Alexander Hamilton1, Charlie Foster1, Justin Richards2
1British Heart Foundation Centre on Population Approaches to Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford
2 Prevention Research Collaboration, School of Public Health and Charles Perkins Centre, University of Sydney
Corresponding author email: email@example.com
Citation: Hamilton, A.; Foster, C.; Richards, J. A systematic review of the mental health impacts of sport and physical activity programmes for adolescents in post-conflict settings. Journal of Sport for Development. 2016; 4(6):44-59.
Children and adolescents exposed to violent conflict are at high risk of developing mental health problems. Sport and physical activity is increasingly incorporated in post-conflict assistance for young people. Implementing agencies make a broad array of health claims for which there is currently a fragmented evidence base. The purpose of this review was to summarise the impact evidence for sport and physical activity based programmes on the mental health of adolescents in post-conflict settings, and highlight the limitations of current practice. Methods: A systematic review of 12 electronic databases, 12 journals and leading humanitarian websites was conducted in August 2014. Studies were eligible for inclusion if they described a sports or physical activity based intervention for adolescents between the ages of 12-19 in a post-conflict setting.Results: A total of 11,722 publications were initially identified, of which 3 met the inclusion criteria and were included in a narrative synthesis. Two studies described projects in northern Uganda; one reported a decline in intervention in boys’ mental health when compared to controls, the other a non-significant improvement. The third study reported continual improvement in symptom presentation in ex-child soldiers in Sierra Leone. Common limitations were short study duration and follow-up, poor or unreported adaptation of methods and a lack of treatment mechanisms research.Conclusion:There is a shortage of high-quality and available information, which limits the strength of conclusions that can be drawn. Despite the international furore surrounding the use of sport for assisting conflict-affected populations, there is not yet convincing evidence of its efficacy as a mental health intervention. Future evaluation and research should aim to identify the mechanisms and processes behind the intended impact of interventions.
Mental illness is recognised as a major contributor to the global burden of disease. 1 The common mental health disorders (for example, depression, generalised anxiety disorder and alcohol and substance abuse) account for 14% of the global burden of disease, about 7.4% of disability-adjusted life years worldwide and roughly a quarter of all health lost due to disability. 2-4 Mental disorders affect 10-20% of children worldwide 5 and roughly 20% of children experience a mental health issue in any given year. 6 Child and adolescent mental health disorders have wide-ranging social and economic impacts on individuals and states. 7 Research in this area is scant, yet results from longitudinal, clinical and population-based studies indicate that emotional and conduct disorders can impair normal development for age, and can influence subsequent quality of life for those affected and their families.7,8
Estimating the global burden of child and adolescent mental disorders is complex and there are a number of barriers that limit accurate analyses.5,9,10 There is inadequate provision of resources for assessing mental disorders worldwide upon considering the low awareness and priority of mental health in many countries. 9 In addition to this the definition, expression and diagnoses of mental disorders vary cross-culturally. 10 This limits the accuracy of global estimates and these difficulties are particularly prevalent in low- and middle-income countries and post-conflict settings.3
Exposure to conflict and conflict-related stressors is a risk factor for elevated levels of poor mental health. 11,12 Conflict not only exposes people to violent and traumatic events which are known to increase mental health problems, but can also radically change the social and economic environment which can catalyse the emergence of psychiatric disorders. 13,14 A lack of social support, prolonged displacement, breakdown of community structures and deprivation of basic needs are common. 15 Factors such as these contribute to poor levels of mental health among conflict-affected populations. 16,17 Typically, populations suffer from, for example, elevated levels of post-traumatic stress disorder, anxiety-type disorders and increased substance and alcohol abuse. 18,19
In academic literature, mental health assistance to conflict-affected populations is often characterised as ‘psychosocial’ or ‘medical.’ The psychosocial approach aims to use non-intrusive methods to assist populations with their recovery. 20 Approaches are both formal (such as school-based cognitive behavioural therapy, narrative approaches and art therapy) and informal (typically education, play or story-telling activities) and aim to empower communities to recover without individual therapy or drug treatments. 21,23
Sport is increasingly incorporated into psychosocial assistance programmes for conflict-affected populations and is a sub-category of a wider movement, known as Sport for Development and Peace (SDP). 24 SDP is defined as:
“The intentional use of sport, physical activity and play to attain specific development objectives in low-and middle-income countries and disadvantaged communities in high-income settings…” 25
SDP and psychosocial healing agencies have commonalities and overlapping methods.26 SDP covers a broad array of actors such as multilateral organisations (e.g. UN agencies), international non-Governmental Organisations (e.g. Right to Play), private entities and academic institutions, which implement a spectrum of program models and claim manifold cross cutting positive outcomes.27
Agencies and practitioners make a diverse array of claims relating to the impacts of SDP programs.28 Of particular interest are the mental health-related claims of SDP and sport for psychosocial healing organisations. According to Coalter (2008), the majority fail to back up these up with convincing evidence, and the claims appear to outweigh the current evidence base. 29 Indeed, there is a growing body of evidence for various positive impacts of sport and physical activity (PA) on the physical, mental and social wellbeing of young people, including those ‘at-risk’ in developed, peaceful settings. 30-32 However, it is not certain that these outcomes can be replicated in a post-conflict setting.26
There has been a proliferation of SDP projects. Currently, 585 organisations and 213 projects are registered on the International Platform for Development and Peace, a number that has almost tripled since 2008 since the search was conducted on August 23rd, 2014. Consequently, it is necessary to take stock and identify what works, for whom and why.28 There is a need to evaluate the success and failures of these programmes systematically to consolidate the efficiency, efficacy and sustainability in the face of limited resources.
