A reflective learning report about the implementation and impacts of Psychological First Aid (PFA) in Gaza

Abstract

Psychological First Aid (PFA) is the recommended immediate psychosocial response during crises. As PFA is now widely implemented in crises worldwide, there are increasing calls to evaluate its effectiveness. World Vision used PFA as a fundamental component of their emergency response following the 2014 conflict in Gaza. Anecdotal reports from Gaza suggest a range of benefits for those who received PFA. Though not intending to undertake rigorous research, World Vision explored learnings about PFA in Gaza through Focus Group Discussions with PFA providers, Gazan women, men and children and a Key Informant Interview with a PFA trainer. The qualitative analyses aimed to determine if PFA helped individuals to feel safe, calm, connected to social supports, hopeful and efficacious – factors suggested by the disaster literature to promote coping and recovery (Hobfoll et al., 2007). Results show positive psychosocial benefits for children, women and men receiving PFA, confirming that PFA contributed to: safety, reduced distress, ability to engage in calming practices and to support each other, and a greater sense of control and hopefulness irrespective of their adverse circumstances. The data shows that PFA formed an important part of a continuum of care to meet psychosocial needs in Gaza and served as a gateway for addressing additional psychosocial support needs. A “whole-of-family” approach to PFA showed particularly strong impacts and strengthened relationships. Of note, the findings from World Vision's implementation of PFA in Gaza suggests that future PFA research go beyond a narrow focus on clinical outcomes, to a wider examination of psychosocial, familial and community-based outcomes.

Psychological First Aid (PFA)

Based on the Guidelines for Mental Health and Psychosocial Support in Emergency Settings¹, Psychological First Aid (PFA) describes “a humane, supportive and practical response to a fellow human being who is suffering [in the immediate aftermath of exposure to serious stressors] and who may need support.”¹ Based on international expert consensus, PFA is now viewed as an alternative to psychological debriefing^2,3 and is the recommended immediate psychosocial response during emergencies.⁴ PFA evolved as a framework to help meet some of the fundamental needs of people affected by crisis or in distress. Since it is not a clinical or emergency psychiatric intervention^1,5, PFA frameworks, such as that published by World Health Organization, War Trauma Foundation and World Vision International⁵ are designed for administration by both mental health professionals and non-professionals (such as lay counsellors or lay helpers), after a brief PFA orientation.

PFA was first and foremost envisioned as an approach to “do no harm."⁶ It was also based upon international consensus and informed by evidence from disaster studies that articulate key constructs important for assisting people to recover from crisis. These constructs include supporting people to feel (1) safe, (2) calm, (3) connected to social supports, (4) hopeful and (5) a sense of self and community efficacy (control over one's situation).³ It has been suggested that PFA might also support short and long term functioning post-crisis,⁷ although there is currently insufficient research evidence to support this finding.

Despite PFA being evidence-informed and universally accepted as an early intervention for crisis-affected people,⁷ there is a dearth of empirical evidence about impacts of PFA.⁸ As the humanitarian sector widely utilises PFA in crisis and conflict settings, it is imperative to share learnings from various humanitarian settings to understand the impacts of PFA for affected populations and most effective modes of delivery and orientation. At this early stage of PFA evaluation, descriptive findings - although not empirical in nature - may further determine the benefits of PFA in humanitarian psychosocial support programs and inform appropriate approaches to PFA research.

PFA in Gaza

PFA was first introduced to the World Vision Gaza program as part of the Australia-Middle East NGO Cooperation Agreement (AMENCA2) program, implemented from 2009 to 2015. PFA was envisioned in the program as a way to promote overall wellbeing of girls, boys, women and men and as a foundation on which to build community and family support, as recommended in the IASC Guidelines on Mental Health and Psychosocial Support.¹

