Alyans pou Pwoteksyon Timoun Pwojè: Yon Revizyon Sistematik Rechèch ak Meta-Analiz

MARCH 2017 Alliance for the Protection of Children Project A Systematic Research Review and Meta-Analysis Yael Kidron Quita Keller This publication was produced by American Institutes for Research (AIR) for review by the United States Agency for International Development. It was prepared by AIR Researchers Yael Kidron and Quita Keller . The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States government. ALLIANCE FOR THE PROTECTION OF CHILDREN PROJECT A Systematic Research Review and Meta - Analysis March 2017 Yael Kid ron Quita Keller USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — iii Contents Page Abstract ........................................................................................................................................... 1 Objective ..................................................................................................................................... 1 Methodology ............................................................................................................................... 1 Findings ...................................................................................................................................... 1 Conclusions and Implications for Research and Practice ........................................................... 2 Introduction ..................................................................................................................................... 4 The Importance of Combating Violence Against Children ........................................................ 4 Prevalence of Violence Against Children in Haiti...................................................................... 5 Types of Programs to Combat Violence Against Children ........................................................ 6 Purpose of This Systematic Research Review ............................................................................ 7 Methodology ................................................................................................................................... 7 Identification of Studies .............................................................................................................. 7 Thematic Review ...................................................................................................................... 10 Level of Evidence ..................................................................................................................... 10 Statistical Meta-Analysis .......................................................................................................... 11 Overview of the Studies Reviewed ............................................................................................... 12 Findings From the Thematic Review ............................................................................................ 13 1. Psychosocial Interventions................................................................................................. 13 2. Communitywide Models .................................................................................................... 16 3. Vocational and Life Skills Training ................................................................................... 18 4. Parent/Caregiver Education ............................................................................................... 19 5. Safe Spaces Programs ........................................................................................................ 19 Findings of the Meta-Analysis ...................................................................................................... 20 Summary and Discussion .............................................................................................................. 22 Implications for Research and Practice......................................................................................... 24 Conflict of Interest ........................................................................................................................ 25 References ..................................................................................................................................... 26 Appendix A. Search Strategy...................................................................................................... A-1 USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — iv Appendix B. List of Studies Reviewed ....................................................................................... B-1 Appendix C. Forest Plot.............................................................................................................. C-1 Tables Page Table 1. Rating Criteria for Level of Evidence............................................................................. 11 Table 2. Effectiveness of Programs in the Studies Reviewed ...................................................... 21 Table B1. Psychosocial Interventions ......................................................................................... B-1 Table B2. Communitywide Models ............................................................................................ B-5 Table B3. Vocational and Life Skills Training ........................................................................... B-8 Table B4. Parent/Caregiver Education ....................................................................................... B-9 Table B5. Safe Spaces Programs .............................................................................................. B-10 Figures Page Figure 1. Study Selection Process for the Systematic Review and Meta-Analysis ........................ 9 Figure 2. Number of Studies by Publication Year ........................................................................ 12 Figure 3. Number of Studies Reviewed by Country ..................................................................... 