Cronin et al (2011) discourage the wide-ranging reviews of evidence for SDP programs, since they are unlikely to provide meaningful results given the growth of the field. 33 There are several reviews that point to psychosocial and SDP interventions in general, but none that attempt to isolate the impact of sport and PA specifically. This review was an extension and development of a review performed by Richards that analysed all the health-related outcomes for adolescents of sport programmes in post-conflict zones, which identified a single publication relating to northern Uganda. As a result, few conclusions were drawn. 34 This review focused on the mental health impacts of programs for adolescents in post-conflict settings, which had clearly defined intervention sport or PA elements. The research objective was to collate and critique the available evidence for the mental health impact of sport and physical activity programmes on adolescents in post-conflict settings. This was in hope that the independent effects of sport and PA might be analysed as opposed to more general intervention methodologies.
Inclusion and exclusion criteria
The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and registered on Prospero (CRD42014010833). 35 A completed PRISMA checklist is attached in Appendix 1.
Articles considered in this study were screened for type, population, intervention, and outcome measure. To ensure that the maximum number of mental health publications was identified, no specific mental health outcome measure search terms were included. All articles found in academic literature and grey literature from international organisation archives were eligible for inclusion in the study. Conference abstracts and posters were not included and were not considered for review. All English publications from January 1980 (if available) to August 2014 were included.
Evidence related to adolescents aged 12-19 years living in a post-conflict region across a school or community setting was included in the study with no exclusion based on gender or ethnicity. The review used the WHO definition of an adolescent. 36 All articles that described an intervention in a post-conflict setting were eligible for inclusion and were not excluded based on study design in anticipation of a shortage of relevant literature. Articles describing interventions in high-income countries or in peaceful settings were excluded on the grounds that the socio-ecological environment influences the outcomes of interest. 37
Studies were eligible for inclusion if they described an intervention that was sport or physical activity based. For the purpose of this review the WHO definition of physical activity was used. 38 Initially, publications were to be categorised based on the frequency, intensity and type of physical activity or sport that participants engaged in. However, it was clear from early on that this was not possible because many publications provided very little information on the nature of the use of physical activity or sport. There was also a shortage of information on the dose of physical activity or sport that people received in both excluded and included publications. Publications were included if the following criteria were met:
- Type of sport or physical activity clearly stated.
- The duration of the physical activity sessions was stated in the study.
- A minimum of an hour per week of sport or physical activity.
This review included interventions that specifically addressed mental health and those in which mental health was a secondary outcome. As a result, database search terms were broad and incorporated all sports-based programmes that might have mental health impacts in post-conflict settings. The primary outcomes of interest were indicators of negative mental health, such as post-traumatic stress disorder; depression or generalised anxiety disorder; and indicators of positive mental health and wellbeing such as self-efficacy, self-esteem or emotional wellbeing.
Academic online databases including Ovid, EBSCOhost, Education Resources Information Centre and PubMed were searched. Manual searches of several selected online journals were conducted including the ‘African Journal of Physical Health Education, Recreation and Dance’ and the ‘Journal of Health and Sports Science and Child and Adolescent Mental Health.’ Additional resources included humanitarian and other grey literature websites, including Google Scholar and Relief Web. Appendix 2 contains a full list of all searched websites and academic databases. All the relevant interventions across review publications were identified and cross-referenced with the primary articles retrieved through the electronic search.