By 2014, the AMENCA2 project had delivered PFA training to more than 7,500 individuals, comprising project staff and partners, Community Based Organization (CBO) staff, social workers, women's groups, youth, mothers and fathers. The project's Child Friendly Spaces (CFS) were used as a medium for engaging families to participate in PFA training. This enabled individual support and capacity building for men and women who gathered in gender-defined groups to learn about positive coping, active listening and other basic PFA strategies. The PFA training additionally helped them as parents to support their children, many of whom experience behavioral and emotional difficulties since the 2008 ‘Operation Cast Lead' war, the 2012 ‘Operation Pillar of Defense’ incursion and the ensuing protracted conflict and blockade environment. In a qualitative study published by AMENCA2 staff,⁹ project participants reported substantial benefits from the integrated psychosocial support elements of the AMENCA2 project. Specifically, the findings supported the theory that improved feelings of wellbeing and a reduction of daily stressors may be functioning to mediate psychological impacts of traumatic events.¹⁰ Furthermore, the study showed that the whole-of-family approach, by supporting men, women and children, was particularly useful for reducing stress within the family unit.

In July-August 2014, Gaza faced further conflict in a war referred to as ‘Operation Protective Edge’. This conflict was one of the worst experienced in Gaza, with 2,104 people killed and damages estimated in the billions of dollars.¹¹ Loved ones, livelihoods, homes and personal possessions were lost. Exposure to unrelenting bombing, shelling and conflict in the evening hours had an enduring impact on Gaza's population, particularly on many aspects of their psychosocial wellbeing. Based on learnings from AMENCA2 programs, World Vision, in partnership with 40 CBOs, quickly established 40 CFS programs running for at least 3 months. Three hundred (300) individuals previously trained in PFA were mobilised to offer first-line and basic psychosocial support to more than 13,400 households, reaching approximately 61,000 individuals. This was achieved via door-to-door home visits of PFA providers to families, enquiring about whether support was needed, as well as receiving referrals from community members about families or individuals known to be struggling. PFA was additionally provided in groups for mothers with children attending the CFS programs.

Purpose of the reflective learning report

Anecdotal reports from the Gaza community indicate that World Vision's use of PFA was enormously helpful in the aftermath of the 2014 conflict. The feedback suggested that PFA formed part of a continuum of psychosocial care and services, while also being an important gateway for more comprehensive psychosocial support. Therefore, further exploration of how PFA was being implemented and understood in the Gaza context was undertaken. In particular, the study intended to explore whether PFA helped people to feel safe, calm, hopeful, in control and socially connected, and without causing harm.

Although quantitative and empirical findings about the impacts of PFA have been called for in the literature^7,8 – albeit with respect for the challenges of implementing such research - the Gaza project was not established to formally research PFA outcomes. Providing immediate support to the crisis-affected population was deemed the highest priority and establishing an empirical research protocol felt to be impractical. It could also be argued that since PFA has been described as a “do no harm” approach⁶ to support people in the immediate aftermath of crisis and does not claim to prevent or treat symptoms of mental illness, such analyses may not be aligned to the principles of PFA. Irrespective of this debate, AMENCA2 staff was only able to explore the use and impacts of PFA in Gaza in a retrospective and qualitative way. The study was not intended to be rigorously systematic or generalisable.

Key research questions

Based on the PFA framework developed by WHO, WTF and WVI (2011) utilised as the basis for training in Gaza, key research questions for this study included, but were not limited to:

1. Did PFA cause harm, or was there risk of PFA causing harm?

2. How closely were the action principles of PFA recalled by PFA providers and subsequently used – specifically the action principles of Look, Listen and Link?

3. Did PFA contribute to reducing distress?

4. Did PFA contribute toward improved short term and/or long-term functioning?

5. Did PFA contribute to people accessing practical support – and if so, in what ways?

6. Did PFA help people to feel and be safe?

7. Did PFA have a calming impact on people?

8. Did PFA support and encourage greater social connections?

9. Did PFA contribute to people feeling greater self-efficacy? (In Gaza, this translated to people believing they had the capacity to be in greater control of their situation.)

10. Did PFA help to instil a sense of hope for people affected by the crisis?

Methodology

Four Focus Group Discussions (FGDs) and one Key Informant Interview (KII) were used to explore the key research questions. This is based on¹² recommendations for exploring specific topics (in this instance, the impacts of PFA) that warrant discussion, debate and idea generation so that various perceptions can be drawn. The FGDs and KII were supplemented with knowledge from AMENCA2 project staff about who was trained in PFA, and when and how they implemented PFA during the 2014 crisis.

