Actividades de la modalidad paliativa

3.1.1 Inclusion and exclusion criteria

The outcomes of interest in this review are coping strategies in response to challenges arising from armed conflict and forced displacement, in the context of mental health as defined by the WHO (2015b). The definition of coping is described in Chapter 2 section

1 _{This Chapter forms the basis for a paper published by Global Public Health and a poster}

presentation given at LSHTM. See Appendix A for a complete list of publications (accepted and submitted) and presentations arising from this thesis.

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2.4; as an attempt to master, tolerate, or reduce internal or external stressors that an individual perceives as exceeding existing resources (Folkman & Lazarus, 1980). Armed conflict is defined as a “contested incompatibility which concerns government and/or territory where the use of armed force between two parties, of which at least one it the government of a state, results in at least 25 battle-related deaths (Wallensteen & Sollenberg, 2000, p. 648).

The population included was adult (aged 18 years or older) conflict-affected civilians. Studies exclusively focused on adolescents and children were excluded as their coping strategies are often very different to those of adults (see Makhoul, Ghanem, & Barbir, 2011; Reed, Fazel, Jones, Panter-Brick, & Stein, 2012). Only populations residing in LMICs were included, selected according to World Bank country classifications (World Bank, 2015). The exclusion of populations in high-income countries was based on the fact that the vast majority of conflict-affected persons globally live in LMICs which may offer more limited resources to support coping (such as strong social safety nets and health care systems) compared to high-income countries. Also excluded were studies exclusively focused on war veterans and combatants as their war experiences, resources and coping strategies may also differ significantly from conflict-affected civilians (Punamaki et al., 2008). Studies which focused exclusively on alcohol and/drug use in post-conflict settings were also excluded, unless such behaviours were explicitly framed as coping-related strategies. Finally, articles which explored the impact of formal professional mental health interventions (cognitive behavioural therapy, narrative exposure therapy, etc.) were excluded as they were deemed outside of the coping approach used in this review (and have previously been systematically reviewed elsewhere) (Tol et al., 2011a).

Four types of conflict-affected persons were included: (i) IDPs who have been forced to leave conflict areas and remain within their country’s borders (Deng, 1998); (ii) refugees who have been forced to leave their country due to conflict (UNHCR, 1951); (iii) former IDPs and refugees who have returned to their home areas (returnees), and (iv) populations living in an area where a conflict was either still occurring or had occurred within the previous 10 years (conflict-affected residents). English-language quantitative and qualitative studies were included.

60 3.1.2 Data search

A search of six bibliographic databases (Medline, PsycINFO, Embase, Global Health, Web of Science, and IBSS databases) was conducted. No limits were placed at the start publication date and the end publication date was 13 May 2014. The search terms were chosen by a preliminary review of relevant papers, and included common mental health disorder terms along with refugees and internally displaced persons. Where available, medical subject headings (MeSH) supplemented the search, including such terms as ‘mental health’ and ‘refugee’. Filters were used to select English-language empirical studies on adult populations in LMICs.

The term ‘coping’ was deliberately not entered in the search. The broad nature of coping meant that some authors may not have explicitly framed their studies about coping but they would nevertheless have incorporated key elements of coping which matched the definition and inclusion criteria of this systematic review.

3.1.3 Study screening, selection and analysis

The selection process followed five stages in accordance with the PRISMA guidelines which was followed for this review (Moher, Liberati, Tetzlaff, Altman, & Group, 2009). First, databases were searched based on the search terms and the articles yielded were downloaded into Endnote. Second, the titles and abstracts were reviewed against the inclusion/exclusion criteria. Third, the full texts of included articles were screened. Fourth, the reference lists of included studies were manually searched for additional relevant articles. Fifth, a final in-depth review of remaining studies was conducted.

Due to the heterogeneity of research designs and coping typologies, descriptive analysis was conducted rather than a meta-analysis and meta-synthesis. For each study, coping strategies were categorized into the taxonomy of Skinner et al. (2003) which includes the following core coping strategies: problem solving, support seeking, escape-avoidance, distraction, and positive cognitive restructuring. Categorization of items into one of these domains was accomplished through an examination of how each item was described in each study.

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Findings are reported by: (i) the types of coping identified (based on Skinner’s categorization); (ii) factors influencing coping strategies and (iii) correlations between coping strategies and mental health outcomes (including general mental health, depression, anxiety, PTSD, and somatization) for the quantitative studies, along with descriptions and explanations of this relationship in qualitative studies.

The methodological quality of the studies was reviewed using the STROBE (Vandenbroucke et al., 2007) and RATS (J. Clark, 2003) checklists for quantitative and qualitative studies respectively. The STROBE checklist was modified to include an item on whether measures used to assess mental health had been validated for the study population. These assessments were not used to screen out studies, but to examine the overall quality of the evidence base.