The search terms are outlined in Appendix 3. A single researcher executed the search strategies and all references were stored in Endnote 7.1. Studies were then screened and included/excluded in three stages; based on titles (stage 1), abstracts (stage 2) and full-text articles (stage 3). After duplicate references were removed from the Endnote database, a single researcher reviewed each citation by title and abstract to see if it should be included in the review. After the first reviewer had screened the database, a second researcher reviewed the citations that were deemed ineligible to identify if any potentially relevant articles had been missed.
Humanitarian websites were screened for grey literature and important citations. Grey literature did not always conform to the ‘title-abstract’ format. Likewise, many websites and internal online search engines did not offer the exporting of citations. In this instance, titles and abstracts were screened online. Those that were relevant were imported into Endnote. The abstract/executive summary was reviewed online in later stages of the review process. In the absence of an abstract, the executive summary or introduction was read. All relevant articles that fitted the selection criteria were selected for data extraction.
A data extraction form was designed and used to collect information on the following factors: study design and methodology, sample size, country of origin, age of participants, gender, study aim, programme duration, sport or physical activity type and mental health outcome. Two researchers conducted the data extraction process and compared their results. The bibliographies of those selected for full text review were screened to generate additional references if these were missed in the original searches. In the event that multiple publications on a single intervention were identified, one of the publications was excluded but gleaned for information on the study.
The Effective Public Health Practice Project Tool for Assessing Quantitative Studies’ was used to assess studies. 39 Studies were assessed for study design, confounders, blinding, data collection, withdrawals and dropouts. Two researchers assessed the papers for quality and gave each publication a global rating of strong, moderate or weak. There were no disagreements regarding the quality of the included studies. Qualitative studies were assessed according to the National Institute of Health and Clinical Excellence guidelines for quality appraisal of qualitative studies. 40 Due to the heterogeneity of the studies, a meta-analysis was not possible and studies were included in a narrative synthesis.
Results of the search
Figure 1 depicts the flow of citations throughout the study.
The searches resulted in a total of 11,722 publications. After removing duplicates, 9035 remained. Of these, 9000 were excluded because they did not meet the inclusion criteria. The majority of articles were irrelevant to the review and did not report a sport or physical activity intervention or any mental health outcome. The full text of 35 studies was examined in greater detail. Three studies met the inclusion criteria and were included for narrative synthesis. 41-43 A list of the excluded studies with reasons for exclusion is available in Appendix 4.
Summary of included studies
A summary of the included studies is in Table 1. The studies are heterogeneous according to design, population and intervention method.
Two of the three studies were randomised controlled trials evaluating interventions in Northern Uganda. The third study was a small cohort study assessing the impact of an intervention in Sierra Leone. Three additional publications concerning these projects met the inclusion criteria. 44-46 These publications were read and any additional information on the intervention was extracted for discussion.
Bolton et al conducted a 16-week three-armed randomised controlled trial designed to assess the impact of different interventions for depression-like symptoms among internally displaced adolescents in northern Uganda. 42 Participants in a ‘Creative Play’ arm of the RCT showed no significant improvement in depression-like symptoms when compared to the wait-list control group (difference in adjusted mean score change -3.90, 95% confidence intervals [-11.7 to 3.37]). There was no significant intervention effect on anxiety like symptoms (d = 0.2) or socially unacceptable behaviours (d = 0.4).
Richards et al (2014) conducted a 12-week three-arm RCT nested in a prospective observational study. 41 Richards reported that depression and anxiety-like symptoms scores deteriorated for boys in the intervention group, whilst the scores in the boys wait list and control groups significantly improved. For the boys, there were significant small effect sizes when comparing the intervention group to the wait-listed (depression-like symptoms: ES = 0.67 [0.33 to 1.00], anxiety-like symptoms: ES = 0.63 [0.30 to 0.96]) and control groups (depression-like symptoms: ES = 0.25 [0.00 to 0.49], anxiety-like symptoms: ES = 0.26 [0.01 to 0.50]). Girls in both groups appeared to experience improvements in anxiety and depression-like symptoms, but this was only significant for non-registered control group (depression-like symptoms p = 0.003, anxiety-like symptoms p <0.001). There were small and non-significant effect sizes when comparing the girls for all between group comparisons.
Harris (2007) evaluated the impact of a Dance and Movement Therapy (DMT) intervention for 12 former child soldiers in Sierra Leone.43 Semi-structured interviews established baseline functional capacity indicators along with anxiety, aggression and PTSD symptoms. Repeat interviews were carried out at 1, 3, 6 and 12 months after initial intake. The authors report a continued drop in all outcome measures and the development of coping strategies in participants.