FGDs were held with the following groups:

1. PFA Providers, including 7 women and 1 man, aged 25 to 30 years.

2. Ten (10) women, aged 28 to 50 years, who received PFA, either via home visits and/or groups.

3. Eight (8) men. Six had received PFA in their homes, however another 2 men attended who had not previously received PFA but were seeking support. Ages for the men were not recorded, but they were all married with children.

4. Children - 5 boys and 6 girls, aged 11 to 14 years, who were involved in World Vision's CFS programs and were generally aware that they or their parent(s) had received PFA.

The KII was held with one female PFA trainer who worked for another international NGO and was a Masters level trained psychologist. She was selected as the key informant because she had been the lead trainer and occasional supervisor for the majority of the World Vision PFA providers.

The FGDs and KII were approached in an open format encouraging individuals to comment about PFA without direct enquiry. As the discussions progressed, participants naturally reflected on the majority of the elements of the key research questions; and direct questions were posed to seek out responses to research elements that did not naturally evolve through the discussion.

The FGDs and KII were facilitated in English with Arabic translation. Data was recorded by two Arabic-English speaking note-takers, who documented key ideas as well as direct quotations from participants. Their notes were collated and typed in English for analysis.

Entering into the FGDs and KII, it was hoped that a straightforward or ‘crisp’ form of Qualitative Comparative Analysis (QCA)¹³ could offer some causal themes in relation to the key research questions. However, given lack of rigor of the research approach, limited time and capacity of note-takers, combined with the convenience of the sample group, the data was not sufficient to apply QCA methodology. Therefore, a simple thematic analysis was applied to the data according to recommendations by Braun and Clark¹⁴, given the flexibility of this approach and its tolerance of analyzing qualitative data from a deductive standpoint. For the purposes of this research, thematic analysis relates to the process of identifying, analyzing and reporting patterns from the recorded qualitative data that align with the key research questions.

The thematic analysis process involved transcribed data, including both summarised concepts presented in the FGDs and KII, and direct participant statements. The transcribed data were read multiple times and ultimately sorted into themes as they related to the key research questions. Unique themes not related to the key research questions were coded separately. Where data ideas or statements represented multiple themes, the analyst chose the theme to which is was most aligned, to ensure it was not ‘double-counted’. Ideas or statements that best reflected the themes were highlighted and used to present the findings.

Qualitative findings

For non-mental health professionals, the concept of PFA as a “do no harm” approach tended to be interpreted in terms of safety and protection, rather than an awareness of how some forms of psychosocial support have the potential to cause harm. According to FGD participants, PFA as applied in the 2014 Gaza conflict emergency response was not perceived as psychologically harmful. However, it appears in some instances, PFA was wrongly used to “push” people to speak about their experiences - clearly articulated in the guide as something not to do when offering PFA. For example two PFA providers raised concerns about the challenges some people had exploring sensitive topics during “PFA”, such as memories and feelings about traumatic events and discussions of local politics. The wrong use of PFA remained a risk according to the PFA trainer in the KII.

• We benefit a lot from the PFA sessions. We can't say anything negative about PFA. They work hard to help people psychologically and this is very positive and very good. (Women's group)

• For me, I don't like to remember war time. PFA reminded me of hard things. But even without PFA you can get the same feeling. (Woman, 28 years)

• Actually Gaza political context is very difficult and there are political parties so some people feel afraid and refused to tell us their stories or any information due to the political situation. (PFA Provider)

• Sometimes, they [the PFA providers] push the people to talk about their situation, but don't deal with it there and then. And they let them go home with their pain. People here believe that grieving is the best way, so we push people to talk in our culture. They should know we cannot force people to talk and that it can sometimes be bad for them. (PFA Trainer)

Of note, the action principles of Look, Listen and Link were easily recalled by PFA providers, but only received minor reference in the KII with the PFA trainer. This was the first indication that PFA was being used as an entry point for training in more intensive psychosocial support activities, as anecdotally suggested by AMENCA2 programming staff. Another indication was that “PFA” training was extensive – up to 2-weeks’ training, which is well beyond the one-day PFA orientation program published by World Health Organization.¹⁵ Additional topics covered in the more intensive training included supplementary information about responses to traumatic experiences, referrals, aspects of perception (e.g. Johari windows) and other actions to support expression or relaxation. Nonetheless, PFA was still the framework that shaped and influenced the psychosocial support provided. For example, calming strategies and social supports were encouraged through creative and expressive approaches, such as breathing into balloons or drawing maps to identify community networks. The following statements provide examples of these findings:

