HEARD project 

Background and objectives

Despite the well-recognized risk poor maternal mental health poses to early child development, it is still rarely addressed in global health programming, especially in humanitarian settings where access to health and mental health infrastructures may be limited. Recognizing the critical role of maternal psychosocial wellness in addressing the health and development of children in conflict, Action contre La Faim/Action Against Hunger (ACF) developed the Baby Friendly Spaces (BFS) program. BFS is a holistic, evidenced-based psychosocial support program that aims to enhance mothers’ wellbeing, internal resources, and child caring skills in order to create a buffer against the deleterious health and developmental impacts of conflict on children. 

In Bangladesh, we sought to evaluate the effectiveness of a psychosocial support program for Rohingya refugee mothers and their malnourished children under two years old living in Cox’s Bazar’s camps.  

Methods

For this study, 10 Baby-Friendly Spaces (BFS) program sites were allocated to either services delivery “as usual” or to an “enhanced BFS program” after re-training.   

Due constraintful environment and the COVID-19 pandemic, we provided continuous supportive supervision of the BFS staff throughout the trial period.  

600 mothers and their children were enrolled in the study and attended psychosocial stimulation activities related to child care practices and care for women.  

Data were collected at baseline and 8-week follow-up. Primary outcomes included maternal distress and wellbeing, functioning, and coping.  

For implementation purpose: 

• a survey was administered on confidence at work for all BFS staff and a fidelity observation assessment was conducted. 
• we also examined the RE-AIM dimensions of: 1) reach and effectiveness at the participant level and 2) adoption, implementation, and maintenance at the staff, organization, and policy level, as well as 3) feasibility, acceptability, appropriateness, and sustainability. All mothers enrolled at follow-up (n=580), BFS providers (n=24), and organizational staff (n=14) quantitatively rated implementation domains on a 0-3 scale using the Mental Health Implementation Science Tools (mhIST). Providers, staff, and 23 mothers completed in-depth interviews. 

Findings

1. Relative to “as usual” sites, mothers in enhanced implementation sites reported greater reductions in distress and improvement in wellbeing. These differences were small, but marginally significant with standard estimation;  

2. There was no significant difference between the two groups for daily functioning and coping.  

3. Fidelity varied widely across different components, with some very high and some very low adherence. There tended to be better adherence to procedures in group versus individual sessions and for some specific activities across domains, for enhanced versus standard BFS. 

4. BFS providers in “enhanced BFS program” reported higher confidence in service delivery than their colleagues (p=.01).  

“We can take good care of our child by learning these good things from here. If our children are happy, then we are happy also. Maybe mothers who face problems that I have shared before come to BFS for mental peace. Apa (the psychosocial worker) talks with them softly, respectfully. They feel relief to share their feeling with Apa. They (the Apas) say, ‘Don’t argue with your husband, you can share with us if you have any problem with your husband. You can tell us everything. We are here to listen to you.’” (Mother attending BFS) 

5. Implementation domains were rated highly by mothers, with no significant differences by condition. The most highly rated domains were acceptability and appropriateness of location and perceived effectiveness, while the lowest was cultural fit. Providers also rated domains highly and similarly across conditions, but rated feasibility and reach lowest. Organizational staff rated implementation domains lower than providers; sustainability (mean=1.2) and reach/access were rated lowest.  

Discussion and recommendations

Our results indicate that with supervision and implementation support, integrating manualized psychosocial support activities with nutrition services holds potential for reducing distress and improving subjective well-being of conflict affected mothers of malnourished children, but results were weaker for improving functioning and positive coping.  

More globally, findings highlight the value of innovative study approaches for real-world evidence generation. Small but feasible adjustments to implementation can both improve program delivery for maximizing impact. Consequently, low-intensity psychosocial support activities holds potential for reducing distress and improving subjective well-being of conflict affected mothers.  

Project-related publications

This project was presented in 15 conferences. We have published 4 papers so far. 2 research briefs were shared. One video was produced by our staff. 