13 Figure 4. Number of Studies by Program Participants ................................................................. 14 Figure 5. Number of Studies by Program Setting ......................................................................... 15 USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 1 Abstract Objective This report provides findings from a systematic research review and meta-analysis that aimed to synthesize evidence on the effectiveness of prevention and intervention programs designed to eliminate violence against children and adolescents and provide the necessary supports to victims of abuse, neglect or exploitation. The experience of abuse, neglect or exploitation can cause severe, long-term health and mental health problems. Violence prevention programs are important in Haiti, where abuse, neglect and exploitation is endemic and perpetuated by poverty, hardships caused by natural disasters, and societal norms. To support decision making on investing in potentially promising interventions, this report summarizes the existing literature on relevant programs implemented in Haiti and other Latin American and Caribbean countries, as well as countries in Africa with similar human development conditions. Methodology A systematic review of studies was conducted. The quality of the studies was evaluated with a systematic review guide that captured details on the sample, outcome measures, program implementation, data collection, and study design. The research team screened more than 3,000 studies and identified 144 unique studies for which full text was reviewed. The advanced screening yielded 41 studies that met the review inclusion criteria. Of these 41 studies, eight randomized controlled trials and four quasi-experimental design studies met the criteria for inclusion in a meta-analysis. The results were analyzed by the type of program and outcome, country, gender, and study design. Findings The literature provides an evidence base for five types of programs designed to reduce violence against children and youth: psychosocial interventions, communitywide models, vocational and life skills training programs, parent/caregiver education, and safe spaces programs. More studies of psychosocial interventions used a rigorous study design (i.e., experimental or quasi- experimental design) than studies of other types of programs. Eleven studies of psychosocial interventions used a rigorous design. In contrast, the systematic review identified only two rigorous design studies for three of the other intervention categories – community-wide models, vocational and life skills programs, and parent/caregiver education. The reviewers did not find any rigorous design studies evaluating the effects of safe spaces programs. A small number of rigorous studies reduces our ability to make conclusive statements about the effectiveness of the interventions. The review of the research included a 2-step process. In the first step, all quantitative and qualitative studies that met relevance and research design criteria were reviewed. In the second step, quantitative studies that used an experimental or quasi-experimental research design and reported effect size information were included in a statistical meta-analysis. USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 2 Results of the first step of the review, based on a total of 41 studies, showed multiple positive intervention effects, as follows: • Psychosocial Interventions (17 studies). Positive effects on improved mental and physical well-being and reduced trauma and depression symptoms of victims of violence • Communitywide Programs (11 studies). Positive effects on increased awareness of the prevalence of violence in communities and the role that community members can play in preventing abuse, neglect or exploitation; a reduction in the number of violent incidents; increased access to and use of health and social services by vulnerable populations; reduced child exploitation and increased re-integration of children into families and communities • Vocational and Life Skills Programs (5 studies). Positive effects on a reduced number of violent incidents, increased participation in the workforce and integration into the community as a means of reducing vulnerability to further violence, improved parenting skills of young parents, and improved psychological well-being • Parent/Caregiver Education (5 studies). Positive effects on responsive parenting and parent-child relationships; improved social, emotional, and cognitive skills of children; and reduced child maltreatment • Safe Spaces Programs (3 studies). Improved living conditions for children, youth, and young adults; improved physical and mental health of children; and improved children’s social and emotional skills and supportive relationships with adults None of the studies reported negative outcomes or a mix of negative and positive outcomes. Results of the second step of the review – a statistical meta-analysis with 12 studies – showed that existing programs can be effective in alleviating the harmful effects of violence (e.g., posttraumatic stress disorder symptoms and depression). The overall effect size was high (Hedges’ g = .77). The overall effect for the three studies conducted in Haiti also was high (H edges’ g = .81). However, researchers were able to include only psychosocial interventions and vocational training programs in the meta-analysis. Insufficient statistical information was available on the other types of programs to include these programs in the meta-analysis. Conclusions and Implications for Research and Practice The findings of this research review are encouraging: Programs implemented in low-resource settings with populations suffering from trauma and social marginalization can effectively improve the physical and mental health of children, youth, and young adults and support their re- integration into their communities. The strong research evidence