A Rapid Realist Review of Group Psychological First Aid for Humanitarian Workers and Volunteers

Humanitarian workers are at an elevated risk of occupational trauma exposure and its associated psychological consequences, and experience increased levels of anxiety, depression, and post-traumatic stress disorder (PTSD) compared to the general population. Psychological first aid (PFA) aims to prevent acute distress reactions from developing into long-term distress by instilling feelings of safety, calmness, self- and community efficacy, connectedness and hope. Group PFA (GPFA) delivers PFA in a group or team setting. This research sought to understand ‘What works, for whom, in what context, and why for group psychological first aid for humanitarian workers, including volunteers?’ A rapid realist review (RRR) was conducted. Initial theories were generated to answer the question and were subsequently refined based on 15 documents identified through a systematic search of databases and grey literature, in addition to the inputs from a core reference panel and two external experts in GPFA. The findings generated seven programme theories that addressed the research question and offered consideration for the implementation of GPFA for the humanitarian workforce across contexts and age groups. GPFA enables individuals to understand their natural reactions, develop adaptive coping strategies, and build social connections that promote a sense of belonging and security. The integrated design of GPFA ensures that individuals are linked to additional supports and have their basic needs addressed. While the evidence is sparce on GPFA, its ability to provide support to humanitarian workers is promising.

Resource: There was a need for a system of complementary supports, for both physical and psychosocial needs. Reaction: meeting these needs can an increase an individual's sense of stability, safety, and emotional expression. Outcome: This can help to prevent the escalation of distress over time through reducing secondary stressors and helping individuals to cope on their own.
Context: Following a natural disaster like a typhoon in a low-resource, collectivist country, people are often affected differently and may have various reactions to traumatic events. They may or may not have experienced something similar before. GPFA was provided in a safe location away from the disaster area, where participants felt comfortable.
Resource: Psychoeducation sessions about stress reactions and coping were provided to participants. Reaction: This helped to promote self-efficacy, normalise reactions, and support emotional expression.
Outcome: The outcome is basic psychological needs are met, individuals are better able to cope on their own and prevent the escalation of distress. [1] Context: In the aftermath of a natural disaster in a low-resource, collectivist country, GPFA was provided in a safe location where participants felt comfortable. Reaction: This helps to provide a sense of safety, which can Outcome: help to prevent the escalation of distress over time through reducing secondary stressors.

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Context: Following a natural disaster in a low-resource, low-income, collectivist society, individuals experience varying levels of stress, anxiety, and require different levels of support. When GPFA is provided in a safe location, away from the disaster area, where participants feel comfortable, Resource: and provides information, psychoeducation, social, emotional, and psychological support in a group format, Reaction: individuals feel an increased sense of safety and control over their situation, which can increase emotional expression. Outcome: The outcome can be the stabilisation of emotionally distressed survivors, reducing secondary stressors, and preventing distress escalation. [2] Context: Volunteers in humanitarian crises tend to prioritise others before themselves, and do not take time for self-care. Volunteers are often affected differently and require different levels of support. When PFA/GPFA is provided, and it Resource: provides coping strategies that can be used every day, and links to ongoing support and resources for individuals, Reaction: individuals may be better able to express their emotions and needs to those who are going through similar experiences. Outcome: The outcome can be the prevention of distress escalation and reduced secondary stressors.

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Context: Following a sudden, violent event like a school shooting in a high resource country, people are affected differently [10] Resource: Group discussion provides practical information and support, assure safety, and provide psychoeducation about natural stress responses. Reaction: Increases sense of safety and emotional expression Outcome: Facilitates recovery from trauma, and prevents escalation of distress CMOCs feeding into Programme Theory 3 Source Context: When people experience a similar traumatic event like a natural disaster, and GPFA is implemented early, Resource: this can provide a space for activities and for people to express their emotions. Reaction: Sharing is normalised, and survivors are more receptive about sharing their emotions. Outcome: This can improve uptake and acceptability of GPFA. [5] Context: During an epidemic in a low-resource setting where mental health may sometimes be stigmatised, aid workers are affected differently and may require different levels of psychological support. When GPFA is provided, Resource: it should facilitate service referrals and supports so that Reaction: accessing services becomes normalised and accessible. Outcome: Individuals will then be able to access the full psychological support that they need and that is right for them. [6] Context: In a humanitarian/refugee crisis in a low health resource country, people are often affected differently and require different levels of supports. Resource: PFA should be provided by facilitators that are trained to work with various populations and age groups. Outcome: This ensures that individuals are referred to and access additional services and care that is right for them and their current needs. [12] Context: Following a natural disaster in a high-resource country, basic resource needs may be disrupted, and people may be displaced. Individuals are affected differently and need different levels of support. When an existing support/resource system is already in place, PFA should be integrated and linked into that system. Resource: Facilitators should be able to assess and identify needs, so that Reaction: individuals can be referred to and access additional services and care that is right for them. Outcome: This can reduce secondary stressors, which may help to restore some sense of normalcy/dignity to individuals. [11] Context: Following a natural disaster in a high-resource country, resources may be disrupted and some individuals may be displaced. When evacuees arrive to an unfamiliar place, they may face secondary stressors like finding a job, transportation, identification documents, etc. If there is an existing support/resource system in place, GPFA should be linked into that system. Resource: Integration of psychosocial care with other resource services Reaction: makes psychosocial support and psychoeducation more accessible. Outcome: This can help to reduce secondary stressors while building a social support system. This can help individuals cope and prevent the escalation of distress. [11] Context: Following a natural disaster in a low-resource, collectivist country, people are affected differently and need different levels of support. Resource: Skilled facilitators gauge the levels of stress reactions among participants and identify those having more severe trauma reactions or symptoms. Those with significant symptom levels are grouped together and led by experienced counsellors. Reaction: This ensure individuals receive the level of care and support that is right for them. Outcome: The outcome is reduced secondary trauma to those around them, and respect for the individual's dignity and needs. [1] Context: Following a natural disaster in a low-resource, collectivist country, individuals are affected differently, have different responses, and may need different levels of support. Resource: When GPFA is provided, it creates an open space for members to share challenges, solutions, emotions, coping strategies, and resources. Reaction: Individuals learn ideas from others and problem-solve together, and unmet or unrealised needs may be identified. Outcome: The outcome can be reduced secondary stressors, and individuals are better able to cope on their own.

