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Content Understanding the Needs of Primary School Teachers Operating in International Crisis Response
in the Democratic Republic of the Congo and Ethiopia: Supporting Trauma-Informed,
Emergency Mental Health Services for Children in Conflict and War Zones
by
Julian Thomas Francis Sesma
A Dissertation Proposal Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
August 2024
Copyright 2024 Julian Thomas Francis Sesma

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Abstract
Conflict-impacted countries are home to more than two-thirds of the global child population,
about 1.6 billion children. In low- and middle-income countries (LMIC), 20% of the population
experience a form of mental disorder, and 90% of the population with mental health conditions
receive no treatment. In light of weak or strained mental health infrastructures during
humanitarian crises, NGOs may be ideally positioned to help reduce the wide mental health
treatment gap by providing mental health and psychosocial support. Teachers' perceptions of
their experiences supporting students in conflict and war zones helps provide vital information
about the context, nature, and impact of traumatic and adverse childhood events in school
communities that may inform catered school-based mental health services. Therefore, this study
explored the experiences of primary school teachers at NGO-based schools in conflict zones and
post-conflict zones in eastern Democratic Republic of Congo (DRC) and southern Ethiopia to
understand how they define suffering, healing, trauma, and mental health, their perceived
capacity to support the mental health of students, and their identified needs and those of their
students. Perception data for thirteen teachers, seven from DRC in September 2023 and six from
Ethiopia in November 2023, was collected via a semi-structured interview protocol. The key
findings demonstrated that teachers defined conflict as suffering, a suffering that threatens
families and has nuances based on regional context, including death, displacement, ethnic/tribal
conflict, and disruption to education and other basic needs, and healing as meeting basic needs.
Teachers’ capacity was illustrated in the following way: the versatility of the teacher role in
conflict zones, teacher awareness of their own needs and their students' needs, training to support
teacher capacity in mental health, and the importance of organization leadership. In particular,

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teachers serve critical functions as frontline service providers that preserve, nurture, stabilize
students’ lives and mental health to the measure that their presence is available to students in
conflict and war zones. Still, teachers indicated the need for training to support their limited
capacity to address the sequelae of trauma and mental health concerns. This study stresses the
importance of prioritizing the integration of school-mental health programs and practices in
conflict and post-conflict schools in LMICs, and leveraging the strategic role, access, and
expertise of teachers by building their student mental health support capacity to respond to
humanitarian crises.
Keywords: Conflict, war zone, complex emergency, mental health, refugee, internally displaced
persons (IDP), trauma, suffering, healing, school-based mental health, mental health and
psychosocial support (MHPSS), trauma theory, adverse childhood experiences (ACE), traumainformed care (TIC), culturally appropriate, trauma-informed support (CA-TIS), Democratic
Republic of Congo (DRC), Ethiopia

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Dedication
This dissertation and doctoral degree are dedicated to my Lord and Savior Jesus Christ. I
am so grateful to God for His support throughout my life, for giving me my mom and family, for
my greater, global family of faith that I have had a great joy to know and experience, for the
opportunity to attain a quality education, for the great privilege of supporting children’s mental
health and wellbeing, and for His pleasure in my being in this program at the University of
Southern California. May God receive all the glory, honor, power, and praise, now and forever.
“For I am the Lord your God who takes hold of your right hand and says to you, Do not
fear; I will help you.”
Isaiah 41:13 (New International Version [NIV], 2011)

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Acknowledgements
I would like to thank my mom, Blanca Rosa Sesma, for her life example, her love, and
her constant encouragement and prayer throughout my journey to an Ed.D. She is the hardest
working person I know, and her faith, love, and support has been one of the greatest blessings of
my life. Thank you, mama. I love you.
I am truly grateful to Dr. Cathy Sloane Krop, my dissertation committee chair, along with
my committee members, Dr. Ruth Chung and Dr. Mary Anna Noveck. Their commitment to my
journey at USC and my dissertation process has been a tremendous help and learning experience.
I am especially grateful to Dr. Krop for her kindness, care, and guided support, which gave me
the encouragement, motivation, and strength I needed to continue fighting on. I will never forget
your kindness and help, and may God repay you many times for all that you have done for me.
I would like to thank Dr. Mark Robison, the creator and Chair of the Rossier Global
Executive Ed.D. Program at the University of Southern California. His vision, perspective, and
commitment to education was both incredible and inspiring. The process would not have been
the same without the organization and direction of Dr. Sabrina Chong and all the hard work of
her team, who valued timeliness at every step and term. I am also very appreciative of all the
faculty members at Rossier who have been involved in the design and development of the
program. I am humbled to walk into rooms with such giants in their fields. Your passion and
work have inspired me in so many ways.
I would also like to thank Cassandra Lee, Co-Founder and Executive Director of Justice
Rising and Dr. Seid Aman, Country Director of Imagine1day for their cooperation, collaboration,

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and investment in my research. Thank you for opening doors of opportunity in support of a
future where war zones will be transformed with education and school-based mental health.
To my Cohort 11 family, you are an incredible group of overcomers, professionals, and
kind individuals with big dreams and roles in big places. I am humbled to know you and to have
walked with you in this journey, and so grateful for all that you have taught me and done for me.
May God bless you, keep you and cause His face to shine upon you in all that your hearts pursue.
I want to thank Pastor Jim Heidrick and his wife Maria Heidrick for their attentive care in
and beyond this program. Your love, wisdom, and commitment have been a great blessing to me
and many others. This gratitude is also for all my family of faith and friends that have
contributed to my journey through their prayers, prophecy, and support, and to all my educators
and teachers that have instilled in me a love for learning, exploring, and asking questions.

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Table of Contents
Abstract…….……………………………………………………………………………..……….2
Dedication………………………………………………………………………………………....4
Acknowledgements………………………………………………………………………….….…5
Table of Contexts……………………………………………………………………………….....7
List of Tables ….…………………………………………………………………….…….…......11
List of Figures……………………………………………………………………………………12
Chapter One: Introduction………………………………………………………………………..13
Background of the Problem………………………………………………………………14
Statement of the Problem………………………………………………………………...19
Purpose of the Study and Research Questions……………………………………………20
Significance of the Study…………………………………………………………………21
Theoretical Framework………………………………………………………………......23
Definitions…………………………………………………..……………………….…...25
Conclusion……………………………………………………………………………….27
Chapter Two: Review of the Literature………..…………………………………………………28
The Impact of Childhood Trauma and Adverse Childhood Experiences (ACEs).............28
The Psychological Burden of Conflict and War for Children……………………30
Cultural Considerations of Trauma for Children in Conflict and War Zones…....35
Trauma-Informed Care (TIC) and Culturally Appropriate,
Trauma-Informed Support (CA-TIS).........................................................38

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Context of Childhood Trauma in the Democratic Republic of Congo and
Ethiopia…………………………………………………………………………..40
Mobilizing Emergency Mental Health Response in Conflict and War Zones…………....43
The Evolution of Emergency MH Response in Conflict and War Zones…….….44
Challenges in Mobilizing Mental Health Response for Children in Conflict and War
Zones ……………………………………………………………………………47
Operationalizing Policies & Practices: Mental Health Approaches for Comprehensive
Support of Child Victims of Trauma………….…………………...………………...…..51
Current Applications of Multi-tiered, Multi-level, Trauma-Informed Approaches
for Children………………………………………………………………………54
Psychological First Aid…………………………………………………..58
Schools as Epicenters for Healing………………………………………………………..60
Role of Teachers in Supporting Child Victims of Trauma……………………….62
Conclusion…………………………………………………………………………….....67
Chapter Three: Methods………………………………………………………………………….69
Organization Overview………………………………………………………...…….…..69
Selection Process…….…………………………………………………………………..72
Data Collection and Instrumentation………………………………………….…………73
Interviews……………………………………………………………...…………73
Data Analysis……………………………………………………………….……………78
Credibility and Trustworthiness…………………………………………….……………79
Ethics……………………………………………………………………………………..80

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Role of the Researcher…………………………………………………………………....82
Chapter Four: Findings…………………………………………………………………………...86
Overview of Participants…………………………………………………………………86
Presentation of Findings………………………………………………………………….89
Research Question 1: How Do Teachers Operating in Conflict and Post-Conflict
Zones Define The Experiences of Suffering and Healing As It Relates To Their
Students?................................................................................................................91
Finding 1: “Conflict is Suffering”………….…………………………….92
Conflict Threatens Families………….…………………………..93
Suffering Has Nuances Based on Regional Context……………..95
Finding 2: Healing is Basic Needs Being Met………….………………..99
Summary of Findings for Research Question One………..…………….106
Research Question 2: How Do Teachers Operating in Conflict and Post-Conflict
Zones Perceive Their Capacity To Support The Mental Health Of Students
Impacted By Conflict and War?...........................................................................107
Finding 1: Versatility of the Teacher Role in Conflict Zones……...........108
Finding 2: Teacher Awareness of Needs: Their Students and Their Own.113
Finding 3: Training to Support Teacher Capacity in Mental Health……117
Finding 4: The Importance of Organization Leadership……………..…121
Summary of Findings for Research Question Two………..…………….124
Conclusion……………………………………………………….…………………..…126
Chapter Five: Discussion and Recommendations for Practice………………………………....128