on psychosocial programs demonstrated the feasibility of scaling up strategies, such as offering short-term interventions, adapting the programs to implementation in group settings rather than as one-to-one therapy, and training lay professionals to deliver the intervention. This research evidence combined with the evidence for communitywide models suggests that these approaches in low-resource settings can effectively reduce violence rates and promote population health. However, none of the experimental and quasi-experimental design studies examined the effects of prevention efforts on children. More research is needed on reducing incidents of abuse, exploitation, and neglect in USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 3 communities affected by adversities, including extreme poverty, displacement, and natural disasters. USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 4 Introduction The Importance of Combating Violence Against Children Child abuse, neglect and exploitation are problems that threaten the physical and mental health of children and adolescents in low- and middle-income countries. Violence against children causes adverse effects on children’s short - and long-term development. Children who have been physically abused are at increased risk for several long-term problems, including the following: • Physical Health Problems. In the short term, physical health problems include physical injury, which may result in a permanent disability or health condition (Putnam-Hornstein, Cleves, Licht, & Needell, 2013). Sexual assault and exploitation can lead to sexually transmitted diseases and unwanted pregnancies (Lewis, 2012). Children who are maltreated across a long time period are at greater risk for impaired immune functioning, which increases the chance of illness and can lead to a large range of physical and mental health problems in adulthood (Sachs-Ericsson, Cromer, Hernandez, & Kendall-Tackett, 2009). • Risky Behavior. Aggressive and delinquent behavior and drug abuse, for example, may result from childhood experiences of abuse (Reeve & van Gool, 2013; Springer, Sheridan, Kuo, & Carnes, 2007). • Cognitive Problems. Poor language skills (Lum, Powell, Timms, & Snow, 2015) and numeracy skills (Maguire et al., 2015), lower working memory capacity (Hecker, Hermenau, Salmen, Teicher, & Elbert, 2016), and lower general intelligence (Maguire et al., 2015) are among the cognitive problems that may occur. • Impaired Life Skills in Adulthood. The long term-effects of childhood abuse may include low self-esteem plus alcohol and drug abuse (Longman-Mills et al., 2013), which may impede physical and mental health as well as the employability of young adults (Caribbean Development Bank, 2015). • Social and Emotional Problems. Depression, anxiety, heightened stress, suicide, and low self-esteem are some of the social and emotional problems that may occur (Arata, Langhinrichsen-Rohling, Bowers, & O ’ Farrill-Swails, 2005; Nemeroff, 2016; Yule, 2001). Other common problems include impulsivity, inattention, and hyperactivity (Maguire et al., 2015). A h istory of child abuse also increases children’s risk of engaging in crime and violent behavior and having dysfunctional relationships when they reach adulthood (Cronley, Jeong, Davis, & Madden, 2015). Child abuse and neglect have social and economic costs. Immediate costs include treatment costs, such as hospital costs for medical treatment and the cost of residential care for children removed from abusive contexts. Long-term costs can result from the chronic problems discussed earlier. Mental health problems, a lower level of educational attainment, poor employment outcomes, and relationship problems that children who have been maltreated are likely to experience later in life can increase the likelihood of participating in risky behaviors, such as alcohol and drug abuse, unsafe sex, abusive relationships, aggressive behavior, and crime, which USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 5 perpetuate the cycle of violence and abuse (Brown, James, & Taylor, 2010; Maxwell, Callahan, Ruggero, & Janis, 2016; Subramanian, 2016). Prevalence of Violence Against Children in Haiti Violence against children is endemic in Haiti and perpetuated by numerous socioeconomic factors. A population-based household survey about victimization resulting from physical violence to 13- to 24-year-old Haitians, including those residing in camps or settlements, found that two thirds of respondents experienced physical violence during childhood, and more than one third were victimized in the 12 months before the survey administration (Flynn- O’Brien et al., 2016). Sexual Violence The forms of abuse are many and devastating. About one fourth of young female adults and one fifth of young males living in Haiti today have experienced childhood sexual violence (Sumner et al., 2015). Many children have experienced harsh discipline involving physical or emotional pain. Because harsh discipline occasionally harms the child and is a continuous stressor, it is commonly defined as physical or emotional abuse (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008). Displacement Resulting From Natural Disasters Many children in Haiti experience different forms of exploitation and neglect caused by poverty, natural disasters, and a lack of enforcement related to children ’s rights. The conditions of living in Haiti worsened when a 7.1 magnitude earthquake damaged Haiti’s capital city, Port -au-Prince, in January 2010. Four years after the earthquake, 400,000 people were still living in camps, and the rates of poverty and hunger were persistently high (Cénat & Derivois, 2015). The increased economic stress reduced the ability of adults to care for their children and exacerbated the rates of violence. Young Haitian women and girls in postearthquake Haiti also face an increased risk of being trafficked (Wooding & Petrozziello, 2013). The recent devastation caused by Hurricane