and refugee children.

A critical health-related issue in war-affected areas is how people make sense of adversity and why they show resilience in a high-risk environment. In Afghanistan, the burden of poor mental health arises in contexts of pervasive poverty, social inequality, and persistent violence. In 2006, we conducted face-to-face interviews with 1011 children (age 11–16) and 1011 adult caregivers, randomly selected in a school-based survey in three northern and central areas. Participants narrated their experiences as part of a systematic health survey, including an open-ended questionnaire on major life stressors and solutions to mitigate them. Responses were analysed using an inductive thematic approach and categorised for quantitative presentation, producing a conceptual model. For adults, the primary concern is repairing their “broken economy,” the root of all miseries in social, educational, governance, and health domains. For students, frustrations focus on learning environments as well as poverty, as education is perceived as the gateway to upward social and economic mobility. Hope arises from a sense of moral and social order embodied in the expression of key cultural values: faith, family unity, service, effort, morals, and honour. These values form the bedrock of resilience, drive social aspirations, and underpin self-respect and dignity. However, economic impediments, social expectations, and cultural dictates also combine to create entrapment, as the ability to realise personal and social aspirations is frustrated by structural inequalities injurious to health and wellbeing. This study contributes to a small but growing body of work on resilience in public health and conflict settings. It demonstrates that culture functions both as an anchor for resilience and an anvil of pain, and highlights the relevance of ethnographic work in identifying what matters most in formulating social and public health policies to promote a hopeful future.

Foreword -Peter Piot Bringing Life into Relief: Comparative Ethnographies of Humanitarian Practice -Sharon Abramowitz and Catherine Panter-Brick PART I. INTIMATE INTERVENTIONS: HEALTH WORKER EXPERIENCES IN HUMANITARIAN CONTEXTS Chapter 1. Dignity Under Extreme Duress: The Moral and Emotional Landscape of Local Humanitarian Workers in the Afghan-Pakistan Border Areas -Patricia Omidian and Catherine Panter-Brick Chapter 2. Compassion and Care at the Limits of Privilege: Haitian Doctors amid the Influx of Foreign Humanitarian Volunteers -Laura Wagner Chapter 3. Trust and Caregiving During a UNICEF-Funded Relief Operation in the Somali Region of Ethiopia -Lauren Carruth PART II. THE ARCHITECTURE OF HUMANITARIAN KNOWLEDGE, ETHICS, AND IMPERATIVES Chapter 4. Evidence and Narratives: Recounting Ongoing Violence in Darfur, Sudan -Alex de Waal Chapter 5. Life Beyond the Bubbles: Cognitive Dissonance and Humanitarian Impunity in Northern Uganda -Tim Allen Chapter 6. Staging a "Medical Coup"? Medecins Sans Frontieres and the 2005 Food Crisis in Niger -Jean-Herve Jezequel PART III. STRONG STATES, WEAK STATES, AND CONTESTED HEALTH SOVEREIGNITIES Chapter 7. What Happens When MSF Leaves? Humanitarian Departure and Medical Sovereignty in Postconflict Liberia -Sharon Abramowitz Chapter 8. Humanitarianism and "Mobile Sovereignty" in Strong State Settings: Reflections on Medical Humanitarianism in Aceh, Indonesia -Byron J. Good, Jesse Hession Grayman, and Mary-Jo DelVecchio Good Chapter 9. The British Military Medical Services and Contested Humanitarianism -Stuart Gordon PART IV. THE AFTERLIVES OF INTERVENTION Chapter 10. Anthropology and Medical Humanitarianism in the Age of Global Health Education -Peter Locke Chapter 11. The Creation of Emergency and Afterlife of Intervention: Reflections on Guinea Worm Eradication in Ghana -Amy Moran-Thomas Chapter 12. Medical NGOs in Strong States: Working the Margins of the Israeli Medical Bureaucracy -Ilil Benjamin Conclusion. A Measured Good -Peter Redfield List of Contributors Index