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Discussion of Findings………………………..……………………………...…………129
Research Question 1 Discussion of Findings……………………………...……130
Research Question 2 Discussion of Findings………………………...…………133
Recommendations for Practice………………………………………….……...…….…138
Recommendation #1 - Participatory Process to Create a School-Based Mental
Health Program ………………………………………………………….……...140
Recommendation #2 - Build Capacity to Mitigate Stress Response in the School
Community ……………………………………….……………………………145
Recommendation #3 - Teacher/Leadership Training on Meeting the Mental Health
Needs of Students ………………………………………………...…………….149
Recommendation #4 - Elevating Stories of Students and Teacher from the
Conflict Zone Perspective…………………………………….………..………153
Limitations and Delimitations………………………………………………..…………155
Recommendations for Future Research…………………………………………...……157
Conclusion...……………………………………………………………………………159
“Not Losing Hope When Things Feel Hopeless”................................................162
References………………………………………………………………………………………164
Appendices…………………………………………………………………………………..….197
Appendix A: University of Southern California Information Sheet………………....…197
Appendix B: Formal Interview Protocol - Teacher Interview Guide…………………..200
Appendix C: Informal Interview Protocol - Local Leadership Guide………………….202
Appendix D: Post-Interview Participant Demographic Survey………………...………203

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List of Tables
Table 1: Sample of Mental Health and Psychosocial Interventions on Behalf of War-Affected
Children……………………………………………………………………………………….….57
Table 2: Demographic Information of Thirteen Teacher Participants in the Democratic Republic
of the Congo and Ethiopia…………………………………………………………...……….….87
Table 3: Summary of Key Findings…………………………………….…………….……....….90
Table 4: Teacher Descriptions of Healing for Students in Conflict and War Zones……….......101
Table 5: Ways Teachers Cultivate Safety and Trust for Students in Conflict and War Zones…109
Table 6: Teaching Strategies for Promoting Student Learning in Classrooms in Conflict and War
Zones…………………………………………………………………….…………...…….…...112
Table 7: Teacher Training Received by Region, Source and Description/Type………....….…118
Table 8: Organization Leadership Support Provided to Teachers in Conflict and War Zones...122
Table 9: Key Findings and Recommendations………….……………………...…………...….138

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List of Figures
Figure 1: Maslow’s Hierarchy of Needs and Multilevel Intervention Pyramid for MHPSS in
Emergencies……………………………………………………………………………………...52

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CHAPTER 1: INTRODUCTION
“Defend the weak and the fatherless; uphold the cause of the poor and the oppressed.”
Psalm 82:3 (NIV, 2011)
A quality education is universally considered a fundamental human right for children
because of the pivotal role it plays in their development and formation. Educational systems
utilize the resources within their reach to attempt to provide a comprehensive service experience
to support children with diverse life and learning needs. A right to an education is, however, not
guaranteed to all children, especially in impoverished areas and regions of armed conflict, where
a higher likelihood exists for experiencing severe poverty and exclusion from primary school
enrollment (United Nations Children’s Fund [UNICEF], n.d.). As of 2017, around 27 million
students were not in school in conflict zones (UNICEF, 2023b). According to the United Nations
Educational, Scientific, and Cultural Organization (UNESCO) Global Education Monitoring
Report (GEM) in 2021, 244 million children (ages six-18) were out of school (Antoninis &
Montoya, 2022). Efforts to mitigate inequitable access to a high-quality education for all
continues to be both a matter of current debate, and a distant dream for many.
A public health domain that is growing in attention, especially in light of the negative
outcomes evident during and following the COVID-19 pandemic and the ongoing concerns
revealed in past, current, and imminent zones of conflict and war, is mental health, including
related supports for children in schools. The World Health Organization (2022) asserts that the
right to mental health is an inherent human right for all individuals. It is critical that attention be
given to understanding how various childhood adversities impact young learners in global
settings, including the role and outcome of trauma, and a bridge be established to connect
catered, school-based, mental health systems of support to the urgent needs of children and those

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that serve them, especially in conflict and war zones. Significant is the role that teachers play in
supporting the mental health of students in their schools, especially in regions with high
volatility and weak mental health infrastructure. Investigating the unique and crucial role that
teachers hold shed light on mental health service delivery pathways and access gaps and needs.
This study sought to understand the experiences of primary school teachers at non-governmental
organization (NGO)-based schools in conflict and post-conflict zones, their meaning making of
suffering, healing, trauma, and mental health, their perceived capacity to support student mental
health, and their identified needs and those of their students.
Background of the Problem
Important implications exist for the historical, social, and economic instability and
violence present in conflict and war zones and impoverished contexts, including that
communities located in such regions not only experience prolonged and frequent incidence of
stress and trauma due to home and community-level adversities, but that Adverse Childhood
Experiences (ACEs) “make their own specific contribution to the developmental trajectory of
individuals growing up in such environments” (Anda et al., 2010, p.95). Opaas and Varvin
(2015) found stronger relationships between childhood adversity and traumatic experiences with
mental health and quality of life than the experiences of war and human rights violations in 54
adult refugee patients, highlighting a predisposition of children to later stress, mental health
symptomatology, and reduced quality of life, and the importance of considering childhood
trauma when supporting affected individuals. It is well understood that having supportive and
responsive adults can serve as a preventative measure for children with ACEs (CDC, 2021;
David-Ferdon et al., 2016; Kaufman & Weder, 2010), by buffering the effects of toxic stress and

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its lasting harm on a child (Center on the Developing Child at Harvard University, 2020).
Teachers operate in the educational sphere of providing responsive and nurturing support to
students by fostering a positive classroom climate and culture where students feel safe, accepted,
and loved. Other preventive and mitigating pathways (Merrick et al., 2019), such as traumainformed intervention (Center on the Developing Child at Harvard University, 2020; Child
Welfare Information Gateway, 2022), may be identified to lessen the negative and lifelong health
outcomes of childhood adversity and trauma.
The United Nations (2009) estimated that over one billion children were affected by
armed conflict, with 300 million of them between the ages of zero-five years old. By 2022,
conflict-impacted countries were home to more than two-thirds of the global child population,
where 468 million children or 1 in 6 lived in conflict zones and approximately 96 million
children resided in high severity areas within 31 miles from an active combat zone (Ostby et al.,
2023).
According to 2013 United Nations reports, the Syrian conflict has led to over one million
Syrian children displaced to refugee camps (Nebehay, 2013). As of 2023, close to seven million
children in Syria required humanitarian support, and almost 2.5 million children were out of
school within the country (UNICEF, 2023a). In Cartwright et al. (2015), a parent-report
questionnaire completed by 144 refugee parents revealed the following mental health needs of
refugee children attending a primary school at a NGO: 49% of children had clinically significant
anxiety and withdrawal and approximately 62% had symptoms of fear. Jayuphan et al. (2020)
studied the effect of direct and indirect exposure to violent conflict in students born and raised in
southern Thailand conflict zones. The school-based, self-report questionnaire administered and

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completed by 941 students in the sixth year of school showed that at least one behavioralemotional problem was found in 42.1% of students, 30.5% had post-traumatic stress disorder
(PTSD), and the 44.6% that were directly exposed had a two times higher risk of future mental
health problems. Refugee children living in camps most notably suffer from higher prevalence of
PTSD and depression than children not living in camps (Khamis, 2005). In the Bahcesehir Study
of Syrian Refugee Children in Turkey, of the 301 students who had spent six months in the
Islahiye refugee camp, mental health problems associated with war reduced functioning, with
60% having depressive symptoms, 45% living with PTSD, 22% demonstrating aggressive
behavior, and 65% having psychosomatic symptoms (Ozer et al., 2016). These findings
demonstrate that direct and indirect exposure to traumatic events can impact a child’s mental
health and lead to psychiatric and behavioral and emotional concerns, including PTSD (Dimitry,
2012; Javidi & Yadollahie, 2012; Panyayong & Juntalasena, 2009; Phothisat, 2012; Prasad &
Prasad, 2009), and the increased risk of health and mental health problems among children in
regions of prolonged conflict (Burgin et al., 2022).
The Democratic Republic of Congo, specifically, has experienced centuries of European
colonial slave trade, and decades of armed conflict through national and international actors
since its independence from Belgium in June 1960 (Human Rights Watch [HRW], 2020). A
thirty-two year presidential rule ensued, and the Rwandan Genocide in April 1994 led to the First
and Second Congo wars between 1996-2003 (HRW 2020), of which seven countries participated
in the Great War of Africa (Uppsala University, 2023-a), marked by ongoing decline in
relationships between formerly named Zaire and Rwanda over Hutu and Tutsi ethnic and militant
conflict and violence (Council on Foreign Relations [CFR], 2024). Over the last three decades,

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ethnic and militant emergence and violence has continued, along with the formation of one of the
most notable armed groups, March 23 Movement (M23) in 2012, with its reemergence in the
2020s, backed by Rwanda and Uganda in efforts to further destabilize the Congolese government
(Uppsala University, 2023-a). Over six million deaths have occurred since the DRC conflict
began in 1996 (CFR, 2024).
Over 120 armed militant groups were active in DRC as of May 2024, with human rights
violations and war crimes also perpetuated by government forces and local police (Global Centre
for the Responsibility to Protect [GCR2P], 2024). As of October 2023, security had worsened
and fighting had expanded due to confrontations between M23 and DRC’s armed government
forces (FARDC) (GCR2P, 2024). Foreign relations with Rwanda, Burundi, and Uganda are
weak, and ongoing violence, poverty and the armed contestations for economic power over
mining and natural resources perpetuate displacement (CFR, 2024), including limited shelter,
agricultural recuperation, infrastructure, and development partnerships (U.S. Department of
State, 2022). In 2023, almost four million people had been displaced due to conflict and violence
totaling to 6.7 million internally displaced by the end of 2023, 10.5 million internal
displacements between 2021-2023, with 1.4 million people displaced due to 81 disaster-related
events, mostly caused by volcanic activity and flooding (Internal Displacement Monitoring
Centre [IMDC], 2024-a). Over 23 million people had been projected to be food insecure between
January-June 2024, and about one million Congolese citizens were displaced refugees in foreign
countries (United Nations World Food Programme [UNWFP], n.d; United States Agency for
International Development [USAID], 2024-a). As of February 2024, the North Kivu Province,