Matthew, which hit Haiti on October 4, 2016, placed thousands of additional children at risk of violence. At least 2,000 children who have been separated from their parents or were living in orphanages have been evacuated, and many children are now living without adequate food and medical care. These children may be at increased risk for maltreatment and child trafficking (Save the Children, 2016; World Vision, 2016). Worst Forms of Child Labor An estimated 300,000 – 500,000 Haitian children live and work away from home as unpaid servants ( restavèks; Beyond Borders et al., 2014). These children most often come from impoverished rural families and are sent to serve wealthier urban families. In many cases, restavèk becomes child trafficking and forced labor, meeting international criteria for slavery (Free the Slaves, 2014). Many restavèk children are controlled through violence and cannot escape from the families they serve. They often are abused physically, verbally, emotionally, and sexually (Cooper, Diego-Rosell, & Gogue, 2012). Most children in domestic servitude are USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 6 vulnerable to beatings, sexual assaults, and other abuses by individuals in the homes in which they are residing (Embassy of the United States, 2015). Additional low-income Haitian children work in construction, agriculture, fisheries, and street vending (Embassy of the United States, 2015). A large population of Haitian children as young as 6 years old live and work on the streets. They are exposed to a variety of hazards, such as severe weather, accidents, and crime (Gaity, 2011; Kovats-Bernat, 2006). Children Living in Institutions In 2012, Haiti had 430,000 children who were orphaned (UNICEF, 2015). A small percentage of orphans are placed in institution-based care settings. Although these settings have the potential to provide safe spaces and physical care to children, they are frequently associated with social and emotional deprivation (Whetten et al., 2014). More than 30,000 children in Haiti live in 760 orphanages. Most of these children (80%) have a living parent or a close relative; however, lack of access to schools, health care, and financial and legal support prevent them from reuniting with their families (Lumos, 2012). Street Gangs and Armed Groups Street gangs encompass another group of children exposed to violence in Haiti. According to the United Nations (UN) and Save the Children, Haiti is one of several key conflict areas where the problem of armed boys and girls remains acute. Many children are abducted or forcibly recruited into regular and irregular armed groups. Others are lured by the leaders of armed groups with financial and material resources (Peacebuild, 2008). Armed gangs, mostly in Port-au-Prince, have used children as spies and guards to transport weapons and participate in clashes with the police and UN troops (Child Soldiers International, 2008). These children are recruited into combat and servitude, experience sexual violence and exploitation, are exposed to explosives and combat situations, and experience and witness killings (Schauer & Elbert, 2010). Types of Programs to Combat Violence Against Children Through the contributions of governments, nongovernmental organizations (NGOs), and foundations during the last two decades, a variety of child protection programs have been implemented to combat violence against children. These child protection or violence reduction programs have been designed to be implemented at the multicountry, national, regional, community, family/caregiver, and individual levels. At the national level, such programs often promote public awareness of the extent of the problem and the available means to protect children. Such programs aim to affect public policy, social norms, and the establishment of child protection systems (Ibarguren, 2007). Some programs aim to reduce harsh discipline and corporal punishment at home and school; improve parent-child relationships; and improve coping skills of children and their caregivers who are at high risk for exposure to violence by domestic partners, family relatives, or community members (Knerr, Gardner, & Cluver, 2013). Psychosocial therapy-based programs have been implemented in multiple settings, including shelters, clinics, and schools. These programs offer therapies that are designed to alleviate USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 7 symptoms associated with child abuse and traumatic experiences (Aoto-Sullivan, 2000). For example, victims of abuse often experience maladaptive beliefs and attributions, such as a sense of guilt for their role in the abuse, anger at parents for not knowing about the abuse, feelings of powerlessness, a sense that they are in some way “damaged goods,” and a fear of social stigma (Skar, Sherr, Clucas, & von Tetzchner, 2014). An example of a common psychosocial program is cognitive behavioral therapy — a family of therapy techniques designed to help children conquer their posttraumatic stress disorder symptoms. Such therapeutic programs are appropriate for a wide age range, from young children to adolescents and young adults (Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2013). Other interventions may combine cognitive, experiential (e.g., art, dance, or drama), and social and emotional learning (e.g., coping with stress skills; Ager et al., 2011). Purpose of This Systematic Research Review The aim of this review is to identify studies that have evaluated programs implemented in Haiti and other low-income countries and examine the effectiveness of these programs. The review covers studies that focus on the effectiveness of the programs described previously. Studies that aimed to measure the prevalence of child maltreatment but did not assess program effectiveness were not included in this review. Although some programs are directed solely at children, others target caregivers and the community as conduits for change. This research