Worlds of Pain: A process evaluation of the Caregiver Support Intervention with Syrian refugees in Lebanon

This paper reports on a process evaluation conducted as part of a randomized controlled trial of the Caregiver Support Intervention (CSI), a nine-session preventive group psychosocial intervention, with Syrian refugees in Lebanon (n 1/4 480, 240 families). Fifteen focus group discussions (FGDs) were conducted with 122 CSI participants (51% of participants in the intervention arm of the trial), including 63 female and 59 male caregivers. We analyzed the focus group data to explore the mechanism of impact of the CSI on caregiver wellbeing and parenting. We also examine the impact of multiple adversities on the results of the trial, which was conducted in a context of widespread social unrest, a severe economic crisis, and the COVID-19 pandemic. Despite these adversities, participants described improvements in their psychological wellbeing and parenting as a result of the CSI. Changes in parenting include a reduction in harsh parenting and an increase in warm and responsive parenting. Findings suggest a pathway from the mindfulness practices and anger management techniques taught in the CSI, to improved caregiver wellbeing, to positive changes in parenting. Participants described becoming less angry and more patient, as well as better able to lower their arousal before responding to conflictual situations with their children. Increased knowledge of positive parenting also contributed to changes in parenting. About half of focus group participants reported a marked attenuation of effects following the intervention, which they attributed primarily to the high stress generated by the combination of the economic crisis and the pandemic. We examine specific ways in which the focus group findings diverge from the trial results, and consider the limitations of standalone psychosocial interventions in contexts of extreme adversity.