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Context: Pandemics affect individuals differently, and individuals may need different levels of support. When GPFA is safely provided to refugees in camps, Resource: service and resource connections can be made for those who need more specialised care. Reaction: This means that individuals are referred to and access level of care right for them and their current needs. Outcome: The outcome can be that individuals are better able to cope on their own.

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Context: Following a natural disaster in a low-resource, collectivist country, people react differently and require different levels of support. When PFA is provided Resource: and linked into the available services for those with more acute needs, Outcome: individuals can be referred to and access additional services and the level of care right for them and their current needs. [5] Context: Following multiple natural disasters in a high-resource country, people have faced different levels of exposure, and are affected differently and require different levels of support. When PFA is Resource: provided by skilled facilitators able to gauge an individual's stress levels, Reaction: high risk survivors can be identified and referred to more specialised care. Outcome: The outcome is that individuals receive the level of care that is appropriate for them. [8] Context: Staff who witness trauma in a high-resource country are affected differently, in part due to their age or prior experiences, and may need different levels of support. When psychosocial support is provided Resource: with members who have previous experience coping with trauma, Reaction: individuals can reflect on how they previously coped, and what worked and didn't work for them. This can be shared with other individuals experiencing trauma for the first time. Outcome: Individuals are better able to prevent the escalation of distress and cope on their own.
Resource: workers feel comfortable sharing and get the opportunity to discuss their experiences and fears with others going through the same event.
Reaction: Participants have their feelings validated by others, and get the opportunity to express and share, Outcome: which can lead to decrease feelings of isolation and distress.
Context: When people experience a similar, sudden traumatic event like a school shooting in a high resource country, and GPFA is provided to a heterogeneous group made up of different ages gender or life experiences working at the same or similar levels, who already know each other, Resource: and are led by two trained facilitators, Reaction: individuals with acute needs can be linked and referred to further services. Outcome: This can reduce secondary trauma and ensure individuals receive the level of care that is right for them. [10] Context: In a humanitarian or refugee crisis in a low health resource country, people are often affected differently and require different levels of support. Resource: When GPFA is provided by facilitators that are trained to work with various populations and age groups, and linked into a layered system of complementary supports, Outcome: Individuals can be referred to and access additional services and access a level of care that is right for them in their current needs. [12] Context: Following a natural disaster in a high resource country, when basic resource needs may have been disrupted and people may be displaced, individuals are affected differently in required different levels of support. When there is an existing support/resource system in place, Resource: and GPFA is integrated and linked into that system, and facilitators can identify and assess needs on arrival, Reaction: individuals can be referred to and access additional services and care that is right for them. Outcome: The outcome is that secondary stressors are reduced, restoring a sense of normalcy/dignity to individuals. [11] Context: Following a natural disaster in a low-resource, collectivist country, people are affected differently and require different levels of support. Resource: When GPFA is provided by skilled facilitators who can gauge levels of stress reactions and identify those who are having more severe trauma reactions or symptoms, Reaction: this means individuals can receive a level of care that is right for them and their current needs and can be referred to the appropriate resources and services for them. Outcome: The outcome is introduced secondary trauma to those around them as well as respecting their dignity/ individual needs. [1] Context: Pandemics effect people differently and people will require different levels of support. Resource: When GPFA is provided to refugees in camps by other community members that have been trained in PFA, at a safe distance, Reaction: Individuals can be referred to and access additional services and care that is right for them and their current needs. Outcome: The outcome can be reduced secondary stressors, and prevention of distress escalation. [3] Context: Following a sudden, violent event (like a school shooting) in a high-resource country, with strong mental health support systems, people are often affected differently and require different levels of support. Resource: when group PFA is provided by two facilitators per group, and links to further support, the second facilitator can monitor reactions of members, and take members aside who need further assistance. Outcome: This means that individuals can be referred to and access additional services and access a level of care that is right for them and their current needs. This also helps to prevent members from being exposed to secondary trauma. [10] Context: Following multiple natural disasters in a high resource country, people have faced different levels of exposure and are often affected differently and require different levels of support. Resource: When GPFA is provided by skilled facilitators who can gauge individuals' levels of distress following the event, Reaction: groups can be sorted based on levels of distress and individuals with acute or severe reactions can be referred to more specialised care. Outcome: This means that individuals can be referred to and access additional services and access a level of care that is appropriate for them and their current needs. This also helps to prevent others from being exposed to secondary trauma. [8]