review was structured to accomplish the following objectives: • To summarize the existing literature on relevant programs implemented in Haiti or other Latin American and Caribbean countries, as well as countries in Africa with similar human development conditions. • To identify the main types of interventions with evidence of potentially promising effects. • To analyze findings from comparative research studies across different interventions and populations and estimate the magnitude of the effects of the interventions. Methodology Identification of Studies This study review was conducted in August – September 2016 as part of a larger USAID-funded project focusing on identifying promising interventions for scale-up in the protection of children in Haiti. We conducted a systematic research review and meta-analysis of the empirical research evidence for the effectiveness of programs, practices, and policies to prevent and reduce the harmful effects of violence against children. The synthesis of the research aimed to identify the extent of the evidence and the types of programs that showed potentially promising positive effects on children and their communities. Eligible studies were identified using a systematic search strategy. The search included published and unpublished literature that reported on studies conducted between 1990 and 2016. Literature searches were conducted in both English and French. In addition to Google searches, 14 academic databases were searched: USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 8 • Academic Search Premier • CINAHL • Education Research Complete • Education Source • PubMed • ERIC • JSTOR • EconLit • PsycARTICLES • PsycEXTRA • PsycINFO • Psychology and Behavioral Sciences Collection • SAGE journals • SocINDEX With Full Text The keywords used in the systematic literature search and the countries included are listed in Section A.1 in Appendix A. The search processes aimed to identify studies conducted in Caribbean and Latin American countries plus countries in Africa with a similar Human Development Index as in Haiti. 1 In addition to keyword searches of academic databases, the research team reviewed reference lists in research synthesis articles and evaluation reports and solicited nominations for studies from 10 international experts on research in child abuse and neglect. We included studies that focused on three age groups: childhood (birth – 12 years); adolescence (13 – 17 years); and young adulthood (18 – 24 years). The young adult age group was included in this systematic review because many interventions (e.g., interventions for victims of sexual abuse and conflict survivors) that target young adults also include adolescents in their design and target population. These literature search strategies yielded more than 3,000 reports. 2 The criteria for the initial screening of these records are listed in Section A.2 in Appendix A. Based on a review of report abstracts and executive summaries, 144 unique studies were identified for further screening based on full text. Two independent researchers reviewed these 144 studies for their eligibility to 1 The Human Development Index is calculated by the Human Development Report Office of the United Nations Development Program (2015), which measures people’s level of welfare . 2 The exact number of unique reports is difficult to determine given the numerous duplicates that appeared in multiple databases and the practice among some researchers to have multiple reports on the same study or multiple reports using the same independent sample. USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 9 be included in the review and identified 41 studies that met the inclusion criteria. The criteria for advanced screening for inclusion in the review are listed in Section A.3 in Appendix A. In addition, the 12 studies that reported findings for an intervention and a nonintervention (comparison) group were included in the meta-analysis. The criteria for inclusion in the meta- analysis are listed in Section A.4 in Appendix A. We exclusively relied on experimental and quasi-experimental studies for the meta-analysis because other types of studies are not able to address counterfactual questions. Figure 1 summarizes the literature selection process for this review. It shows the number of studies screened and excluded at each step of the screening process. Figure 1. Study Selection Process for the Systematic Review and Meta-Analysis Identification Screening Eligibility Included Records excluded ( n = 3,068) Reports excluded ( n = 104)  Not a program evaluation (59)  Program not relevant to review (30)  Sample not relevant to review (15) Reports excluded ( n = 29)  Not a quantitative study (12)  No reliable/valid measures (7)  No comparison group (6)  No effect size information (3)  Unit of analysis not at the individual level (1) Records identified through database searching, Internet searches, expert recommendations, and references in review articles ( n = 3,210) Reports identified through initial screening based on abstracts and executive summaries ( n = 144) Reports identified for the research synthesis through advanced screen based on full copies of studies ( n = 41) Reports identified for meta-analysis through coding of study design ( n = 12) USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 10 Thematic Review Forty-one studies were included in the thematic review. Appendix B lists the programs examined in these studies by program type, study, and country. The thematic review aimed to identify and describe categories of programs that were evaluated by researchers and the implementation effects across programs within each category. The data extracted included details on the intervention implementers (e.g., professional roles and training received), participants (e.g., whether parents and community members participated in the programs), characteristics of children and adolescents benefitting from the intervention (e.g., number