Risk of bias
The studies were assessed using the Effective Public Health Practice Project (EPHPP) Tool for Assessing Quantitative Studies’. 39 Richards et al and Bolton et al scored a strong rating and the Harris study scored a weak rating; see table 2 for a breakdown of the scores.
Richards et al and Bolton et al adequately described the method used to generate the allocation sequence. It was not possible to blind participants in these interventions because participation is active. Interviewers and assessors were blinded to participant intervention group and levels of subject retention throughout both RCTs were high, remaining above 80%. There was limited loss-to-follow-up, considering the difficult context.
The Richards et al study did not reach the calculated sample size and it is possible that the sample is non-representative for the outcome of interest. Participants in the Richards et al study were at risk of self-selection bias. As the intervention was sport and physical activity based, it was likely to attract more confident, healthy and fit children than those suffering from mental health issues.47 In light of this, the external validity of the results is questionable.
Reporting in the Harris study was poor; it is worth noting that this is a rewritten version from a paper presentation; the majority of the details required for calculating an EPHPP score were not reported. The publication made claims that are not supported by any indication to measures, methods, quantitative data or statistical analyses. Further, given the small sample size in this study (n=12), statistical analyses would have been of little value. There was no consideration of confounding variables in the study. The lack of repeat measures, a control group, and consideration of confounding factors mean that observed differences over time may not be as a result of the intervention.
Synthesis of results
The studies are not suitable for meta-analyses and so are presented as a narrative synthesis. The studies vary in size, study design, outcome, population, intervention and context. This, along with the lack of included studies, complicates narrative synthesis and limits the strength of the conclusions that can be drawn.
The result of the creative play intervention was equivocal with no significant positive findings reported in the intervention arm of the study. The Sport for Development intervention by Richards et al, reported a significant negative effect on mental health in boys. In contrast, the results of the DMT intervention were positive and reported large reductions in participant symptom expression, as identified by semi-structured interview. The resounding success of the Harris study among adolescent former soldiers should be read with reservations, given the lack of information about the study. The value in the DMT study is the rich programmatic information provided in the additional publication concerning this study. 46
In the included studies, gender may have influenced the strength of the intervention effects. This is in accordance with the results of other reviews that indicate the differential effects of sports and psychosocial programmes on girls and boys.44,48-50 Given the lack of included studies, it is not possible to make any assertions at this point.
There were notable differences in project implementation and design. Both the creative play intervention and the dance and movement intervention were psychosocial, curative interventions. The SDP intervention set up a competitive sports league that included skills training, even if this was secondary to the health and social goals. Three paraprofessional psychosocial counsellors delivered the dance intervention in conjunction with a professional DMT counsellor, while the two RCT interventions were delivered by paraprofessionals who had received limited training in relation to mental health. Furthermore, the DMT intervention took place over the course of 28 weeks, markedly longer than either of the other interventions. Perhaps most notable is the difference in group size between the interventions: the DMT intervention consisted of a total of 12 participants and 4 staff while the other interventions were much larger. Given the shortage of included publications, it is not possible to draw any conclusion regarding the impact of design and intervention implementation on the outcomes of interest.
A notable strength of the two RCT studies was the use of a locally developed and validated mental health assessment tool. There is debate as to the validity of using Western psychological assessment tools in different cultural settings.51
Discussion and comment
The principal finding in this review fails to support the broad claims of the positive effect of sport and physical activity programmes on the mental health of conflict-affected youth. 26,52 The paucity of available high-quality information and the heterogeneity of intervention methods in this review mean that it is not possible to draw a firm conclusion either way at this time. The field of psychosocial assistance is broad; within it, actors implement related but different programme and intervention models. Sport and games are often involved in psychosocial interventions, but are not described in detail or clearly reported. 53,54
Neither the creative play intervention nor the sport for development intervention had a significant positive impact on participants’ depression-like symptoms or anxiety-like symptoms when compared to wait-list or control groups. The studies assessing these outcomes were of good quality, suggesting a limited role for sports and physical activity in the reduction of anxiety or depression like symptoms in this context. The Harris study reports significant reductions in all outcomes measured, but the quality of the reporting is too poor to critically assess these claims.
Several publications have been published that review the field of psychosocial assistance for young people in post-war zones. 24,52,55-57 Typically, systematic reviews have not attempted to isolate the impact of one particular intervention method, rather addressing the field of psychosocial assistance at-large. 49,50,58 There are common problems highlighted by these publications, citing a shortage of evidence, small effect sizes and a lack of treatment modality research.59
Two of the three studies are of good methodological quality. Due to the reporting, it was not possible to assess the quality of the DMT intervention as no information about study design or outcome measures was provided. This illustrates a weakness in the SDP field at-large, in which the majority of evaluations are of poor design and typically implement pre-post methodologies without control populations.28,60 There are notable exceptions to this, but these tend to be clinical studies in different areas, focusing on classroom-based interventions as opposed to physical activity and sport-based methods.53,54,61
The findings of this study support those of other reviews assessing mental health interventions for adolescents.58,62 Gendered differences may be important to consider in future programme designs. Similarly, previous publications have shown age to be an important moderator variable. 48 There were insufficient participant numbers in the studies included in this systematic review to independently examine the impact of gender or age on outcomes.