• The training included the idea of Psychological First Aid; What is PFA; The principles of PFA; Who needs PFA; The principles of Look, Listen and Link; Different subjects such as shock and trauma. (PFA Provider)

• We look at people's causes of distress, relaxation techniques, the Johari windows, village mapping and drawing of social supports. I train using role plays, lectures, discussions, brainstorming, expressive arts, Johari windows… PFA is only about relaxation techniques and the stressors. Then we expanded it to include expressive art and other ways to deal with people; we do role plays for scenarios like when people will not talk. (PFA Trainer)

Despite the more detailed and comprehensive training provided (beyond the scope of PFA orientation), reports about the delivery of PFA to the affected population remained in-line with the intents and purposes of PFA. The outreach approach of implementing PFA in various locations, including homes, shelters and through emergency response activities or partners (e.g., CFS and CBOs), was appropriate to the Gaza context, reached many age and gender groups, and was positively received and valued by those who received PFA.

• During the last war [2014] we started our work by providing PFA inside the shelters, we work with women, men, elderly and children to reduce the trauma to help the people adapt and have more resilience. (PFA Provider)

• In response to how you were introduced to PFA: Through CBOs, CFS and home visits from PFA Trainers. (Women's group)

• PFA is the most important thing I learned. (Women's group)

• In response to what is PFA: We heard about PFA from World Vision, teachers, schools and parents. (Children's group)

• We benefited a lot [from PFA]. World Vision was the only organization that psychologically supported us during the war. (Men's group)

The FGD and KII findings clearly reflect that provision of PFA in the 2014 Gaza emergency response resulted in a range of positive benefits for the psychosocial wellbeing of children, men and women. The findings confirmed that PFA reduced distress in this response. The most prominent finding throughout the FGDs was that PFA facilitated physical safety for those affected – possibly even saving lives when PFA had been learned prior to exposure to conflict events (from a disaster preparedness perspective). PFA taught people calming strategies that they used for themselves, their children and others in their community. It helped people to connect socially, offered them a greater sense of control over their situation and promoted hopefulness. PFA was reported to contribute to improved short-term as well as long-term functioning, including impacts on how parents supported their children during stressful times. Although FGD and KII participants did not emphasize PFA as a means for accessing practical support, people did appreciate that PFA emphasized addressing the most urgent needs first, and could be utilised as a way to prepare for crisis events, including helping to keep others safe. The table above summarizes these key findings with examples from the FGD and KII data.