of participants, age, gender, history of victimization, and residence at the time of the program), sample inclusion and exclusion criteria and recruitment procedures, and implementation process (e.g., duration and intensity, supplies and materials needed for implementation, and program components and activities). Common themes of implementation within the context of program goals and targeted populations were extracted in an iterative review process. The review process culminated in the identification of program categories that share common characteristics to which the positive change may be attributed. Using thematic analysis, the research team classified the interventions in the research studies into five main types: psychosocial interventions, communitywide models, vocational and life skills training programs, parent/caregiver education, and safe spaces programs. Level of Evidence The methodological quality of each study was appraised using the framework depicted in Table 1. For each program type, the level of research evidence was determined as strong, moderate, or limited based on two types of validity of the research (Shadish, Cook, & Campbell, 2002): • Internal Validity. The extent to which a study is able to establish a cause-and-effect relationship between the intervention and the outcomes measured. Internal validity is concerned with the rigor of the study design ― the degree of controlling for potentially confounding variables, such as other events that may impact individuals, and normative growth of social and emotional abilities across time. In this systematic research review, researchers used a three-level classification of the internal validity of studies: high, moderate, and low. Experimental and quasi-experimental design studies are considered rigorous research designs with high internal validity. High internal validity is required to regard findings as conclusive and reliable. Quantitative studies that used other designs with some reference data (e.g., comparison of outcomes to baseline without a comparison group) were classified as demonstrating moderate internal validity. Moderate internal validity indicates that the findings are suggestive: The study has minor flaws or insufficient reliability data but can demonstrate the potential effectiveness of programs or practices. Other study designs were rated as low quality. These studies were not able to establish a cause-and-effect relationship between the program and youth outcomes. • External Validity. The extent and manner in which the results of a study can be generalized to different people and settings. In this systematic research review, researchers used a two-level classification: adequate or nonadequate level of external validity. Studies classified as having an adequate level of external validity matched the USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 11 generalizability criteria of country, age group, and risk factors. These studies were conducted in Haiti and included children, adolescents, or young adults who had experienced or were at risk for one or more of abuse, neglect or exploitation described in the introduction to this report. Table 1. Rating Criteria for Level of Evidence Level Rating Criteria Limited Evidence Base 1. None of the studies meet the criteria for moderate or high internal validity. Moderate Evidence Base 2. The research includes evidence from at least one study with high internal validity . OR T he research includes evidence from at least one study with moderate internal validity and two or more studies that have adequate external validity . Strong Evidence Base Same as m oderate and 3. The research includes evidence from at least one study with high internal validity . AND T he research includes evidence from two or more studies that have adequate external validity. All 41 studies, regardless of their level of evidence, were included in the thematic analysis. Only 12 studies that had high internal validity and sufficient statistical information were included in the meta-analysis in this report. The following section describes the procedures for the statistical meta-analysis. Statistical Meta-Analysis Meta-analysis increases the power of statistical analyses by detecting intervention effects in a set of studies that could not detect effects individually (Cohn & Becker, 2003). The meta-analysis was performed using Comprehensive Meta-Analysis (CMA), Version 3 (Borenstein, Hedges, Higgins, & Rothstein, 2009). For each study, the outcome was transformed into an effect size, also called the standardized mean difference (SMD). Study effect sizes indicate postintervention differences on child maltreatment between the intervention and control groups. Positive effect sizes indicate better outcomes for the intervention group participants. No outliers were found for the study effect sizes. All effect sizes used statistical data based on individuals, not higher units of analysis such as households or community groups. Combined effect sizes were computed using CMA. Commonly, the SMD is calculated as Cohen’s d. However, Cohen’s d has a slight bias in small samples. Because some of the studies reviewed included small samples, we used an u nbiased estimate called Hedges’ g (Hedges, 1981). To interpret the magnitude of the effect size, we used the threshold of 0.25 as a benchmark of meaningful impact as recommended by Hill, Bloom, Black, and Lipsey (2008). This threshold has been applied to both educational and behavioral research (What Works Clearinghouse, 2007). Cohen (1988) offered different guidelines for interpreting the magnitude of effect size in the social sciences: small effect size = 0.20; medium effect size = 0.50; and large effect size = USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 12 0 .80. However, more recent expert recommendations (e.g., Durlak, 2009) make a case for regarding effect sizes at a magnitude of 0.20 or 0.25 as having high practical and clinical significance based on the