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with Goma as its largest city and capital, held 1.7 million internally displaced persons (USAID,
2024-a).
Ethiopia, another context of displacement and war, has experienced centuries of war and
conflict, including European occupation, that has culminated into historical altercations over
“national belonging” (Markakis, 2011, as cited in Matshanda, 2022, p.1283). The Tigray War of
2020-2022 marked a period of human rights violations, war crimes, crimes against humanity,
including ethnic cleansing, following growing decline in intra-communal relations and power
struggles and escalations between major actors, including the Tigrayan People’s Liberation Front
(TPLFs), the Ethiopian National Defense Forces (ENDF), Eritrean Defense Forces (EDF), and
Amhara region forces (CFR, 2023; HRW, 2024; U.S. Department of State, 2023).
Konso Zone, originally from the Southern Nations, Nationalities, and Peoples’ Region
(SNNPR), now the South Ethiopia Regional State as of August 2023, was designated as a 2021
priority region by a multi-sector initial rapid assessment (MIRA) on conflict needs due to
ongoing drought and conflict, which led to the internal displacement of close to 60,000 people
within the zone in host communities (United Nations Office for the Coordination of
Humanitarian Affairs [UNOCHA], 2022). Critical needs identified across all essential services
include, food supplies, emergency shelter and non-food supplies, wash, sanitation, hygiene
(WASH), fodder, medical and nutritional care, education and safety (UNOCHA, 2022). Ethnic
conflict has occurred over power imbalances and territorial and resource disputes as the main
driver of conflict in Ethiopia (Major et al., 2024). This has resulted in close to 37,000 internally
displaced persons in April 2022, over 220 deaths between 2018 and 2023 in the SNNPR, and

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continued violent incidents in March – May 2022 and in 2023 (Ethiopia Peace Observatory
[EPO], 2023).
Violence decreased in Ethiopia from more than 165,000 deaths in 2022 to 2000 in 2023
(Uppsala University, 2023-b). At the same time, in 2023, almost 800,000 had been displaced due
to conflict and violence, totaling 2.9 million internally displaced by the end of 2023, and 8
million internal displacements between 2021-2023, with 1.7 million displaced due to 43 disasterrelated events, mostly caused by drought and flooding (IMDC, 2024-b). As of December 2023,
5.6 million needed assistance due to drought (USAID, 2024-b).
The Democratic Republic of Congo and Ethiopia are classified as conflict-affected
countries on the World Bank Group (WBG) FY24 List of Fragile and Conflict-affected
Situations (FCAS), as heavily indebted poor countries (HIPC) per the 2023 International
Monetary Fund (IMF) and World Bank criteria (International Monetary Fund [IMF], 2023) and
as least developed countries (LDC), low income countries (LIC) in the 2024-2025 flows for the
Organisation for the Economic Co-Operation and Development (OECD) (OECD, n.d.).
Statement of the Problem
In an effort to facilitate more targeted, collaborative and evidence-based efforts in service
of children in conflict and war zones, one important approach is to understand the perceptions of
teachers in their professional roles in order to integrate catered support around the needs they
have identified for themselves, their students, and others within their educational system.
Comprehensive research focusing on teachers’ perspectives on traumatic experiences during
childhood are lacking (Alisic, 2012). Additionally, formal and ongoing professional training on
student trauma is scarce for school staff, which, if implemented, may lead to improved student-

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based supports and student outcomes (Ko et al., 2008; Substance Abuse and Mental Health
Services Administration [SAMHSA], 2014a). A research gap exists evaluating the effectiveness
of school-based, professional development on the service delivery of trauma-informed
approaches (Overstreet & Chafouleas, 2016). Greaves et al. (2021) highlighted the unique
problem of providing psychosocial support for Syrian refugees affected by trauma and within the
surrounding countries who have attempted to provide them with public education and
individualized learning support, stating, “Often native teachers lack the training necessary to help
the children in their care and they lack insight into their lived-experiences” (p. 443). Identifying
teachers’ perceptions around the nature and impact of childhood trauma in their local context,
and their needs towards providing a catered, educational experience with appropriate mental
health supports, is a critical next step towards integrating universal mental health systems of
support within schools in conflict and war zones.
Purpose of the Study and Research Questions
The purpose of this study was to explore and understand the perceptions of primary
school teachers operating in conflict and post-conflict regions in both the Democratic Republic
of the Congo and Ethiopia. Namely, how teachers make meaning of the realities connected to
students affected by conflict and war, their own capacities to support the mental health of
students, and their current self- and student-centered needs within their classroom roles.
The following two research questions guided the research process:
1. How do teachers operating in conflict and post-conflict zones define the experiences of
suffering and healing as it relates to their students?

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2. How do teachers operating in conflict and post-conflict zones perceive their capacity to
support the mental health of students impacted by conflict and war?
Significance of the Study
This study is significant because it gains teacher insight and experiences at NGO-based
schools in a conflict zone in eastern Democratic Republic of Congo and a post-conflict region in
southern Ethiopia. The voices and experiences of primary school teachers, charged with
implementing an academic program for first through third grade students, are critical in attaining
perspectives prior to, during, or after violent events, including perceptions that carry sociocultural nuances and contextual factors specific to the population, region, and history. These
perspectives, while often excluded, may also shed more light on the evolution and impact of
trauma and adversity on students, staff, and greater communities. Additionally, this qualitative
study holds space for an emergent design in hearing the stories of teachers using culturally
appropriate approaches, which may reveal further details about language, communication,
meaning making, and their needs to inform future professional and educational approaches,
interventions, and improved support for students with adverse experiences and trauma.
Gaining pivotal information around teachers’ perception of mental health, trauma,
suffering, and healing will also allow for more comprehensive recommendations and prospective
support for educational systems located in conflict and war zones, including catered support for
victims with trauma and adverse childhood experiences. Between 9-17% of total disease burden
in low-income and middle-income countries (LMIC) are mental health and substance-abuse
related disorders (McDonald, 2021), and upwards of 90% of people with mental health
conditions receive no treatment (Sweetland, et al., 2014). In conflict-impacted communities in

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LMICs, 20% of the population experience a form of mental disorder, and 10% live with a
moderate or severe mental disorder (McDonald, 2021), a rate of 1.5 to 2 times that of the total
population (Charlson et al., 2019).
No comprehensive mental health program exists for supporting the school populations at
the NGO-based schools in DRC and Ethiopia. The implications of addressing mental health
needs may increase the development and aid impact of both NGOs in DRC and Ethiopia.
Understanding culturally derived terms and meanings may also lead to catered, school-based
mental health service delivery at local, national, and international levels, including via culturally
appropriate approaches to supporting the needs of traumatized persons. Additionally, the role of
teachers may be better understood and supported to leverage their role and impact on student
mental health. In the event that government health care infrastructure may be overwhelmed by
conflict, war or other humanitarian crises, NGOs providing mental health and psychosocial
support services may be ideally positioned (Upadhaya et al., 2014) to help reduce the wide
treatment gap (Visalakshi et al., 2022). Meeting the organizational need being investigated is
related to the larger problem of understanding the mental health impact of the complex array of
adversities and trauma specific to both contexts, in light of weak mental health infrastructures
(Mutombo et al., 2024). Therefore, closing the mental health treatment gap may occur in
building the mental health infrastructure. This includes increasing access to mental health
supports, for example, through existing care systems, such as schools, and effectively supporting
vulnerable populations via evidence-based, tiered interventions for children, families, staff, and
greater communities with the hope of averting further suffering and mitigating negative, life-long
health outcomes.