Biocultural research remains a challenge in the field of global mental health. We sought to test associations between blood pressure and idioms of distress in a population survey.We drew on a randomly selected sample of 991 adults (498 men, 493 women) in Afghanistan, for whom physiological and psychosocial data were systematically collected. Assessment of mental health (Self-Reported Questionnaire, Afghan Symptom Checklist) included conceptualizations of distress related to pressure (fishar), anxiety, and dysphoria, as well as dimensions of negative affect and aggression. We used principal component analysis to map survey responses to fishar, and multiple regressions to examine associations with systolic/diastolic blood pressure, controlling for age, body mass index, and wealth, and differentiating by gender, mental health, and medication.The Afghan sample averaged 129/80 mmHg, with 27.14% of hypertensive individuals. SBP showed inverse associations with reports of low fishar (β = -4.58, P .001) and high fishar (β = 6.90, P .001), as did DPB with low fishar (β = -1.55, P .001) and high fishar (β = 3.77, P .001). Low and high fishar responses accounted for substantial proportions of SBP data variation (RSubjective reports of fishar map onto physiological blood pressure more robustly than other conceptualizations of mental distress related to anxiety, dysphoria, negative affect, or aggression. Our results point to the utility of mapping biological and cultural measures of stress and distress, advancing biopsychosocial understandings of wellbeing in global mental health surveys.

In the field of global mental health, there is a need for identifying core values and competencies to guide training programs in professional practice as well as in academia. This paper presents the results of interdisciplinary discussions fostered during an annual meeting of the Society for the Study of Psychiatry and Culture to develop recommendations for value-driven innovation in global mental health training. Participants (n = 48), who registered for a dedicated workshop on global mental health training advertised in conference proceedings, included both established faculty and current students engaged in learning, practice, and research. They proffered recommendations in five areas of training curriculum: values, competencies, training experiences, resources, and evaluation. Priority values included humility, ethical awareness of power differentials, collaborative action, and “deep accountability” when working in low-resource settings in low- and middle-income countries and high-income countries. Competencies included flexibility and tolerating ambiguity when working across diverse settings, the ability to systematically evaluate personal biases, historical and linguistic proficiency, and evaluation skills across a range of stakeholders. Training experiences included didactics, language training, self-awareness, and supervision in immersive activities related to professional or academic work. Resources included connections with diverse faculty such as social scientists and mentors in addition to medical practitioners, institutional commitment through protected time and funding, and sustainable collaborations with partners in low resource settings. Finally, evaluation skills built upon community-based participatory methods, 360-degree feedback from partners in low-resource settings, and observed structured clinical evaluations (OSCEs) with people of different cultural backgrounds. Global mental health training, as envisioned in this workshop, exemplifies an ethos of working through power differentials across clinical, professional, and social contexts in order to form longstanding collaborations. If incorporated into the ACGME/ABPN Psychiatry Milestone Project, such recommendations will improve training gained through international experiences as well as the everyday training of mental health professionals, global health practitioners, and social scientists.

Homeless and street children are commonly portrayed in the academic and welfare literature as a prime category of ‘children at risk’. They have attracted world‐wide attention due to rising numbers in cities of the Western and developing world coupled with a discourse of childhood that ascribes risk to poor urban children unaccompanied by adults on the streets. This paper presents a critique of views about homeless and street children that rest upon an unhelpful blanket generalization of risk and, more specifically, that adopt polemical or categorical statements about homelessness as the most salient risk factor for poor health. Current research is distancing itself from a discourse that sets global characteristics for a ‘street lifestyle’, aiming instead to contextualize research on street children. Many studies have also questioned the stereotypical expectation that homeless children are the most vulnerable in deprived environments, arguing that poverty, not homelessness per se, carries the most signific...