nature of the outcomes (e.g., mental health and behavioral outcomes). Although both fixed-effects and random-effects analyses results are reported, the discussion of findings focuses on random-effects models, which allow for the possibility that random differences exist between studies that are not associated with sampling error and thus take into account differences in study populations and intervention characteristics (Borenstein, Hedges, Higgins, & Rothstein, 2010; Lipsey & Wilson, 2001). Q statistics were computed to test the heterogeneity across studies. In addition, we computed 95% confidence intervals (CIs) for the point estimate of each set of effect sizes. Overview of the Studies Reviewed The programs evaluated addressed a wide range of ages. The majority of the evaluations (20 reports) examined programs for adolescents; nine reports addressed programs for children, three evaluations examined programs for young adults, and eight evaluations examined programs that covered all ages. Most of the existing research evidence is recent. All 41 studies identified through the systematic literature searches were published within the last decade (2006 – 2016). Figure 2 shows the distribution of studies by publication year. Figure 2. Number of Studies by Publication Year As Figure 3 shows, 11 studies on child abuse and neglect were conducted in Haiti. In total, 17 of the studies reviewed were conducted in Caribbean countries, 10 studies were conducted in Latin America, and 14 were conducted in Africa. 2 2 0 0 1 3 4 6 10 7 6 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Number of Studies Publication Year USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 13 Figure 3. Number of Studies Reviewed by Country Findings From the Thematic Review The research team categorized the interventions in the 41 studies for this systematic review into five categories: (1) psychosocial interventions to promote coping skills, (2) child protection policies and campaigns, (3) vocational and life skills training, (4) parent/caregiver education, and (5) safe spaces programs. These categories are further described in the following sections. 1. Psychosocial Interventions Level of Evidence: Strong Evidence Of the 41 studies reviewed, 17 studies examined the effects of psychosocial programs. These programs are described in Appendix B, Table B1. The 17 studies reviewed reported positive effects in three main outcome categories: • Reduced trauma symptoms (11 studies; 61%) • Reduced depression symptoms (5 studies; 29%) • Improved mental and physical wellness (7 studies; 41%) The evidence base is strong because of the number of studies that used a rigorous study design (i.e., experimental or quasi-experimental; 11 studies; 61%). 3 The remainder of the studies reported on changes from baseline to posttest but did not use a comparison group. External validity of the evidence base under this category is high. Three studies with a rigorous design were conducted in Haiti. In total, six studies were conducted in the Caribbean (Haiti and 3 Only nine of the 11 studies reported effect size information and were included in the meta-analysis in this report. 1 1 1 1 1 1 1 1 1 1 2 2 2 3 4 7 11 0 2 4 6 8 10 12 B U R U N D I C O L O M B I A D O M I N I C A N R E P U B L I C M E X I C O M O Z A M B I Q U E M U L T I P L E ( A F R I C A ) P E R U R W A N D A S I E R R A L E O N E T R I N I D A D A N D T O B A G O D E M O C R A T I C R E P U B L I C O F C O N G O J A M A I C A M U L T I P L E ( C A R I B B E A N ) M U L T I P L E ( L A T I N A M E R I C A ) B R A Z I L U G A N D A H A I T I USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 14 Jamaica), five studies were conducted in Latin America (Brazil, Colombia, and Peru), and six studies were conducted in Africa (Burundi, Democratic Republic of Congo, and Uganda). Program Participants and Settings Nearly one third of the studies (5 studies; 29%) reported on the results of psychosocial programs for former child soldiers who were victims of violence or witnessed violence in war-afflicted areas. Another one third of the studies (5 studies; 29%) examined outcomes of victims of child maltreatment, including neglect, sexual abuse, and harsh discipline. Three studies examined the effects of programs delivered in internally displaced persons (IDP) camps. Of these studies, one was conducted in postearthquake Haiti (Bastien, 2014). Figure 4 shows the distribution of studies by program participants. Figure 4. Number of Studies by Program Participants Psychosocial interventions address the prevalence and salience of trauma-related symptoms among children who were victimized or have witnessed violence. The interventions in the studies reviewed were implemented in schools, care institutions, community centers, and IDP camps (Figure 5). One third of the studies (six studies) reported on interventions implemented in school buildings with children and youth identified as needing intervention because of their exposure to violence or a history of being victimized by adults. The interventions included both students enrolled in the school and youth from nearby neighborhoods. An additional five studies reported on interventions implemented in care institutions, defined as residential institutions where children and youth do not live with their biological or alternative families but under the supervision of care authorities. Two types of care institutions were included in the studies: residential facilities for recovery from trauma and orphanages. Three studies reported on interventions located in community centers. The centers were selected primarily because of their proximity to where children lived and their attractiveness (e.g., a municipal sports club). Finally, in three studies, the intervention was provided in the shelters or homes of displaced families in IDP camps. 