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Theoretical Framework
This study was based upon the theoretical framework of trauma theory, with an emphasis
on Adverse Childhood Experiences (ACEs) and trauma informed care (TIC) via culturally
appropriate, trauma-informed support (CA-TIS). These concepts, further discussed in the
Literature Review in Chapter 2, form the basis for this study’s research questions, interview
protocol, findings and recommendations for practice through engaging the voices of primary
teachers working in conflict and post-conflict regions in both the Democratic Republic of the
Congo and Ethiopia.
Trauma theory is the theoretical framework upon which this study is based and
establishes that stressful or traumatic experiences, including childhood trauma, also occur in
developing countries and demonstrate the profound impact on short- and long-term health and
well-being outcomes (Anda et al., 2010). The theory establishes that the perception and
experience of trauma is person-specific and contingent on individualized dispositions, the type,
degree, and intrinsic properties of those experiences, and on held cultural beliefs, values, and
norms (Hollan, 2013). Thus, the task of “thinking critically about culture” (Ballard-Kang, 2020)
guided the course and approach of this study and was explored through how teachers illuminate
their paradigms, understandings, and experiences around mental health, trauma, suffering, and
healing, and their challenges, needs, and perceived capacities for their educational roles in
supporting childhood trauma in conflict and war settings. Therefore, trauma theory provided the
basis for addressing and analyzing the historical, current, and potential life-long impact of all
traumatic experiences, including adverse childhood trauma, for teachers, students, and the
greater communities in each setting that was investigated. By understanding teachers'

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perceptions through the lens of trauma theory, the role and impact of trauma can be better
understood in the educational context, and cultural, regional, and other contextual categories for
adverse childhood experience can also emerge.
The development of trauma studies in the 1990s originated from Sigmund Freud’s
psychoanalytic conceptualization of traumatic experiences in the 19th and 20th century through
his work with war-affected individuals and those with a history of childhood trauma, such as
abuse (Balaev, 2018). The recognition of post-traumatic stress disorder in the Diagnostic and
Statistical Manual of Mental Disorders third edition (DSM-III) by the American Psychiatric
Association in the 1980s (Balaev, 2018) was influenced by the re-defining work that was
developed around the lived experiences of Holocaust survivors (Bohleber, 2010; Radstone, 2007;
Suleiman, 2008). Herman (1992) first coined the term “trauma theory,” which was characterized
by compromised human adaptive functioning via threatening circumstances, such as violence or
death, that may lead to dissociation, that is, minimal or no conscious recollection of traumatic
memory after repeated or multiple exposures to trauma (Suleiman, 2008) and may be
environmentally influenced. In Herman’s conceptualization of post-traumatic stress disorder
(PTSD), its criteria included an overwhelming event that compromises adaptive functioning with
a sense of helplessness and intense fear present (Herman, 1992). According to Bergmann (1996),
trauma theory shifted from an inability to account for the symptomology and experience of
survivors toward a more fundamental conceptualization of the nature of trauma.
Trauma theory is based on the premise that traumatic experiences can hinder one’s
mental and emotional well-being via the following symptoms: heightened arousal, intrusive
manifestations, and emotional constriction (Huang et al. 2021). Trauma is defined as any

25
event(s) that is physically or psychologically detrimental or threatening with enduring adverse
outcomes on daily functioning and biopsychosocial or spiritual wellness and reflects an
understanding that not all traumatic experiences result in adverse outcomes (SAMHSA, 2014a).
Following the 2013 Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5)
revision, mental health criteria and terminology shifted in the area of traumatic exposure, and, in
the early 2000s more attention was directed towards developing the concept of developmental
trauma and adverse experiences in children. The National Child Traumatic Stress Network
(NCTSN, 2018) defines complex trauma as repeated exposure to persistent and overwhelming
traumatic events that have lasting negative outcomes. A trauma-informed care (TIC) approach
emphasizes knowledge awareness on trauma, including knowledge of ACEs and childhood
trauma in different contexts. This also includes responsive action that meets diverse needs while
creating conditions to prevent retraumatization. Culturally appropriate, trauma-informed support
takes the principles of TIC and adjusts its approach further to inform care and services for
displaced populations with high attention for the role of culture. Trauma theory as a theoretical
framework is important for this study because it integrates a broad conceptual understanding of
the scope and impact of trauma, and a TIC and CA-TIS approach helps to apply a child-centered
approach to understanding trauma from diverse regions, cultural contexts, and conflict and postconflict settings.
Definitions
In the context of this research, the subsequent terms are defined in the following manner:

26
1. Child: “For the purposes of the present Convention, a child means every human being
below the age of eighteen years unless under the law applicable to the child, majority is
attained earlier” (United Nations, 1989).
2. Conflict, armed (armed conflict): According to the Uppsala Conflict Data Program
(UCDP), an armed conflict refers to “a contested incompatibility that concerns
government and/or territory where the use of armed force between two parties, of which
at least one is the government of a state, results in at least 25 battle-related deaths in one
calendar year.” A major armed conflict would involve 1000 or more deaths in battle per
calendar year (Uppsala University, n.d.). The literature reveals that armed conflict is
usually referred to as war (Davis, 2018; Geneva Conventions, 1949; Schwartz & Perry,
1994; Stewart, 2003) and will be thus used concurrently, including to capture broader
conceptualization and perceptions related to each.
3. Mental health: “...is a state of mental well-being that enables people to cope with the
stresses of life, realize their abilities, learn well and work well, and contribute to their
community” (World Health Organization, 2022).
4. Refugee: According to the 1951 Convention Relating to the Status of Refugees, a refugee
is “someone who is unable or unwilling to return to their country of origin owing to a
well-founded fear of being persecuted for reasons of race, religion, nationality,
membership of a particular social group, or political opinion” (UNHCR, n.d.-a).
5. Trauma: an “event, series of events, or set of circumstances that is experienced by an
individual as physically or emotionally harmful or life threatening and that has lasting

27
adverse effects on the individual’s functioning and mental, physical, social, emotional, or
spiritual well-being” (SAMHSA, 2014a, p.7).
Conclusion
This qualitative study sought to gain the insight and experiences of primary school
teachers in the Democratic Republic of the Congo and Ethiopia around their cultural perceptions
of mental health, trauma, suffering, and healing, their capacity to support the mental health of
students, and their needs connected to their professional role and support for students. By
investigating teacher perceptions, the mental health needs of students and staff can be better
identified and understood. This gained understanding can also inform prospective school-based
mental health services that are comprehensive, multi-tiered, and culturally appropriate with the
prospect of taking action to close the mental health gap at both organizations. Chapter One
included a background of the problem, statement of the problem, the purpose and significance of
the study and its research questions, the theoretical framework, and relevant definitions for this
study. Chapter Two provides a literature review on the impact of childhood trauma and adverse
childhood experiences, the psychological burden of conflict and war for children, mobilizing
emergency mental health response in conflict and war zones, and operationalizing policies and
practices through mental health approaches for comprehensive support of child victims of
trauma, and schools as epicenters. Chapter Three provides the qualitative, semi-structured
interview methodology for gaining the perceptions of primary school teachers in the Democratic
Republic of the Congo and Ethiopia. Chapter Four presents the findings of the study, and
Chapter Five discusses the findings, recommendations for practice, limitations and delimitations,
and future recommendations for research and practice in school-based, mental health.

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CHAPTER TWO: REVIEW OF THE LITERATURE
This chapter provides a review of the extant literature for an overview of the impact of
childhood trauma and adverse childhood experiences (ACEs), mobilizing emergency mental
health response in conflict and war zones, operationalizing policies and practices via mental
health approaches for comprehensive support of child victims of trauma, and schools as
epicenters for healing. This research base highlights the needs of children with trauma
backgrounds and informs the role of supportive adults, including teachers, educators, and mental
health practitioners. In addition, there will be a focus on the role of teachers in supporting child
victims of trauma in school settings.
The Impact of Childhood Trauma and Adverse Childhood Experiences
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines
trauma as a single, or collective set of, stress activating occurrence that carries perceived or
actual psychological or physical injury, including potential, life-long adversity (SAMHSA,
2014a). Adverse childhood experiences are defined as “potentially traumatic events that occur in
childhood (0-17 years)...aspects of the child’s environment that can undermine their sense of
safety, stability, and bonding” (Centers for Disease Control and Prevention, n.d., para. 1). The
Center for Disease Control and Kaiser Permanente conducted the Adverse Childhood
Experiences Study to examine the relationship between childhood abuse and family dysfunction
with behaviors associated with health risks and the adult onset of disease (Felitti et al., 1998).
The 17-question survey, completed by approximately 9,500 respondents, highlighted this
iteration’s seven categories of adverse childhood experiences (also known as conventional
ACEs), including: physical, emotional, and sexual abuse, domestic violence, and a household

29
dynamic involving substance abuse, mental illness/suicidality, and imprisonment (Felitti et al.,
1998). The results of the ACE study were as follows: almost 70% of respondents reported one
category of an adverse childhood experience, 25% reported 2 or more categories, and individuals
who reported 4 or more categories, compared with no categories, experienced health risks that
were up to four to 12 times higher for alcohol and drug abuse, depression, and suicidality (Felitti
et al., 1998). The findings of the ACE study established 1) that ACEs were more common than
previously understood, and 2) a direct relationship between childhood trauma and health status in
adulthood, including chronic disease, behavioral health risks, and social and psychological
challenges, and highlighted the overall lasting impact of childhood trauma on health and wellbeing (Fairbank & Fairbank, 2009; Felitti et al., 1998). The demographic makeup of the original
ACE study was characterized by a majority of participants being white, college-educated, and
middle to upper-middle class, and focused on at-home experiences (Cronholm et al., 2015).
The Philadelphia Ace Survey, the first to identify the incidence of conventional ACEs in
lower socioeconomic, urban communities comprised of racially diverse adults, integrated five
community-level adversity categories (also known as expanded categories) evident in urban
settings in their survey design: racial discrimination, witnessing acts of violence, living in an
unsafe community, encountering bullying, and a history of foster care placement (Cronholm et
al., 2015). The survey included approximately 1700 participants and revealed that almost 73% of
participants experienced one conventional ACE category, approximately 63% experience at least
one expanded ACE category, almost 48% experienced between 1-3 conventional ACE
categories, 50% experienced between 1-2 expanded ACE categories, and almost 50%
experienced both a conventional and an expanded ACE category (Cronholm et al., 2015).