Positive reported impact of PFA	Direct quotations from qualitative analysis
PFA helped to reduce distress for people who received this form of psychosocial support.	• … then she started crying and talking a lot about every family member and she told them the story of the death and at the end of the session she felt better and asked the trainers to return back to her house. (PFA Provider)
PFA helped people to feel safe and to implement important safety measures throughout the crisis – for self and others.	• In response to what you learnt from PFA: How to make first aid to the injuries. (Women's group) • We teach them how to stay safe and protect themselves, find safe place for them and their children, how to prepare a safety bag which contains important papers, some food, medicine and everything important to the family. (PFA Provider) • PFA is preparedness. (Women's group) • PFA is safety. (Women's group) • After the last war in 2012, my son grew very frightened. In this war, when he heard the bombs and I had to evacuate the family, he became angry and stubborn and refused to leave the house. We could not pick him [up] or get him to leave the house. I helped him to breathe, relax and calm [down]. I learned this in PFA. He followed me and let me take him away from the house. Two hours later our house got destroyed. It saved my family's life and my son. (Woman, 38 years)
PFA contributed to people learning skills for helping themselves, and others, to be calm.	• I am a mother-in-law. I took PFA session after 2012 war. During 2014 war my son's wife was afraid and cry all the time, my role in the war was to tell her what I learned in the PFA session to make her calm and relax. (Woman, 44 years) • Doing the breathing and relaxation techniques during the day makes me relax. (Woman's group) • In response to how can you not be afraid: through playing, different activities, being patient… Sports, theater, playing, drawing, dancing… Expressing our feelings and emotions. (Children's group)
PFA supported and encouraged social connectedness for individuals and particularly influenced how those who received or learned about PFA supported others, including their own family members.	• In response to what the women's husbands thought of PFA: They accept it, feel happy… They acknowledge that PFA is helpful to us. My husband is now helping me by doing massage and relaxation with me! (Woman, 50 years) • I support my cousin when his brother died during the war by playing with him to make him happy. (Boy, 11 years) • PFA provides us with great social support. (Men's group) • Some children used to sleep in their father's arms due to war effects but they get better after doing the PFA techniques by their fathers such as watching movies, going with their children on trips, social support, telling them stories and making some activities for them. These actions succeeded in transferring the negative view for children to a positive direction which helped them in continuing their life with hope. (Men's group)
PFA helped people to feel they had greater control in their crisis situation, particularly in an emotional capacity.	• I am able to control my fear in front of my children. (Women's group) • The lack of job opportunities makes us feel stress. But the PFA sessions helped us to become better in controlling ourselves. (Men's group)
PFA promoted feelings of hope for people affected in the crisis.	• The PFA changes me from dark to light, it is very useful to me. (Woman, 56)
PFA contributed toward improved functioning of individuals in various ways. For children it seemed to help them manage difficult emotions. For parents, PFA taught them ways to support their children, which also seemed to strengthen family relationships.	• A mother who has twin children, one of them died during the last war so the other child was so sad all the time and didn`t want to go to school alone without his twin brother. So when we visit their house her mother was really tired and crying [we] told them about the Child Friendly Spaces and persuade him to participate … he was very happy and engaged in the different activities … he finally return back to school. (PFA Provider) • In response to if you are feeling angry: When I feel really, really angry I talk to my friends and parents, instead of throwing things around. (Boy, 12 years) • PFA helps us to deal with our children and not to use violence with them. I used to hit my boy when he behaved badly. Now I try to talk to him and understand how I can help him to feel better. (Men's group) • PFA is very useful for today and tomorrow. (Women's group)

In addition to findings that PFA was delivered as described in the PFA framework⁶, additional themes emerged from the data. These included the changing psychosocial needs of people throughout the emergency response, differences in how PFA was received and provided for men and women, the added benefit of a whole-of-family approach and that PFA was viewed, at times, as synonymous with other psychosocial support activities.

A number of participants recognized that PFA alone was not sufficient to meet the needs of the crisis-affected population – that new psychosocial support approaches were needed after the initial crisis and that PFA was best provided when directly linked with material supports.

• Some people lost all their house and suffer from poverty so when we provide them with PFA they accept it for a while then they told us that we want homes, financial support. (PFA Provider)

• The most common problem is the economic situation. So people can say OK, I know about myself but the needs are still there. So it [PFA] needs to be combined. Income and groups…It would be better. (PFA Trainer)

Gender differences were noted by PFA providers in the Gaza context. Men and women responded differently to PFA (men were generally less open to psychosocial support) and providers had to adapt their delivery of PFA support accordingly. However, when PFA providers attended to the whole family, such as via home visits, men became more accessible and open to receiving PFA, as well as becoming more active in strengthening the relationships within their family units.

• As women we have many different ways to express our feelings and we cry and talk. Men do not express their feelings; they are more violent. We do more teaching for men but more expressive activities for women. (PFA Trainer)

• In 2013 war we targeted only women in the PFA. It works a lot with the women but men refused to hear from the women about PFA. After 2014 war, we targeted all the family (women, men, youth, elderly and children). Men now know what is PFA, they listen to our speech, follow our guides and now they are dealing with their wives and children very well. (PFA Provider)

The chid FGD participants did not distinguish PFA as a separate approach from the general psychosocial support they received within CFS program activities. Men also tended to merge the two, as shown in the following statements:

• In response to what is the best thing about PFA: Drawing and trips, helping us [the children], listening to us, expressing ourselves freely, talking in friendly ways, strength in our personality. (Children's group)