5 5 3 2 1 1 Child Soldiers Child Maltreatment Children and Women in IDP Camps Street Children Restavèk Children Children in Orphanages USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 15 Although most of the studies (10 studies; 59%) evaluated interventions delivered by mental health professionals (e.g., psychologists), nearly one half of the studies (seven studies; 41%) reported on interventions delivered by teachers, university students, volunteers, and members of NGOs and community-based organizations who received training and clinical supervision. According to the studies reviewed, the inclusion of lay professionals enabled the implementers to build on a larger workforce. But more importantly, it was perceived by communities as an opportunity to build capacity to more effectively work with children, parents, and primary caregivers and better understand the behavior of children, identify their problems, and communicate with victims of violence in a trauma-sensitive manner. Figure 5. Number of Studies by Program Setting Implementation Components The studies demonstrated the feasibility of group therapy (versus one-on-one interventions), which can increase the number of individuals who can benefit from treatment. Of the 17 studies reviewed, 15 studies (88%) reported on programs created for or adapted to be delivered in small groups. All programs were manualized, and most programs (88%) were short term (ranging from five to 15 sessions). The programs tended to use progressively structured sessions. Some sessions included discussions about safety and control, self-awareness, self-efficacy, self-esteem, and personal narratives of traumatic events. All sessions included relaxation and calming techniques and strategies for adaptive coping with stress. Activities varied and included discussions as well as creative expression through play therapy, role-play, drama, art, music, movement, and yoga. Several programs used a train-the-trainer approach to enable local lay mental health workers to deliver a structured curriculum and teach basic coping skills. A common example of a psychosocial intervention was trauma-focused cognitive behavioral therapy, which is designed to reduce negative emotional and behavioral responses associated with child sexual abuse, domestic violence, traumatic loss, other traumatic events, and other 6 5 3 3 Schools Care Institutions Community Centers IDP Camps USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 16 affective disorders (e.g., depression and anxiety) and cognitive and behavioral problems. Such therapy — based on learning and cognitive theories — addresses distorted beliefs and attributions related to the abuse and provides a supportive environment in which children are encouraged to talk about their traumatic experiences. In some of the studies reviewed, the intervention was delivered by trained mental health personnel, such as social workers, and at times was integrated into another intervention, such as vocational training courses. This program type also often included sessions with parents/caregivers who were not abusive to improve the supportive environment at home. 2. Communitywide Models Level of Evidence: Moderate Evidence Of the 41 studies reviewed, 11 studies evaluated communitywide models for violence prevention (Appendix B, Table B2). The 11 studies reviewed reported positive effects in four main outcome categories: • Improved advocacy for children and women’s rights and increased public awareness of the scope of local violence problems and the role that community members can play in preventing domestic violence, neighborhood violence, and child exploitation (four studies; 36%) • Reduced rates of violence, ranging from harsh discipline to homicide (three studies; 27%) • Increased access to and use of health and social services by vulnerable populations (three studies; 27%) • Reduction in the number of families that send their children into Restavèk slavery or other forms of hazardous work and an increase in the number of children rescued from labor that involved violence or abuse who are then rehabilitated and integrated into their families and society (two studies; 18%). The level of evidence was rated as moderate because of a lack of studies with Haitians that used a rigorous study design (e.g., experimental or quasi-experimental design). One randomized controlled trial of the effects of a community mobilization intervention in Uganda to prevent violence against women provided evidence of effectiveness for using a communitywide model. A second randomized controlled trial is an impact e valuation of USAID’s community-based crime and violence prevention approach in Central America. This study showed positive effects of a communitywide model on reduced violence (e.g., murder, unsafe streets, and gang fights) and increased community participation in creating safe neighborhoods. The other eight studies reported case studies and descriptive statistics of the implementation results. Of these eight studies, three were conducted in Haiti. Targeted Groups and Settings Of the 11 studies, five reported on implementation models that sought to benefit all members of the community, three studies evaluated programs that targeted women and girls, and two studies evaluated interventions for children and youth. The settings for implementation included agency offices, health clinics, churches, and participants’ homes. USAID/Haiti Alliance for the Protection of Children A Systematic Research Review and Meta-Analysis — 17 Implementation Components Communitywide implementation models include components directed at individuals, families, and the community. For individuals and families, communitywide models offered skill building workshops and access to resources and services. Examples of activities for vulnerable individuals and families included the following: • Skill-building workshops to promote life skills (e.g., assertiveness, problem solving, employability skills, and coping techniques) and knowledge of one’s rights • Improved access to information on how to obtain health, mental health, and social services • Su