Post-conflict contexts are a difficult setting in which to conduct high-quality research. They are often characterised by instability, a lack of security and human resources and limited infrastructure.63 Participant recruitment, engagement and tracking can be difficult in such settings. This can impede the development and management of evaluations and complicate long-term analyses. Formative and process evaluations are crucial as they help ensure the success of an intervention and provide valuable learning lessons for future practice. Formative evaluation should involve the pre-testing and adaptation of methods to ensure their cultural appropriateness and feasibility in the specific research context.
Best practice advice encourages both interventions and associated evaluations to be long-term to observe intervention effects over time.56 Nesting studies in more permanent structures, such as schools, enables the tracking of participants over time for repeat measures to strengthen study designs and the evidence base. This practice is common in the field of psychosocial assistance. 48,53,61,64
There is a lack of process evaluation and treatment mechanisms research in the included studies. Richards et al briefly elude to a process evaluation, but the results and insights of this are elementary and reported elsewhere.65 Process evaluation is essential for identifying the ‘active’ components of the interventions, a key finding for practitioners. This is indicative of the field at large, in which research is typically ‘impact’-oriented rather than process-oriented. This may be a product of asymmetrical donor-recipient relationships, in which donor preferences typically prevail. 66
The study could be criticised on its strict inclusion criteria. There are many borderline publications from which useful methodological information could be gleaned. 49,59,64 More lenient inclusion criteria may have affected the results of the review, as non-included studies reported improvements in participants’ mental health. We did not contact authors, researchers and interventionists to request relevant literature in this systematic review. As a result, we may have missed important publications reporting the impact of SDP programmes on mental health.
There was significant difficulty in identifying the ‘dose’ of sport that individuals received, resulting in borderline publications that may have been informative being left out. The lack of good-quality evidence meant that the independent impact of sport or physical activity on mental health in post-conflict LMICs could not be identified from this review. Further, the results of this review are skewed geographically and by gender towards Ugandan, male youth. This may limit the generalizability of the review’s findings. It does, however, provide useful reflection on the state of the SFD field at large.
Despite the international furore surrounding the use of sport for assisting conflict-affected populations, there still exists a dearth of convincing evidence of its efficacy as a mental health intervention. Reviews of SDP evidence and best practice guidelines have been published in grey and academic literature. The contents of these review publications need to filter down into practice and be systematically tested. The role of sport in psychosocial assistance is unclear. Certain programmes implement sporting elements, but rarely is the sporting component measured effectively or in detail.
Currently, the majority of SDP evaluations are ad hoc and poorly designed. The SDP evidence base would benefit from more detailed investigations of how intended intervention effects are achieved and maintained over time. Such evaluations will allow the identification of the ‘active’ elements of programmes that can be bolstered and developed. However, in order for this to happen, investment in evaluation is needed at all stages: formative, process and impact. 67
Given the results of many psychosocial interventions and reviews, there is a need to examine the differential effects of interventions on children across gender and age groups. Researchers should draw on the successes of other sectors to inform the design and evaluations of sports-based interventions. Sport and physical activity may be an important tool for social development in post-conflict settings. Many organisations are implementing socially minded sports programmes that were not included in this study. It was not within the scope of this review to assess the broader social outcomes of sports programmes, but the results of such a review would be of considerable academic and practical interest.
In this review, of note is the use of locally validated mental health assessments to evaluate programme impacts in northern Uganda. Improved measurement tools with good psychometric properties that are culturally acceptable may help improve future longitudinal research. Additionally, the use of locally validated tools means that the results are useful for local stakeholders and may capture local idioms of distress more effectively than international mental health assessment tools. 51 It is worth noting that while potentially improving local relevance of studies, the use of emic mental health measures limits the external validity of results.
In summary, there is a shortage of contextually relevant information for sport in the assistance of conflict-affected populations. Future investment in evaluation and research in the area should aim to identify the mechanisms and processes behind the intended impact of interventions to ensure the efficient and effective use of finite resources in challenging settings.
We would like to take this opportunity to thank Generations For Peace. They were responsible for funding this systematic review.
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