• PFA provides happiness for our families, especially for the children. (Men's group)

Participants expressed the belief that PFA was important at all times, suggesting that many PFA providers and recipients viewed the approach as generic to social support. Nonetheless, PFA providers acknowledged the limitations of PFA and reported a desire for more in-depth training to be able to support Gaza families with an array of difficulties they face. When the idea that PFA and psychosocial support were seeming to ‘merge’ was presented to the PFA Trainer, she provided a strong justification indicating that specific to the Gaza context, with protracted conflict, poverty and other challenges, the tenets of PFA and psychosocial support cannot be separated.

• The PFA trainers want new training, new techniques, new manuals because people in Gaza are suffering a lot from the impact of the war in addition to very difficult family problems, divorce, violence, early marriage, poverty, political parties, child labor, etc. So there is a massive need for the PFA all the time. (PFA Provider)

• In response to the statement that PFA and psychosocial support are merging into one: Yes, both are together. The purpose is the same. To help people be supported. To survive and continue, so it's connected. (PFA Trainer)

• In response to the question why she [the PFA trainer] believed PFA and psychosocial support seem to have merged: Because we have ongoing trauma. Every day we have different things. So we also need disaster preparation. Safe places to hide. We teach mothers how to keep children safe. It's not stable here. You will not stay away till it's finished. It's about the situation. It's also because of the donors. They won't give us funds for psychosocial support, but they will fund PFA. It is a key to the door. It would still help a woman improve her skills, life skills, her confidence. And if we can combine this with income generation – these need to happen together. PFA is the key to the door so we can begin to see the whole picture. (PFA Trainer)

The final theme identified in the data was the impact that PFA had on those trained. PFA providers believed their work in providing PFA and support to others gave them personal strength and perspective in their own life struggles. This finding supports other PFA research that shows the approach has an empowering impact on those supporting others in crises.^16,17

• I entered a lot of different houses and saw different problems so I feel that my problems are very small and I am better than the others and I thank God a lot for his blessings. (PFA Provider)

Limitations of findings

As previously noted, this study was not designed to be a rigorous examination of PFA. Instead, it aimed to be a reflective exploration of providers' and recipients' experiences with PFA in the 2014 Gaza conflict response; and whether or not PFA contributed to positive psychosocial impacts. The findings from this study cannot be generalized to other contexts or the wider use of PFA, particularly in light of the fact that PFA formed part of a wider continuum of psychosocial support strategies in Gaza. PFA may also be conceived and operationalized in a range of ways in other humanitarian emergency programs, and may similarly be offered in synergy with other types of psychosocial support interventions, particularly in protracted crisis situations.

The authors acknowledge that 1) this study was based solely on a convenience sample, 2) the data recording procedures and translations were not systematic and 3) the final thematic analysis was approached in a relatively simplified way with potential bias given that all aspects of the study were undertaken by those with direct involvement in the program. However, irrespective of these limitations, the results of this exploratory process clearly substantiate that PFA delivered important and much-needed psychosocial support and assistance to children, women and men affected by the 2014 Gaza conflict. Results also indicate that PFA promoted the factors felt to be important to coping and recovery of people affected by crisis events (Hobfoll, et al., 2007). Therefore, while these study findings cannot be viewed as concrete and definitive evidence for impacts of PFA, they nevertheless provide a strong rationale that PFA likely supports positive psychosocial wellbeing outcomes for those who receive it.

Discussion

Reflecting on the implementation of PFA as a psychosocial support activity in the 2014 Gaza conflict (Operation Protective Edge), children, women, men, PFA providers and one PFA trainer confirmed that PFA was beneficial in a range of ways, akin to what PFA was designed to offer. The findings showed that PFA, as utilized in this emergency response, promoted improved safety of the crisis affected population, and enabled strategies for calming, and improved social connection, a greater sense of control and hope despite adverse circumstances. It was also reported to support daily life functioning for affected people with a particular emphasis on strengthening family relationships and improving parenting skills to meet the needs of affected children. These findings add credence to the aims of PFA based on international consensus of what promotes recovery of people in the aftermath of crisis³ and how best to support more healthy functioning even in the most difficult situations.⁷