30
According to Cronholm et al. (2015), “...data suggest that certain demographic groups may be
more prone to specific adversities than others” (p. 358).
Blodgett and Lanigan (2018) investigated ACE prevalence in Title 1 elementary schools
and discovered at least one ACE category exposure occurring in less than 50% of the student
population, and 13% of students experiencing at least three or more ACE categories.
Additionally, a significant relationship between ACE exposure and free and reduced meal
enrollment (FRM), and overall, a higher prevalence of ACEs existed in schools serving lowsocioeconomic student populations. Thus, the relationship entails that a higher prevalence of
ACE categories is occurring in socioeconomically disadvantaged populations.
The association between trauma and childhood adversity is related to negative school
outcomes, including diminished academic performance, chronic absenteeism and termination of
enrollment, problematic behavior (Blodgett & Lanigan, 2018), psychological concerns, impaired
brain and nervous system states, and poor self-regulation and social skills (Hertel & Johnson,
2013; Mendelson et al., 2015). The immediate and lasting impact of childhood adversity and
trauma is known to affect multiple domains, including scholastic, developmental, physiological,
and psychosocial domains (Alisic, 2012; Crosby, 2015; Fairbank & Fairbank, 2009; McInerney
& McKlindon, n.d.). Despite previous belief, extensive research reveals that children are more
susceptible to trauma, and repeated and ongoing exposure places children at increased risk of
serious physical and psychological issues in their adult years (Felitti et al., 1998; Fairbank &
Fairbank, 2009).
The Psychological Burden of Conflict and War for Children

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An estimated 25% of the global population is impacted by mental health disorders
(Markosian et al., 2021). Children between the ages of 0-14 represent 25% of the global
population (The World Bank, 2022). I visited an internally displaced person refugee camp in
northern Iraq in the summer of 2016. On one particular day, the conditions were difficult to fully
comprehend, marked by 120-degree temperature, a tarp tent city layout with limited space for
larger families, and almost no sign of air conditioning units for most. It was said that the
conditions were very difficult to weather within the camp, which was likened to being in a jail,
where refugees were obligated to surrender their government identification cards or papers
before leaving the camp as a way of ensuring their return. There was a portable classroom
designated as a child-safe space, but no kids were seen at that time of the day. It was especially
hard to imagine the quality of life for children within the camp, and one could only wonder about
the long-term impacts that such a reality would have on their development and joy. After a time
of hearing stories about how individuals and families were affected by their experiences, the
prospect of any sort of a hopeful future seemed very dim.
Regions of conflict and war are characterized by complex, ongoing, and multifactorial
issues that further compound a nation's burden for mental disorders. Research shows that
resident proximity in or near conflict, post-conflict and war-affected regions is associated with
increased susceptibility for mental health disorders, including anxiety, depression, and PTSD (De
Jong et al., 2003; Hoppen & Morina, 2019; Hoppen et al., 2021; Jayasuriya et al., 2016; Karam
et al., 1998; Morina et al., 2020). As of 2015, over 12 million people needed humanitarian relief
support in Syria, for example, where half affected were children, 7.6 million people were
internally displaced and 4 million were displaced to nearby countries (UNHCR, 2015). Internal

32
displacement from the home community and the economic impact of unrest caused by conflict is
associated with higher psychiatric symptoms (Jayuphan et al., 2020). Especially in countries with
poor economic development, unemployment has a negative impact on mental health (Paul &
Moser, 2009, as cited in Markosian et al., 2021). Markosian et al. (2021) underscores the
increased risk for mental health disorders resulting from the unique conditions of a frozen
conflict between Armenia and Azerbaijan (where armed conflict has ceased, but no treaty or
political solution has been reached), namely prior traumatic exposure to conflict, fear of potential
harm to self or close relationships, possible reigniting of conflict, and severe unemployment due
to regional safety concerns. These issues and many more contribute to the overall burden of
conflict and war on a region or country.
According to the World Health Organization (WHO) (2022), an estimated 274 million
people were in need of humanitarian support in 2022, and one in five people in conflict-impacted
regions had a mental disorder (WHO, 2022). By the end of 2022, the United Nations High
Commissioner for Refugees (UNHCR) reported an estimate of about 108 million forcibly
displaced people around the globe, 40% are children less than 18 years old, and 76% of the
displaced persons are hosted in low- and middle-income countries (LMICs) (UNHCR, n.d.-b).
Between 2018 and 2022, around 1.9 million children were born as refugees (UNHCR, n.d.-b).
These numbers prompt urgent care and intervention for children, one of the most vulnerable
population groups to the initial consequences of war, and suggest the need for comprehensive
support, including mental health and psychosocial services, has never been more dire.
In settings of war, variables such as the intensity, duration, and frequency of trauma,
torture of detained persons, and all the realities of life warrant further examination when

33
considering how individuals or communities respond at the onset of trauma exposure
(Almoshmosh, 2016). Almoshmosh (2016) shares a clinical vantage point for understanding
individual variation in traumatic reactions and possible psychological complications, including
the examination of baseline personality, availability of a support system, previous exposure to
trauma, and chronic stress. The possible outcome of posttraumatic distress is described as either
decreasing or persisting into long-term psychopathology that severely affects the welfare and
developmental growth of children (Berger et al., 2007). Almoshmosh (2016) described several
possible realities that children face within the war context, including displacement, sense of loss
of ease in previous domestic surrounding, interruption to education and regular routines, the loss
of loved ones and/or becoming an unaccompanied child, heightened susceptibility to abuse or
exploitation, or forced labor, physical harm or injury, seeing heavy artillery attacks, and more.
Children can exhibit a range of psychological reactions in response to traumatic events, including
but not limited to heightened dependency, speechlessness, challenges with forming attachments,
anxious behavior, disruptions to their normal routines, bedwetting, and PTSD (Almoshmosh,
2016). In settings of disaster, conflict, or war, the following symptoms of psychological
morbidity have been found in youth that include: post-traumatic stress disorder, depression,
anxiety, anticipatory fears, affect-control dysregularities, sleep disturbances, somatic complaints,
regressive behaviors, learning difficulties, and substance abuse (Baker & Shaloub-Kerkovian,
1999; Kinzie et al., 1986; Koplewicz et al., 2002; Laor et al., 1997; Pat-Horencyk et al., 2007).
Additional literature further reveals the impact of indirect, violent exposure on children.
For example, children hearing gunshots and bombs explode and learning about the evolving
details of conflict via news sources and/or other adults (Jayuphan et al. 2020) leads to “more

34
anticipatory anxiety and cognitive expressions of distress” (p. 61). These findings indicate the
need to determine how violent content is received by students (Burgin et al., 2022; Dimitry,
2011), and reaffirms the need for specialized training on child-specific challenges and necessities
(Masten & Narayan, 2012). The prospect of parent and caregiver psychoeducation (Jayuphan et
al., 2020) may assist them in understanding and resolving the impact of indirect, violent
exposure and provide additional support strategies.
Identifying the length and breadth of exposure to trauma, including associated, first-hand
accounts of survivors, helps build contextual knowledge and assess the impact of conflict and
war on young lives. Panter-Brick et al. (2009) referenced the dichotomy in children’s responses
to war related trauma, first highlighting Van de Put (2002) in a 1997 UNICEF study, who
interviewed 300 children and found that 90% believed they would be killed in war, and 80%
expressed feelings of sadness, fear, and an inability to deal with life. On the other hand, De Berry
et al. (2003), in a 2001-2002 Save the Children qualitative study of over 400 children and 200
adult caregivers, the common notion was that youth in Afghanistan were free from fear or trauma
induced by war. The notion discovered by De Berry et al. (2003) seems to exemplify the
protective role that Afghan families and parenting styles have in the coping, resilience and
mental framework of children affected by war, namely that positive outlooks were achieved as
children actively depended on the strength of their greatest social support and resource, their own
families. A study conducted by Panter-Brick et al. (2009) assessed mental health, trauma
exposure, and psychosocial functioning of 1,011 Afghan youth, ages 11-16 years old, via a
school-based survey, showing that the level of exposure to trauma and the mental health status of
caregivers significantly contributed to child outcomes. Additionally, the study concluded that

35
about 66% of children experienced traumatic exposure, five or more traumatic experiences were
significantly associated with PTSD symptomology, and the most distressing traumatic events
reported by children included accidents, medical treatment, violence within families and
communities. Reflecting the typical range of 20% for socio-economically disadvantaged
communities (Thabet & Vostanis, 2002), the population of children with psychological and
behavioral conditions was 22.2% that met indicators of likely psychiatric diagnosis (Panter-Brick
et al., 2009). It is important to consider the meaning that children make of their experience with
trauma in conflict and war zones, including its psychological impact, as they may reflect actual
and cultural perceptions that shed light on specific needs and appropriate interventions.
Cultural Considerations of Trauma for Children In Conflict and Warzones
Providing culturally relevant interventions, including through the insight and experiences
of those affected, is critical to helping populations heal from the trauma of conflict and war.
Understanding the nature of mental health concerns for children from the specific socio-cultural
perspective that they ascribe to is significant towards establishing collaborative relationships and
identifying and addressing needs, even through a participatory process (Veronese et al., 2021),
where teachers and caregivers, for example, may provide critical insight into how the population
prefers and needs to be supported. Also, understanding the nature of the data collection
processes, including ethical and culturally relevant recruitment (Jayuphan et al., 2019), is an
important design feature for future research. Fisher (2020) in “People First, Data Second”
emphasizes a framework for engaging in field research with refugees in war zones, asserting that
implementing this humanitarian approach requires a strict fidelity to the UN protection mandate,
understanding and adherence to community norms and values, and protecting conditions that