MHPSS knowledgehub website 

ACF Bangladesh Project – MHPSS Knowledge Hub 

Bangladesh – ISC 

Publications 

• Le Roch, K., Bubendorff, P., Rahaman, K. S., Clouin, L., Lasater, M., Tonon, B., Murray, S., Nguyen, A. (2024, May 15). Supervision and training to support implementation of a flexible psychosocial support program for refugee mothers and babies: A case study of Baby Friendly Spaces in Cox’s Bazar, Bangladesh. https://doi.org/10.31219/osf.io/vq3ty 
• Nguyen, A., Murray, S. M., Rahaman, K. S., Lasater, M. E., Barua, S., Lee, C., Schojan, Tono, B., M., Clouin, L., and Le Roch, K. (2024). Psychosocial impacts of Baby Nguyen AJ, Murray SM, Rahaman KS, Lasater ME, Barua S, Lee C, Schojan M, Tonon B, Clouin L and Le Roch K (2024). Psychosocial impacts of Baby Friendly Spaces for Rohingya refugee mothers in Bangladesh: A pragmatic cluster-randomized controlled trial. Cambridge Prisms: Global Mental Health, 11, e64, 1–11 https://doi.org/10.1017/gmh.2024.58. 
• Armijos, A., Bonz, A.G., Brown, Felicity L. Brown, Charlet, D., Cohen, F., Greene, M.C., Hermosilla, S., James, L.E., and Le Roch, K., on behalf of MHPSS Implementation Science Learning Collaborative (2023). Ensuring equity in mental health and psychosocial support during the COVID-19 pandemic and beyond. Confl Health 17, 7. https://doi.org/10.1186/s13031-023-00500-5 
• Nguyen, A. J., Bhardwaj, A.^†, Rahaman K. S., Barua, S., Le Roch, K., Lasater, M., Shojan, M., Lee, C., Berg, K., & Murray, S. Measuring the psychosocial wellbeing of refugee mothers of malnourished children in Cox’s Bazar, Bangladesh. F1000 Research. (Under Review; preprint available at: https://f1000research.com/articles/11-1402/v1)  
• Le Roch, K., Nguyen, A. J., Rahaman, K. S., Lasater, M., Barua, S., Lee, C., Schojan, M., Clouin, L., & Murray, S. M. (2023). Assessing the effectiveness and observing fidelity of a psychosocial support program for Rohingya refugee mothers and their children in Cox’s Bazar, Bangladesh. European Psychiatry, 66(Suppl 1), S356–S357. https://doi.org/10.1192/j.eurpsy.2023.776 

Conferences 

• Yan L, Lasater M, Rahaman Kh S, Hassan S, Nguyen A, Clouin L, Le Roch K, & Murray S. “We need everything”: A qualitative study of Rohingya men’s MHPSS needs and service engagement in Cox’s Bazar, Bangladesh [poster presentation]. International Society for Traumatic Stress Studies, Boston USA. September 25-28, 2024. ISTSS 40th Annual Meeting | International Society for Traumatic Stress Studies 
• Victoria Ngo, Weanne Estrada, Claire Greene, Amanda Nguyen, Felicity Brown, Flora Cohen, Karine Le Roch, Leah James, Lindsay Stark, Michel Rattner-Castro, Nicolas Garcia, Sabrina Hermosilla, Samantha Ski, Sarah Murray. Community-based PSS interventions for populations affected by conflict and displacement: Lessons from a multinational collaborative study. Annual Conference of Dissemination and Implementation in Health in Arlington, VA, on Tuesday, December 12th 2023. 
• Karine Le Roch, Amanda Nguyen, Kh. Shafiur Rahaman, Pauline Bubendorff, Molly Lasater, Laetitia Clouin, Sarah Murray. Contextual and cultural adaptation process of a manualized psychosocial intervention protocol for Rohingya mothers and their children refugees in Cox’s Bazar, Bangladesh. 14^h EUSPR Conference, Sarajevo, Bosnia-Herzegovina. October 4-6, 2023.