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Children in low-resource contexts are particularly vulnerable to trauma from adverse childhood events including abuse, famine, community violence, and political conflict. In Zimbabwe, recent crises including Cyclone Idai and the COVID-19 pandemic which destabilized social protection systems (Sharma et al., 2021; UNICEF Zimbabwe, 2023) have exacerbated these risks for youth. Although the Zimbabwean government has made efforts to strengthen mental health services, two critical gaps remain (Mangezi & Chibanda, 2010; UNICEF Zimbabwe, 2022): (1) Lack of culturally-responsive youth interventions tailored for low-resource settings, and (2) Severe shortage of mental health providers needed to deliver such interventions. Singing to the Lions (STL; Brakarsh et al., 2022), a locally developed and culturally tailored biopsychosocial intervention, was created to build resilience among trauma-affected children and adolescents. The intervention is comprised of six interactive modules incorporating culturally tailored elements of cognitive behavioral therapy and narrative therapy through facilitator-guided activities including music, drawing, storytelling, movement, visualization, and group discussion. Workshops are delivered by lay professionals who receive in-depth training prior to facilitation and supervision throughout implementation. This mixed-method cluster RCT evaluated the effectiveness of Singing to the Lions for building resilience among vulnerable Zimbabwean youth.
Methods
This cluster randomized waitlist-controlled trial represents the first formal evaluation of the STL intervention, assessing its impact on resilience outcomes among youth in Zimbabwe. Adolescents were randomized by school (n=13) to the immediate intervention arm or waitlist control arm. Demographics and trauma symptoms were assessed at baseline, the latter with the Zambia-validated symptom subscale (Murray et al., 2011) of the UCLA PTSD-RI (Steinberg et al., 2004). Outcome measures were assessed at baseline, post-test, and 3-month follow-up; these included the Rosenberg Self-Esteem Scale, Child Version (CRSES; Wood et al., 2021), Self-Efficacy Questionnaire for Children (SEQ-C; Muris, 2001), Children's Hope Scale (Snyder et al., 1997), and locally-created measures of social support and self-calming (Brakarsh, 2017). Linear mixed models were used to examine changes in target outcomes over time for each outcome variables.
Results
The sample (n=1,285) ranged in age from 11-18 years (=14.9); the majority of children were girls (54.9%) and rural (52.4%). At baseline, youth endorsed an average of 7.6 symptoms (SD=4.5; out of 18 possible) with significantly higher rates among girls (t[1325]=3.39, p=.0007). After adjusting for baseline trauma levels, intervention participants demonstrated significantly greater increases over time in self-calming (β=1.74, SE=0.26, p<0.0001), self-efficacy (β=1.65, SE=0.34, p<0.0001), self-esteem (β=1.18, SE=0.34, p=0.0006), social support (β=1.26, SE=0.19 , p<0.0001), and hope (β=1.36, SE=0.18, p<0.0001). Differences between treatment groups were sustained at the 3-month follow-up assessment for self-efficacy, self-esteem, and social support, but not for self-calming or hope. Analyses revealed no significant differences in intervention impact based on participants’ gender, age, or community. Qualitative data supported these findings and offered additional insights into intervention impact.
Conclusion
Singing to the Lions offers a promising short-term intervention for trauma-affected and other vulnerable youth in Zimbabwean communities lacking formal mental health services. Results support potential scale-up of this locally-created, community-driven intervention to address adolescent mental health in other low-resource contexts in the Global South.