36
foster refugee autonomy. The United Nations High Commissioner for Refugees (UNHCR)
protection mandate involves the international and humanitarian protection, assistance, and
solution-oriented support provided to refugees, stateless persons, and internally displaced
persons in collaboration with governments and agencies (UNHCR, 2024-a).
Without a culturally appropriate lens and approach to supporting diverse populations,
especially populations where researchers/practitioners are non-native, there runs the risk of
imposing norms, values, or beliefs about subject areas or methodology that is foreign to the
existing value system and way of life. Language, norms, expectations, and principles specific to
a particular cultural context need to be thoroughly examined to minimize the potential to cause
harm, to protect trust, and to operate as closely as possible to the client’s cultural frame of
reference, that which is most familiar to doing and being within that home, community, or
region. Additionally, considerations to protect participants, community, and/or the relevant way
of life therein may benefit when culture is better understood according to its systemic role in and
on the individual, when applicable and pertinent, for example, the historical context of region,
situational factors, personal life experiences, including childhood and developmental milestones,
family dynamics, and communal practices, traditions, and norms. On the journey to better
understanding culture, the perceptions of the target audience are important for gaining insight
into the participants’ world in their own words and in their own way.
A critical component of implementing any care process is accurately identifying
appropriate interventions for the target population, that is, a package or process that is tailored to
the context and culture of those receiving support (Jordans et al., 2013), which is initiated by first
understanding the distinctive contextual qualities of a community when providing respective

37
supports and services (Arredondo & Rice, 2004; Ko, 2005). According to Hodes and Vostanis
(2019), when supporting refugee children from low- and middle-income countries, key factors to
consider include understanding the target population’s perception of mental health and related
stigma, developing targeted interventions that are culturally adapted, and taking into account the
scarcity of child mental health specialized supports. Ko (2005) underscored the cultural
competency initiative by the National Child Traumatic Stress Network (NCTSN) to represent
diverse populations in discussions of race and ethnicity, including, but not limited to, immigrant,
refugee, and homeless youth, youth with disabilities, LGBTQ+ youth, youth with varying
religious and spiritual backgrounds, and youth in rural settings. Taken together, the work
suggests it is vital to understand the cultural background and perceptions that diverse
communities hold in order to better respect their dignity and meet specific needs in the way that
honors their cultural perspective.
How children understand and cope with a crisis, that is, the sociocultural meaning that
they ascribe to the experience of war, has associated social and psychological implications
(Betancourt & Khan, 2009), and is essential to identifying culturally relevant practices and
interventions. The perspectives that youth take around their necessities and objectives should
influence interventions (Daiute, 2021), including the cultural role of healing and coping in the
context of war and conflict (Betancourt & Khan, 2009). The demand exists for implementing
programming that does not “pathologize children…rather, they build upon strengths inherent in
cultural beliefs and community processes that traditionally protect and support children”
(Betancourt & Khan, 2009, p. 323). Daiute (2021) further examined how past insights from
youth narratives during and following times of war are relevant when investigating how youth

38
experienced and coped with the crisis of the COVID-19 pandemic. Storytelling, or the narration
of personal experience, is the means by which youth exercise four relevant, psychosocial
mechanisms that include: meaning making, or comprehending events of personal relevance;
seeking connection or distance with others; engaging in imaginative or creative thinking as a
coping and problem-solving strategy; and imparting wisdom to others (Daiute, 2021).
The central directive of UNHCR is to protect and support refugees and provide catered
support according to the cultural identities and needs of specific population groups. According to
UNHCR (2024), refugees do not all represent one homogenous group, but rather a richly diverse
collective of individuals and communities that hold distinctions in cultural and religious beliefs.
As such, to provide protection and support obliges that dignity and respect be maintained to the
highest standard, including the cultural practices and customs of refugees, and that assets,
positions, and priorities be adequately attended to when developing and implementing security
and aid projects.
Trauma-Informed Care (TIC) and Culturally Appropriate, Trauma-Informed Support (CATIS)
Trauma-informed care, when addressing a trauma-informed approach, exists when:
“a program, organization, or system that is trauma-informed realizes the widespread
impact of trauma and understands potential paths for recovery; recognizes the signs and
symptoms of trauma in clients, families, staff, and others involved with the system; and
responds by fully integrating knowledge about trauma into policies, procedures, and
practices, and seeks to actively resist re-traumatization” (SAMHSA, 2014b, p. 9).

39
Trauma-informed care is explained through a socio-ecological model through which to
conceptualize trauma and its impact, including the multi-systemic understanding and interaction
of the role of risk and protective factors, developmental phases, and culture influences
(SAMHSA, 2014b). The six principles of trauma-informed care proposed by SAMHSA reflect a
response that supports minimizing harm at all levels within the organization and include “safety,
trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and
choice, and cultural, historical, and gender issues” (CDC, 2018, p. 1; SAMHSA, 2014, p. 7).
Clervil et al. (2013) identified eight core principles of trauma-informed care for displaced
persons, including refugees, asylum seekers, migrants, internally displaced persons, and stateless
persons. These encompass SAMHSA’s six core values, which include promoting trauma
awareness, ensuring safety, upholding autonomy, sharing power and decision making,
establishing cultural competence, comprehensive care, supporting relationships, and facilitating
recovery. Ballard-Kang (2020) created the concept of culturally appropriate, trauma informed
support (CA-TIS) which is defined as “a strengths-based framework that is grounded in an
understanding of and responsiveness to the impact of trauma, the role of culture, and promotes
physical, psychological, emotional, and cultural safety for both refugees and those serving
refugees” (p. 29-30). The intention of the CA-TIS conceptual model, with theoretical origins in
social-cognitive theory, trauma theory, and second culture acquisition models is to increase
interconnection within various domains of refugee system care to promote perceived safety and
bi-cultural self-efficacy for refugees (Ballard-Kang, 2020). A trauma-informed care and
culturally appropriate, trauma-informed support approach will help uphold the UNHCR mandate
to protect and support refugees, stateless persons, asylum seekers, and returnees (UNHCR, 2024-

40
a) by adopting a culturally responsive lens that fosters safety and provides appropriate support
for vulnerable populations including the childhood trauma context.
Context of Childhood Trauma in the Democratic Republic of Congo and Ethiopia
Discerning the depth, diversity, and context of mental health needs in LMICs is critical to
bridging the gap to culturally relevant and targeted services for children and the general
population. Childhood adversity is an urgent global concern (USAID, 2022), and there is more
awareness and sensitivity to the challenges faced by children and their associated developmental
outcomes in settings of conflict and war (Shaw & Harris, 2003). The contextual background of
the Democratic Republic of Congo and Ethiopia, including historical and geographical factors,
are worth noting when considering their short-term and long-term impact of trauma and
adversity on children. Such historical examples include colonial rule, slave trade, occupation,
past and present wars and conflict, post-colonial political escalations, political and ethnic
conflict, and a proclivity for natural or climate-related disasters such as heavy inundation,
drought, volcanic activity, and epidemics, which pose major threat to economic stability (World
Bank Group, n.d.). Other notable risks for children include extremist terrorism, continued civil
conflict, other forms of violence and ongoing humanitarian crisis and displacement, famine,
malnutrition, extreme poverty, the COVID-19 pandemic, and the burden of other communicable
diseases. Existing adversity is further exacerbated by child marriage, domestic violence, child
solider recruitment, threats of violence, emotional, sexual abuse, and physical abuse, human
trafficking, substance abuse, and more.
Important mental health considerations in LMICs in conflict highlight increasing
disparities and are important to note. First, LMICs hold upwards of 80% of the global population
and less than 20% of the mental health resources, with even greater disparities among the poorest

41
nations (Santos, 2011). Conflict zones, even in LMICs, continue to reflect the impact of the
COVID-19 pandemic (Burgin et al., 2022), ongoing bombardment, and the threat of war
(Markosian et al., 2021). Furthermore, in LMICs, less than 10% of the population have access to
treatment (Demyttenaere et al., 2004). The central challenges to closing the global mental health
treatment gap in LMICs, are: 1) mental health stigma at all levels and lack of understanding as to
the benefits of supporting mental health needs, 2) limited resource allocation of capital and
skilled personnel, and 3) weak research infrastructures hindering innovative evidence-based
practices (Sweetland et al., 2014). Addressing the needs of vulnerable populations, including
basic needs and mental health help mitigate long term health outcomes.
By March 2024, there was an inflow of 230,000 internally displaced persons en route to
Goma, Democratic Republic of Congo due to M23 conflict, resulting in further strained
infrastructure and resources for IDPs and an increase in human protection violations, including
forced child soldier recruitment, violence against women, and abductions (USAID, 2024a).
Boothby et al. (2006) highlighted the 1987 UNICEF narrative surveys of Mozambican children
to give insight into the inculcation process of rebel/conflict groups, which includes the
conditioning tactics of humiliation, brutality, and emotional restraint to build unquestioned
devotion to authority in the execution of tasks and persons, and to sever any child’s ties from any
grasp to their former lives, including to kinship, society, and cultural heritage. Many wounded
persons tend to be children, and over 319,000 children were identified with severe acute
malnutrition in DRC in 2023 (USAID, 2024-a). After 25 years of presence and protection in
DRC, per the request of the Congolese government and to gradually transfer security
responsibility to the government, it is anticipated that the withdrawal of the United Nations