This article examines comparative energetic data on hunter-gatherers in the context of evolutionary scenarios of the sexual division of labor, with respect to both specific task allocation and overall levels of daily physical activity. The division of labor between men and women, well marked in contemporary foraging societies, was once posited as the "true watershed" for the evolution of the genus Homo. Some research on brain-wiring even links sex differences in cognitive and spatial abilities to sex-specific foraging activities. Most recent evolutionary arguments posit that men focus on hunting and women on gathering activities to realize potentially conflicting mating and parenting goals. A range of cooperative strategies (male/female and female/female) for child provisioning is also under investigation. Attention to energetic and reproductive trade-offs has usefully challenged the proposition that women are excluded from big-game hunting due to constraints of foraging ecology and reproduction. Simplistic assumptions about gender roles are thus increasingly questioned in anthropology, as well as in archaeology. Current models in behavioral ecology explore ways in which foraging practices vary with ecological circumstances, aiming to derive testable hypotheses from fine-grained data on the behavior of contemporary hunter-gatherers. Data on overall physical activity levels (PAL) can also serve to evaluate relative male/female workloads in modern groups, reconstruct hominid energy requirements and activity profiles, and examine changes with subsistence intensification. Male/female PAL ratios show that a task-specific division of labor does not readily extrapolate to 24-hour energy expenditure and that male/female differences in workloads were not necessarily reduced with the transition to agriculture. With respect to gender roles and PAL, a shift away from facile stereotypes of human behavior is evident. The challenge is to incorporate a range of behavioral responses to ecological circumstances in reconstructions of our evolutionary past.

Studies in the Gambia, using the lactulose–mannitol dual-sugar intestinal permeability test (lactulose:mannitol ratio) as a non-invasive way of investigating mucosal damage, have shown that food malabsorption is significantly associated with early growth retardation. In this cross-sectional study, 210 poor urban Nepali children, 0–60 months old, were recruited and measured for height or length and weight, 167 were examined for intestinal permeability and 173 for parasite infection. Weaning and morbidity data were collected from 172 caretakers. Children were mildly stunted (mean height-for-age Z-score −1·45) and underweight (mean weight-for-age Z-score −1·62). The lactulose:mannitol ratio (0·26) was poorer than that of UK children (0·12), but similar to that found in Bengali children of the same age (0·24). Two stages of weaning, the onset supplementary feeding (6 months) and the cessation of breast-feeding (23 months), were shown to have differential impact. In children currently breast-feeding, the duration of supplementation was negatively related to lactose (PPP=0·031), and poorer height-for-age (P=0·024), which was an unexpected result. No significant relationships were found between intestinal permeability and growth, or with morbidity and helminth infection, except in children withGiardia lambliawho had worse lactulose:mannitol ratios than those without (0·43v.0·25 respectively,P=0·014). It is likely that insults to the gut (e.g. Giardia) and challenges to the immune system (weaning) have a different impact in early and late infancy.

Experts investigate the role of child development in promoting a culture of peace, reporting on research in biology, neuroscience, genetics, and psychology. Can more peaceful childhoods promote a culture of peace? Increasing evidence from a broad range of disciplines shows that how we raise our children affects the propensity for conflict and the potential for peace within a given community. In this book, experts from a range of disciplines examine the biological and social underpinnings of child development and the importance of strengthening families to build harmonious and equitable relations across generations. They explore the relevance to the pursuit of peace in the world, highlight directions for future research, and propose novel approaches to translate knowledge into concrete action. The contributors describe findings from research in biology, neuroscience, evolution, genetics, and psychology. They report empirical evidence on children living in violent conditions, resilience in youth, and successful interventions. Their contributions show that the creation of sustainable partnerships with government agencies, community leaders, policy makers, funders, and service providers is a key ingredient for success. Taken together, they suggest possible novel approaches to translate knowledge into concrete action.

