Multi-Level Culturally Adapted Mental Health Prevention Strategies for De-Institutionalized Children in Azerbaijan: Evidence from a Factorial Clinical Trial

Background and Purpose: About 2.7 million children reside in institutional care, with post-Soviet and Eastern European countries having the highest rates of institutionalization, surpassing the global average by more than fivefold. Deprivation, family separation, and maltreatment in institutions put these children at elevated risk for mental health issues. Given ongoing deinstitutionalization reforms in these regions, it is critically important to address the impact of institutionalization on mental health as these children transition to family care. This study assesses the prevalence and correlates of mental health among deinstitutionalized children in Azerbaijan, as well as preliminary intervention effects of culturally adapted multi-level interventions.

Methods: To prevent mental health problems among 7-12 children (N=434) transitioning from residential institutions to their families (N=304) in Azerbaijan, this NIH-funded clinical trial (ClinicalTrials.gov: NCT05396625) is testing three interventions: family strengthening (adapted from SAFE, an existing EBP in the US), asset-based economic empowerment intervention in the form of Financial Education with Matched Child Savings accounts (an adapted intervention from Uganda), and trauma-focused mental health services, guided by the Attachment, Regulation, and Competency (ARC) model. All three interventions have been adapted to incorporate local practices and cultures into their intervention components. To determine the most optimal intervention combination (e.g., economic intervention together with family strengthening), the trial employs the cutting-edge Multiphase Optimization Strategy (MOST) and uses a fractional factorial design with eight experimental conditions (2³=8). Baseline and 1-year follow-up assessments were conducted with children, caregivers, and teachers. Clinicians rated the mental health of children assigned to the mental health condition.

Results: About 51.88% of deinstitutionalized children exhibited above the clinical cut-off scores for child-reported depression, 36.45% for child-reported PTSD symptoms and 36.78% for parent-reported ADHD symptoms. Almost half (44.45%) were classified as high-risk on parent-reported SDQ emotional and conduct problems. Single-parent households and low caregiver SES (less than a high-school education, unemployment) were associated with poorer child mental health outcomes. Following the mental health intervention, children demonstrated a significant reduction in clinician-rated HoNOSCA score (Cohen’s d=3.4, p<.001) as well as child-reported CES-DC depression score among girls (Cohen’s d=1.78, p<.05) and CRIES-8 trauma score among boys (Cohen’s d=1.36, p<.05). For the family strengthening intervention, large effect sizes were observed for reductions in children’s emotional and behavioral difficulties reported by parents (SDQ emotional problems Cohen’s d=0.87, conduct problems d=0.75, hyperactivity d=0.77, and peer relations d=0.65). In addition, the combination of family strengthening and economic intervention reduced the symptoms of child-reported depression (Cohen’s d=0.6, p < .05) at one year follow-up.

Conclusions and Implications: The high prevalence of mental health issues among deinstitutionalized children as they transition back to family care in the wake of deinstitutionalization reforms highlights the imperative to introduce targeted early-age mental health preventive interventions, particularly for those from socially and economically vulnerable backgrounds. Programs that integrate family-strengthening, poverty-alleviation, and trauma-focused approaches with cultural adaptation hold great potential for enhancing mental health in low resource settings and across multiple levels of intervention. This study sheds light on both culturally sensitive mental health practices and context-specific implementation strategies.