42
Organization Stabilization Mission in the Democratic Republic of Congo (MONUSCO) by the
end of 2024 may lead to further decline in child protection capabilities (United Nations, 2024).
Armed conflict is ongoing in Northern Ethiopia, including in the Amhara, Oromia, and
Tigray regions, and flooding and drought is also presenting obstacles to humanitarian assistance,
with 21.4 people needing humanitarian relief in 2024 (USAID, 2024-b). Communicable disease,
severe hunger, and inadequate nourishment, at integrated food security phase classifications
(IPC) of crisis-3 and emergency-4, were anticipated for May to September 2024 across the
country, including the southern regions, at a scale that was not likely to be resolved in the short
term (USAID, 2024-b).
A 2021 UNOCHA Conflict Needs Assessment in the Konso Zone in southern Ethiopia
demonstrated the following: 15 school closures, 8,300 displaced students were out of school, and
affected schools experienced total loss or damaged and stolen school supplies, major shortage in
furniture and needed school supplies, and parents unable to provide for school related needs such
food, clothing and school supplies (UNOCHA, 2022). In a 2022, random sample of 423 children
and adolescents between the ages of 5-14 in a southern Ethiopian hospital, the Child Trauma
Screening Questionnaire (CTSQ), which identifies at-risk children for PTSD, revealed a
prevalence of 17.5%, or one in six children, a rate that was related to family size, parent
education, and emotional distress in youth (Berhanu et al., 2023). In 2023, there were no armed
conflict events documented in the South Ethiopia Regional State (Uppsala University, 2023-b),
though several conflict related incidents had occurred (EPO, 2023).
By the end of 2023, the United Nations confirmed almost 33,000 grave violations were
committed against approximately 22,500 children in 26 conflict zones across the world, with

43
5301 deaths and 6348 mutilated or injured, a 35% increase in a year (United Nations, 2024).
Grave violations against children monitored by the United Nations included murder or injury,
child soldier recruitment, kidnapping, school and hospital attacks, denial of humanitarian aid,
and sexual violence (United Nations, 2024). Overall, the armed conflict in eastern Democratic
Republic of the Congo and the post-conflict context in southern Ethiopia has had and will
continue to have a profound effect on the well-being of children, and continued research and the
development of catered systems of support will help maximize the efficacy of any current and
future mental health response systems.
Mobilizing Emergency Mental Health Response in Conflict and War Zones
The field of mental health, including its evolution and role in emergency settings, is one
of the most important issues of our day and will have major implications on how humanitarian
support is effectively administered in conflict and war zones for years to come. The mental
hygiene movement of the early 20th century helped establish the global promotion of mental
health, which was marked by action towards integrating mental health fundamentals into
disciplines and fields starting in the 1920s and 1930s (Beers, 1935). The mental health hygiene
movement re-gained traction in the 1970s, and studies began acknowledging the value for
implementing mental health practice in other disciplines (Kovess-Masfety, 2005). Mental health
as a discipline is fairly recent with technical descriptions occurring as early as the 1950s
(Bertolote, 2008). The world wars of the 20th century prompted understanding about the role and
impact of war on mental health (Murthy & Lakshminarayana, 2006). For example, United States
psychiatrists initially centered on, through screening and treatment, the mental health of military
members more than on the civilian population impacted by trauma, which notably surpassed that

44
of military personnel (King & Martin, 2001). Regarding humanitarian efforts in conflict and war
zones, a relatively new feature to this work is disaster mental health, describing support for
responders and survivors in natural or man-made disasters, including armed conflict (Heath et
al., 2009).
In 2001, the World Health Organization, in its World Health Report 2001: Mental
Health: new understanding, new hope, published a 10-recommendation framework that first,
raised awareness on the significance and impact of mental health, and second, highlighted the
global need to increase mental health access in health care (Kakuma et al., 2011), medicine
treatment availability, community outreach and education, national legislation and policies,
training and development of service providers, multi-sectoral collaboration, monitoring of mental
health status at communal levels, and resources for continued research (WHO, 2001). Former
Director-General, Dr. Gro Harlem Brundtland, introduced the report by comparing a previously
held mental health paradigm as remiss in the global arena, with a critical, novel understanding of
mental health that establishes it in the community and calls for global attention and action
(Bertolote, 2008). To better understand the current and future world of emergency mental health
response, including current challenges, it is helpful to review how relief efforts have evolved in
various forms of emergency mental health service delivery.
The Evolution of Emergency MH Response in Conflict and War Zones
The changing nature of conflict and war zones and the immediate crisis needs that ensue
have prompted an evolution in how governments, organizations, and other entities provide
emergency mental health services. Research suggests a need exists to transition short-term
awareness of mental health issues during crisis situations to the building or rebuilding of

45
effective and long-term mental health systems, especially in developing countries where access
to mental health support is limited and a weak infrastructure exists (Lima, 1987; WHO, 2023).
As a result, developing countries look to existing primary health care channels for mental health
service provision (North, 2007). A rapid evolution has occurred in countries that have been
impacted by ongoing, armed conflict and natural disasters. For example, the conflict in Syria has
made the need evident to provide multiple tiers and avenues for mental health response,
including during and following emergencies, which entails a transition of mental health services
primarily based in mental hospitals to integrative development into primary, secondary, and
social settings, and school-based approaches (WHO, 2023). Nine years since the inception of the
Syrian war in 2011 has resulted in continued negative mental health outcomes propagated by
extreme distress and insecurity, internal displacement of almost 6 million people, over 5.5
million refugees, most of whom are women and children, and reflects an ongoing public health
and humanitarian concern (Hamza & Hicks, 2021). The central challenges regarding the
provision of mental health services in the Syrian refugee crisis involved the lack of mental health
infrastructure prior to the war, immediately overwhelmed by its progression and concentrated
violence against the mental healthcare infrastructure, and the question of delivering socioculturally attuned mental health services within the context of mass trauma and death and
virtually no exposure to a culturally stigmatized mental health system (Hamza & Hicks, 2021;
Murray et al., 2014). Key considerations to implementing mental health services in Syria, and
elsewhere, include a broad scale and culturally appropriate mental health infrastructure, the
training of non-clinical workers in mental health support and intervention, a context specific lens
on the role and impact of horizontal violence, destigmatized and culturally specific language and

46
terminology when providing mental health support, and cultural sensitivity, including individual
and cultural protective factors that bolster resilience and acceptance of clinical intervention
(Hamza & Hicks, 2021).
Another example reviews how Israel has shifted its emergency mental health response, a
40-year evolution characterized by the contextual nuances of a middle eastern geopolitical
context, from studying the impact of war on mental health and the efficacy of its mostly statefunded psychotherapeutic intervention system to a current three-tiered system (Bodas et al.,
2015). The three tiers include rapid, local intervention, standalone mental health support sites,
and continuous initiatives to promote community resilience in ordinary circumstances (Bodas et
al., 2015), which presents immediate, local and accessible, and ongoing, resilience-based
supports as a more systematized and comprehensive way to deliver emergency mental health
services. According to Bodas et al. (2015), a shift in discourse on mental health, namely by
adopting an inclusive outlook towards its complexity, adversity, diverse forms, and a
“maturation” process via lessons learned in the field, was pivotal towards the growth and
evolution of Israel’s emergency mental health system.
The case studies reflect the novelty of the field combined with contextual factors and
ecosystemic reactions in active and post-conflict settings. The evolutionary shift in mental health
service delivery was unique to each context and defined by the crisis and ability, or lack thereof,
to universalize awareness, access, and effective intervention. It is clear that the scope, duration,
and intensity of the violence will affect the capacity and efforts to systematize a nation-wide
mental health system. Additionally, socio-culturally appropriate and informed approaches to care
delivery are an important consideration. It is essential to consider context specific needs, lessons

47
learned, and implementation of long-term, large scale, mental health systems development and
improvement to be able to effectively operationalize emergency mental health responses to meet
the diverse array of challenges unique to conflict and war zones.
Challenges in Mobilizing Mental Health Response for Children in Conflict and War Zones
The dynamic nature of war and conflict creates ongoing conditions for increased
susceptibility and vulnerability to various forms of childhood adversity. Catani (2018) asserts the
critical value of applying an ecosystemic perspective to more accurately identify risk factors
impacting a child during and in the aftermath of conflict and war. This approach originates from
the need to better understand cycles of violence, including the catalytic relationship between
violence in conflict settings and ensuing psychopathology with child abuse and domestic
violence (Catani, 2018). A prominent consideration is the long-term effects of traumatization to
war that lead to increased risk of maladjusted behaviors and an overall higher risk of
experiencing mental health problems (Catani, 2018). For refugee children, for example, severe
mental disorders are more likely (Hodes & Vostanis, 2019).
The diverse situational factors specific to conflict and war zones also impact relief
organizations’ operational capacity to mobilize response efforts. A critical barrier to providing
humanitarian support is ongoing warfare (Kimball & Jumaan, 2020). Allen (2022) describes the
rapidly evolving progress of disaster response: “The emergence of unexpected and threatening
conditions weaken the capacity of organizations to make sense of new contexts and develop
adaptive solutions…the limited time, dynamic conditions, and intense pressure that relief agents
work under” (Allen, 2011, p. 447). In the case of Yemen, for example, with no prospective
conflict resolution in place and a constantly shifting landscape of geographical and political