In recent years, anthropologists have become increasingly present in medical humanitarian situations as scholars, consultants, and humanitarian practitioners and have acquired insight into medical humanitarian policy and practice. In 2012, we implemented a poll on anthropology, health, and humanitarian practice in which 75 anthropologists discussed their experiences in medical humanitarianism. Our goal was to move beyond the existing anarchy of individual voices in anthropological writing and gain an aggregate view of the perspective of anthropologists working in medical humanitarian contexts. Responses lead to six inductively derived thematic priorities. The findings illustrate how anthropologists perceive medical humanitarian practice; which aspects of medical humanitarianism should be seen as priorities for anthropological research; and how anthropologists use ethnography in humanitarian contexts.

Culture and resilience prove to be slippery concepts unless deployed with care and attention. In this chapter, I demonstrate why a fine-grained approach to culture is important to the study of resilience, helping us avoid common pitfalls such as equating culture with society, religion, or ethnicity in ways that offer limited insights about people’s lives and local contexts. I advocate greater clarity of purpose with respect to concepts, methods, and evidence in resilience research, with a view to inform next steps for theory and practice. I illustrate mixed-methods approaches that operationalize vulnerability and resilience across cultures, as well as ethnographic approaches to resilience across cultures that uncover a political economy of health consonant with a quest for dignity, social justice, and respect. Resilience is driven by culturally specific, diverse, and often-changing goals: for youth, the relationship between culture and resilience is akin to bricolage, in the sense of navigating an array of pursuits, goals, and values. Thus resilience has important moral, social, and political dimensions, beyond the consideration of poor wellbeing or development.

Background: Despite robust evidence of fathers’ impact on children and mothers, engaging with fathers is one of the least well-explored and articulated aspects of parenting interventions. It is therefore critical to evaluate implicit and explicit biases manifested in current approaches to research, intervention, and policy. Methods: We conducted a systematic database and a thematic hand search of the global literature on parenting interventions. Studies were selected from Medline, Psychinfo, SSCI, and Cochrane databases, and from gray literature on parenting programs, using multiple search terms for parent, father, intervention, and evaluation. We tabulated single programs and undertook systematic quality coding to review the evidence base in terms of the scope and nature of data reporting. Results: After screening 786 nonduplicate records, we identified 199 publications that presented evidence on father participation and impact in parenting interventions. With some notable exceptions, few interventions disaggregate ‘father’ or ‘couple’ effects in their evaluation, being mostly driven by a focus on the mother–child dyad. We identified seven key barriers to engaging fathers in parenting programs, pertaining to cultural, institutional, professional, operational, content, resource, and policy considerations in their design and delivery. Conclusions: Barriers to engaging men as parents work against father inclusion as well as father retention, and undervalue coparenting as contrasted with mothering. Robust evaluations of father participation and father impact on child or family outcomes are stymied by the ways in which parenting interventions are currently designed, delivered, and evaluated. Three key priorities are to engage fathers and coparenting couples successfully, to disaggregate process and impact data by fathers, mothers, and coparents, and to pay greater attention to issues of reach, sustainability, cost, equity, and scale-up. Clarity of purpose with respect to gender-differentiated and coparenting issues in the design, delivery, and evaluation of parenting programs will constitute a game change in this field. Keywords: Research design, coparent, father involvement, child development, violence, prevention, family.

In the spirit of critical reflection, we examine how the field of global health might surmount current challenges and prioritize its ethical mandate, namely to achieve, for all people, equity in health. We use the parlance of mastering deadly sins and striving for greater virtues in an effort to review what is needed to transform global health action. Global health falls prey to four main temptations: coveting silo gains, lusting for technological solutions, leaving broad promises largely unfulfilled, and boasting of narrow successes. This necessitates a change of heart: to keep faith with the promise it made, global health requires a realignment of core values and a sharper focus on the primacy of relationships with the communities it serves. Based on the literature to date, we highlight six steps to re-orienting global health action. Articulating a coherent global health agenda will come from principled action, enacted through courage and prudence in decision-making to foster people-centered systems of care over the entire lifespan. Keywords : equity; scale-up; leadership; health systems; global health; interventions (Published: 28 March 2014) Citation : Glob Health Action 2014, 7: 23411 - http://dx.doi.org/10.3402/gha.v7.23411