Although the findings did not suggest that PFA caused harm to those who received it, the “do no harm” imperative of PFA may need to be clarified and emphasized to ensure that PFA providers are not only aware of the potential physical harms to which people in crisis are exposed, but also that improperly delivered PFA or psychosocial support can itself cause harm (e.g., forcing people to discuss distressing events). Further to this, the study found that training in “PFA” in this context was much longer than the recommended one-day orientation¹⁵ and more comprehensive, including other psychosocial support strategies. This may have influenced both the understanding of what “PFA” is and the impacts for study participants who appear to have benefited from unique and creative approaches in the delivery of PFA. Nevertheless, PFA was still seen to be the guiding framework from which this psychosocial support was provided, signifying that the key elements of PFA remain a robust structure for supporting children, women and men affected by crisis.

In addition to findings that PFA offered a range of positive, practical and emotionally supportive outcomes for people, the exploration showed the importance of adapting PFA for context, culture and gender. For Gaza, provision of PFA within the family whole seemed to extend the reach of support to men as well as women and have subsequent benefits for children and familial relationships.

In this study, PFA and psychosocial support tended to ‘merge’ to some extent, with many acknowledging that the two are difficult to separate. This was especially difficult for children and some men to describe how PFA and other supports, such as CFS for children, differed. This reflects the importance of understanding the role of PFA within a wider system of essential mental health and psychosocial support, as established in the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings.¹ As noted by study participants, PFA alone is insufficient for meeting the extensive psychosocial needs of the crisis-affected population. It is important for program implementers – as well as donors – to recognize the place of PFA within this larger continuum of services, particularly in a protracted crisis setting. All participants acknowledged that PFA was a beginning and opening for supporting people, but more intensive psychosocial support approaches may be needed in the recovery period, as well as additional programmatic supports, such as shelter, livelihoods and other basic needs. The role of PFA in the acute setting – as delineated by the action principles of Look, Listen and Link – is both to provide immediate, humane psychosocial support and to help people to begin to meet their basic needs through linking with available services and strengthening their personal coping abilities.

Lastly, the methodology points to a compelling range of psychosocial wellbeing outcomes aligned with the aims of PFA that may be useful in future impact evaluation studies. As PFA is not a clinical intervention, PFA research utilizing clinical outcomes (e.g, reduced longer-term prevalence of mental disorders) may not be a suitable research goal.

Figure 2.

Gaza volunteer provides Psychological First Aid and support to families, in their homes, in the days following the 2014 conflict.

Figure 3.

Cover for Psychological first aid: Guide for field workers, in Arabic.

Figure 1.

Children attending a World Vision Child Friendly Space that provided them and their families with Psychological First Aid, amongst other psychosocial support activities.

Conclusions

PFA, despite being globally implemented as first-line psychosocial support for people affected by crisis events, remains largely under-researched.^7,8 This reflective, qualitative study of PFA being implemented following an acute crisis event in the midst of a protracted conflict has the potential to inform further research into PFA in other settings, as well as to inform future research design and outcomes for measurement. In summary, learnings from this examination of PFA in the 2014 Gaza conflict emergency response demonstrate that:

• PFA is part of a continuum of care to meet psychosocial support needs; and that PFA itself can be a ‘key to the door’ or gateway for establishing what additional psychosocial skills, knowledge, care and access to services are necessary in a given context;

• PFA delivered in a whole-of-family approach appears to strengthen its impact and reach, supporting stronger familial and community relationships;

• Mental health and psychosocial support programmers and donors can utilize PFA as a part of – and an entry point for – meeting the psychosocial support needs of people affected by protracted conflict; and

• The range of psychosocial wellbeing outcomes from PFA is deserving of further study. Rather than focusing narrowly on clinical outcomes, future research to examine the broader psychosocial impacts of PFA is justified and indeed critical to glean an accurate assessment of the benefits of PFA for crisis affected people.

Disclosure of potential conflicts of interest

Leslie Snider is the director and founder of Peace in Practice, a consultancy firm that, amongst various activities, provides and is paid to deliver PFA training to other organizations. No other potential conflicts of interest were disclosed.