Needs and Challenges of Developing an Integrated Mental Health Prevention Program for Institutionalized Children and Their Parents in Azerbaijan: Results of Formative Work

Background: The countries of the former Soviet Union (fSU) and Eastern Europe have the highest number of children in institutional care worldwide--up to 1.3 million children. Due to the economic crisis following the collapse of the Soviet Union, Azerbaijan hosts an exploding population of ‘social orphans’, children left by destitute parents in publicly-run orphanages. Although orphanages provide food, clothing, and education to children, separation from parents, high staff-to-child ratio and neglect and abuse in orphanages severely heighten the risk of mental health problems among institutionalized children. Current de-institutionalization reforms in the region are aimed at promoting family-based alternatives to institutional care. However, traditional de-institutionalization programs provide basic case management services and 1) do not address mental health problems among institutionalized children and 2) do not attend to the poverty-related factors that cause social orphanhood in the first place. Evidence-based culturally-tailored mental health preventive interventions for this population are absent in post-Soviet countries. The purpose of this qualitative study was to explore mental health needs of institutionalized children and their parents and identify the potential motivators and barriers to a mental health preventive intervention feasible in a low-resource country with limited mental health resources.

METHODS:Between 2015-2016, the team conducted a) 18 key informant interviews with professionals providing care to children and families (e.g., orphanage staff, case workers, mental health professionals, and social welfare specialists) and b) 47 semi-structured in-depth interviews with children and parents involved in the institutional care system (currently living in an orphanage or recently reunited with their family). The interviews collected narratives on experiences of living in an institution, children’s and parents’ experiences, difficulties and obstacles to readjustment following deinstitutionalization, and motivation and potential obstacles for family reunification. Interviews were conducted in Azerbaijani language, transcribed verbatim, translated into English and coded thematically in both languages using Dedoose software.

Findings: Children and parents provided rich narratives on the mental health effects of institutionalization as well as problems associated with transition from an institutional care into a family environment. The quality of child-parent relationships was severely affected by the strong sense of abandonment and broken trust reported by children. Children’s behavioral and emotional problems were manifested in withdrawn and socially distant behavior or in overtly aggressive behavior toward family members, including younger siblings. The majority of caregivers were single mothers who were overwhelmed by the feeling of guilt and a sense of powerlessness. Due to their poverty level, mothers were often faced with no other option, but to place their child in an institution, particularly in a predominantly Muslim society with limited employment or income generating opportunities for divorced or widowed mothers.

Conclusions: This formative phase will guide the development of a mental health intervention for institutionalized children reintegrating back in society. Children’s and parents’ reactions and suggestions will inform the development and cultural adaptation of the core intervention components and delivery methods. The study shows the importance of integrating mental health intervention with family-based economic empowerment strategies to promote family stability and improve psychosocial well-being of institutionalized children.