This study of two natural fertility Nepali groups, the Tamang and Kami, identifies biological and behavioral factors associated with population differences in fertility. Previous research had established that Tamang experience longer interbirth intervals than Kami despite similarly intense nursing practices, and bear considerably higher energy expenditure due to workload. This cross-sectional study of 71 breastfeeding women includes prolactin determinations on three blood spot samples collected 5, 30, and 50 minutes following a timed nursing bout, and data on maternal age, BMI, menstrual status, previous birth interval, parity, infant age, nursing bout length, and durations of supplementation and postpartum amenorrhea. The findings show that Tamang breastfeeding mothers have higher average prolactin levels than Kami for as long as 22 months postpartum. Tamang mothers sustain average prolactin levels above those of nonpregnant, nonlactating women for nearly 2 years postpartum, whereas prolactin levels among Kami breastfeeding mothers are the same as this latter group after 1 year postpartum. Furthermore, the findings indicate that Tamang mothers have higher average prolactin levels regardless of maternal age, physical status (BMI, weight, or height), or infant age, and the rate of decline in prolactin from 5 to 50 minutes after suckling is significantly greater for Kami than Tamang. Since factors associated with prolactin levels differ by group, the findings also emphasize that populations vary not only in the strength of effects that proximate determinants have on fertility regulation, but also in the pathways by which they exert their effects (direct physiological versus indirect behavioral). Am. J. Hum. Biol. 10:191-210, 1998. © 1998 Wiley-Liss, Inc.

Food shortages occur periodically and predictably in over- populated areas of the foothills of the Himalaya, leading to extensive outmigration and to indebtedness of farmers. A survey of four administrative areas and in-depth interviews of 120 households (a sample of diverse caste and ethnic groups, stratified by land area) was undertaken in two districts of western Nepal to document the severity of shortfall in local agricultural production and the range of household coping strategies. The duration of food shortages averaged 5 months of the year, but ranged enormously across households, with 4% of sample families being entirely landless. Out-migration, wage labor, petty trade, high-interest loans, and land mortgage were well-established coping strategies, beneficial for some families in generating income and the possibility for investment, but for others leading to progressively greater debt, economic marginalisation and impoverishment. This study highlights the importance of encouraging diversified strategies for subsistence farmers to ensure cash revenue, much of which is derived from debt and emigration, and reviews the geographical and socioeconomic factors influencing both constraints on household subsistence and responses to seasonal food deficits.

This study compares the lifestyles of street children in Kathmandu in Nepal with three control groups: rural villagers urban squatters and privileged students. Contact was established through Child Workers in Nepal (CWIN) a local group that provides safe houses. The sample which had a range of contact with CWIN included 329 boys aged 6-14 years: 130 were homeless 54 were from rural areas 62 were squatter children and 83 were students. Data were obtained from short and long interviews and home visits during July-December 1993. The homeless tended to be older. About 50% of homeless boys and 66% of students belonged to the Indo-Aryan high caste. Over 50% of squatters were low-caste members; all villagers were Tibeto-Burman. Over 50% of homeless boys had both parents at home under 10% were orphans and 23% had stepparents. Family structure age and ethnicity explained about 30% of the variance. 82% left home before the age of 12 years. The average time since leaving home was 3.0 years. 35% left for economic reasons; 42% left due to family problems; and 23% desired independence. Only 16% came from Kathmandu. Travel time to home ranged from 5-7 to 24 hours. 25% never returned home 50% visited annually and 25% made more visits. Children from single-parent families had the most contact. Children from two-parent families visited annually. There was more limited contact if at all with stepfamilies. 66% were rag pickers; 20% were beggars. Higher earners tended to be older. Beggars were younger than rag pickers. Income was significantly related to age. Over 40% of homeless boys had insufficient income to meet food needs. The homeless were less stunted than squatter or rural controls. The children had well developed peer social networks that provided material and emotional support. Most denied being a thief but reported that stealing was common. More in-depth analysis is planned for examining controversial behaviors.