Your study looks at how the COVID-19 pandemic has affected the mental health of vulnerable populations, within the context of conflict-affected and internally-displaced people in Colombia. What was the motivation behind the study and how does it fit into your broader research agenda?
Andrés Moya and Pieter Serneels: This study allows us to understand the mental health consequences of the COVID-19 pandemic among victims of violence and internally displaced persons, focusing on caregivers of young children, in the early stages of the pandemic. More broadly, the study sheds light on how events that affect mental health can reinforce poverty and socioeconomic exclusion in the absence of suitable health care.
The study is part of a larger project and, as much other COVID-19 related research, came about as a response to the unexpected health crises. In 2013, we (at Universidad de los Andes) partnered with researchers at the Child Trauma Research Program at the University of California, San Francisco to design a group-based psychosocial model aimed at promoting maternal mental health both as an outcome itself, but also as a pathway to promote healthy and nurturing child-parent relationships. These relationships are important to foster early childhood development. This is likely even more important in contexts of violence and forced displacement, because they can prevent the frequent exposure to traumatic and systematic episodes of violence translating into toxic stress, which is detrimental for brain development architecture in early childhood and can have strong repercussions later in life.
Starting in 2018, the randomized controlled trial (RCT) was under implementation in Tumaco, a municipality in the Pacific coast of Colombia, on the border with Ecuador. The treatment was randomized over time with two cohorts treated early, and two later on. Tumaco is gorgeous–culturally and geographically rich–but it has also been torn by the armed conflict because its location is suitable for the cocaine drug trade and different armed groups are struggling for its territorial control. As happens across Colombia, one of the strategies to take such control is to exert widespread violence against the civilian population and the people in Tumaco have suffered greatly as a result.
The COVID-19 pandemic and associated lock down struck just before the planned collection of the last wave of data for the two ‘late’ cohorts. In response, we adapted plans and transformed the last round into a short phone survey, which took place 4 weeks after lockdown started. By getting data right at the onset of the pandemic, we conjectured that either families would not be affected yet and we would have the required data to evaluate the impact of the RCT intervention, or there would be a possibly small impact of the pandemic, which would be of interest in itself. We had not expected what we found: in the four-week period since the lockdown, distinct key dimensions of mental health (anxiety, depression and stress) had already passed risk threshold levels. Families lost their jobs and livelihoods, reported high levels of food insecurity, and no longer had access to the community-based care, inducing high levels of stress in the child-parent relationships. The paper, developed with an interdisciplinary team, focuses on this causal relationship and investigates the driving factors behind it.
What does the existing literature have to say on this issue and what knowledge gaps were you hoping to fill?
AM and PS: Existing literature has very little to say about the mental health consequences of the pandemic among forcibly displaced persons. This is quite unfortunate because in addition to the pandemic, we have been dealing with an unprecedented “refugee crisis.” According to UNHCR data, by the end of 2021 there were over 82 million forcibly displaced persons, which accounts to a little bit over 1 percent of the global population. This is the largest number of forcibly displaced persons in modern times. But this is not only a refugee crisis strictly speaking; it’s a crisis of forced displacement that includes 21 million refugees and 48 million internally displaced persons (IDPs). And despite popular narratives in Europe and the United States, it’s a crisis that has mainly affected developing countries, which currently host over 80 percent of all forcibly displaced persons and in many cases lack the capacities and resources to support them.
Despite the magnitude of this crisis, we were unable to identify studies that provided descriptive or rigorous evidence on the psychosocial effects of the pandemic in fragile and conflict-affected settings or among forcibly displaced people. We came across quite a lot of research on the mental health consequences of the pandemic but most of it in the Global North, with a few studies in the Global South. But almost two years after the COVID-19 pandemic started, we actually know very little about how IDPs and refugees are coping and dealing with the pandemic.
This is unfortunate because they are one of the more vulnerable groups worldwide and are more susceptible to the mental health effects of the pandemic. They reside in fragile environments characterized by protracted conflict and violence, and socioeconomic exclusion. Their previous experience of violence and displacement increases their likelihood of pre-existing mental health conditions, which then makes them more vulnerable to the consequences of the pandemic. And they were also largely ignored and left behind in the health and social protection measures implemented to tackle the consequences of the pandemic. In other words, the vulnerability of IDPs and populations in fragile and conflict-affected settings can enhance the mental health consequences of the pandemic, exposing them to simultaneous and reinforcing risks, which can bring consequences for well-being and poverty dynamics well beyond the pandemic. Our article tries to shed light on this and contribute to filling this gap in the literature.
Mental health can be a difficult concept to define and measure. How did you go about measuring it for the purpose of this study? What data did you use?
AM and PS: This is a great question and something that the referees and editor of our paper paid special attention to. In our larger study we are using a set of distinct scales that we have piloted and used early on and in another project. For mental health, we use an adapted version of the Symptoms Checklist 90-Revised, which provides data on different symptoms of psychopathologies and is not restricted to anxiety and depression as the Generalized Anxiety Disorder Scale (GAD7) and the Patient Health Questionnaire-9 (PHQ9) that have been frequently used elsewhere. This allows us to take a more comprehensive look on the different manifestations of stress among IDP.
The scales we use have been validated in Colombia (or in the region); its psychometric properties give it validity. In our article you can find a short discussion on this analysis, which includes the standard Alpha Cronbach and Confirmatory Factor Analysis.
In this specific paper, we only analyze the three above mentioned measures, administered by two scales ––a short version of the adapted SCL-90-R and the short-form Parenting Stress Index Scale– because we did not want to overburden participants during a phone interview. Despite the challenges of conducting interviews over the phone, the scales performed well, as shown by the psychometric analysis.
What were the main findings of the study?
AM and PS: We found substantial increases in average symptoms of anxiety, depression, and parenting stress, 4-7 weeks into the pandemic, with specific groups suffering from stronger deterioration in mental health (see below). Our data also points towards relevant stress factors, with the majority of participants reporting food insecurity (71%) and more than half (56%) reporting that they lost their jobs or main source of income.
Because we have between-cohort variation in the time at which the data were collected, with some cohorts assessed before the pandemic and others a few weeks into the pandemic, we can credibly identify the causal effects on mental health and parenting stress, using a lagged-dependent variable model (similar to an ANCOVA model).
We found that the pandemic increased the likelihood of reporting anxiety symptoms above the risk threshold by 14 percentage points (pp), by 5pp for depression, and by 10pp for parenting stress. These effects are substantial, especially when we consider the vulnerability and pre-existing mental health conditions of this population.
Furthermore, we find that the deterioration in mental health was stronger for those experiencing a larger number of COVID-related stressors (like income loss and food insecurity) as well as for IDP, and participants with lower education or pre-existing mental health conditions.
What recommendations do you have for policymakers based on the results?
AM and PS: Our study highlights the heightened struggle faced by more vulnerable populations in coping with COVID-19. Although the study is set in a particular setting in Colombia, many of the observed challenges are common to fragile and conflict-affected settings elsewhere. In this sense, our study is essentially a call for action so that governments and donors implement inclusive approaches to mitigate negative mental health effects of the pandemic, particularly among IDPs and communities exposed to violence worldwide. For example, our study highlights the need for increased provision of mental health services, which in combination with improved social protection can be a promising way to help reduce disparities that have been exacerbated by the pandemic.