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divergence between opposing parties, its pre-conflict status placed it at low Human Development
Index rankings, while its current, complex and multisystemic status is characterized by: a) food
insecurity and malnutrition, b) lack of access to water, sanitation, and health care, c) significant
economic decline and currency volatility, d) partially operating healthcare infrastructure, e) and a
cholera epidemic with coinciding disease outbreaks (Camacho et al., 2018; Kimball & Jumaan,
2020).
Allen (2011) asserts the need to understand the key characteristics that are conducive to
organizational collaboration when mobilizing emergency responses. Post-disaster settings
present conditions of urgent decision making, heightened uncertainty, and a sense of impending
danger (Boin et al., 2005; Lagadec, 1990: 21; Weick, 2012) and require that the time-sensitive
nature of mounting response efforts include the delegation of all responsibilities, supplies
distribution, and prompt and close coordination of all relief activities (Allen, 2011). The need to
consider organizational collaboration came from the challenges experienced by the Taiwan Red
Cross (TRC) during the 2004 Asian Tsunami, that included a lack of practice working in the
international arena of relief efforts and working with populations of different language and
culture contexts (Allen, 2011). In the immediate, post-disaster response following the 2008
Wenchuan Earthquake, the TRC held a collective meeting with domestic organizations
committed to providing aid that resulted in a shared vision to collaborate towards meeting the
needs of victims that would also ensure ongoing, joint involvement with local authorities and
volunteers (Allen, 2011).
Specific barriers to implementing wide-ranging mental health interventions in support of
children impacted by the trauma of terrorism, include: 1) children with PTSD neglecting,

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regardless of ability, to pursue treatment or are not referred to therapeutic supports by family or
schools (Gurwitch et al., 2002), and 2) a lack of an extensive, locally driven, and affordable
organization to meet the high needs of terrorism exposure and consequential high incidence of
distressed children (Berger et al., 2007). It is important to note that children presenting with
PTSD symptomatology may not seek and find needed therapy, for reasons that also include age,
ability, and access to resources within the community. Secondly, the concrete lack of an existing
mental health infrastructure, further overwhelmed by terrorism, war, or disaster, and the quality
of that access presents a tangible barrier to children finding help. El-Khoury, Barkil-Oteo, and
Adam (2021) state that non-government organizations mainly provide short-term efforts in
support of common mental health disorders, even though sustained and adaptable support is
needed, especially with severe mental health cases and already scarce government support. These
realities signal a need to refine referral processes for children, including building caregiver
capacity to identify children with symptoms or markers of traumatic distress and PTSD.
Additionally, a demand exists to build upon the pre-existing mental health infrastructures in
countries receiving NGO mental health aid and the work stemming from these short-term efforts
into more effective and comprehensive mental health systems to carry the work in the long-term.
Finally, the need to train and deploy mental health practitioners across the national stage,
including specialists with expertise in working with severe cases and vulnerable populations is
crucial to the development of these multi-tiered systems of mental health support.
Another important first step towards improving service delivery for refugee children is
understanding help-seeking behaviors and increasing the use of existing mental health
infrastructures (De Anstiss et al., 2009). Rickwood and Thomas (2012) define a help-seeking

50
behavior as: “...any action of energetically seeking help from the health care services or from
trusted people in the community and includes understanding, guidance, treatment and general
support when feeling in trouble or encountering stressful circumstances” (p. 83). Umubyeyi et al.
(2016) explored help-seeking barriers and self-efficacy in young adults with suicidality and/or
depression. The role of structural barriers like transportation, poverty, and low educational level,
individual barriers, such as mental health illiteracy and lack of trust in the health care system,
and stigma-related barriers when seeking mental health care in Rwanda are suggested as focal
points for future intervention. A gender difference was also identified with women experiencing
more structural barriers, including, for example, access to services due to transportation issues,
possibly pointing to women lacking resources and/or problem-solving resources (Umubyeyi et
al., 2016). Individual barriers include men’s and women’s perception around the quality of
mental health as either ineffective and/or not trustworthy, with men believing the problem would
resolve itself over time, a possible manifestation of avoidance and stigma (Umubyeyi et al.,
2016).
It is also understood that parental attitudes and perspectives towards events that are
catastrophic, or traumatizing are mirrored through short- or long-term dysfunctional responsivity
in children (Chrisman & Dougherty, 2014). Additionally, determinants of childhood
psychopathology to related events include disaster induced, impaired psychological functioning,
overbearing protection and prevention of regressive behaviors, and role reversal in dependency
in parents, and adverse, emotional and stressed climate in the family system (Frankenberg et al.,
2008). Therefore, in settings of conflict, war, or disaster, in the presence of mental health
concerns and traumatizing events, children may mirror, or default, to familial mindsets and

51
reactions towards adversity and the mental health systems that are meant to be supportive and
needed. The unique features of conflict, war, or related issues of violence present diverse barriers
that complicate organizational effectiveness in the emergency response process and emphasize
the need for mobilizing comprehensive approaches as a step towards supporting traumaimpacted children.
Operationalizing Policies and Practices: Mental Health Approaches for Comprehensive
Support of Child Victims of Trauma
This section will review current applications of multi-tiered, multi-level, and traumainformed approaches for children with a focused, introductory section on the mental health and
psychosocial support (MHPSS) framework as the international standard for providing mental
health and psychosocial support services in humanitarian settings, including psychological first
aid (PFA) as an immediate intervention in emergency settings, schools as epicenters for healing,
and the role of teachers in supporting child victims of trauma.
The origin of the MHPSS has roots in the biopsychosocial model created by George
Engel (Engel 1977; Engel 1980), which linked the biomedical model that emphasizes a
relationship between health and disease with psychological and social determinants of health.
The model for medicine shifted clinical perspective and practice to incorporate a more holistic
and humanistic lens for patient care, with the biopsychosocial model altering the way disease and
suffering and health and healing are applied and continuing to be taught in medical schools today
(Smith, 2002).
In 2007, the Inter-Agency Standing Committee (IASC) developed the IASC Guidelines
on Mental Health and Psychosocial Support in Emergency Settings, including specifications for

52
the development and implementation of collaborative response in support of populations in
emergency settings. These responses are characterized as both minimal and requiring urgent
action to help safeguard and ameliorate mental health and psychosocial well-being during and
following emergencies (IASC, 2007). The following definition created by IASC (2007) will be
used when referring to mental health and psychosocial support, “...any type of local or outside
support that aims to protect or promote psychosocial well-being and/or prevent or treat mental
disorder” (p. 1), a definition that was developed to inclusively account for the diverse types of
mental health supports, including preventative, protective and intervention services (IASC,
2007). The MHPSS framework represents the first international consensus standards for how to
enact mental health and psychosocial supports for children in conflict and war zones,
(Wessels, 2017) and is an organizational priority for the United Nations and the United Nations
Children’s Fund (UNICEF) (UNICEF, 2022).
Bürgin et al. (2022) underlines the synchronous importance of promptly meeting a child’s
needs at all levels with a multi-tiered, or a multilevel approach, which is reflected via a side-byside comparison of a Maslow’s hierarchy of needs with the multilevel intervention pyramid for
mental health and psychosocial support in emergencies developed by the IASC (2007), as shown
in Figure 1.
Figure 1
Maslow’s Hierarchy of Needs and Multilevel Intervention Pyramid for MHPSS in Emergencies

53
Note: from Maslow, 1943; IASC, 2007, as cited in Bürgin et al., 2022, p.848
The pyramidal model of MHPSS is characterized by four tiers with humanitarian
functions affecting all (lowest tier) to few (highest tier) in emergency settings that include: 1)
ensuring protection, security, and basic needs for all people, 2) social supports that sustain
psychosocial well-being, 3) basic psychological intervention provided by trained workers,
including psychological first aid and basic mental health, and 4) more intensive psychological or
psychiatric supports for those presenting with more severe concerns impacting daily functioning
(IASC, 2008). Communal and psychosocial supports (Wright et al., 2013), which have helped
diminish the effect of war related trauma on psychological distress (Llabre et al., 2015) and
decreased PTSD symptoms (Thabet et al., 2009), need to be “tailored to the nature of the
trauma” (Cartwright, 2015, p. 10) and culturally relevant and preventative against possible harm
(Wessells, 2017). According to Werner (2012), the following protective social supports may also
mediate the effects of war-related trauma on children: 1) attachment to primary caregiver; 2)

54
maternal mental health status (Dimitry, 2011); 3) availability of further caregivers; 4) support of
community members with shared difficult experiences (Dimitry, 2011); 5) common values; 6)
religious-based meaning to suffering (Dimitry, 2011); 7) protective responsibility towards others;
8) sense of control over life’s circumstances; and 9) humor and concern and support of others.
Multi-tiered, multi-level approaches that are trauma-informed, such as MHPSS, the current,
global standard for humanitarian support, are suited to support the comprehensive needs of
children affected by trauma in crisis settings.
Current Applications of Multi-Tiered, Multi-Level, and Trauma-Informed Approaches for
Children
Humanitarian intervention that adequately, immediately, and comprehensively addresses
the sequelae of trauma is paramount to harm reduction and recovery in children in conflict and
war zones. Bürgin et al. (2022) reviews the influence of war and flight on the mental health
status of children in conflict and war zones, asserting the need for a multi-tiered and multisystemic, resilience-based, and a trauma-informed care approach when providing targeted
support for children. Multi-systemic and resilience-based refers to the role an ecological
framework has between an individual and various systems of society and the role and
prospective impact of resilience, both individually and across those systems (Wessels, 2016;
Wessels, 2017).
The following is a summary of six, multilevel intervention steps for supporting children
affected by war and displacement (from Bürgin et al., 2022): 1) Provide immediate aid and
attention - ensuring basic needs to establish safety and trust and implementing psychological first
aid to reduce initial impact of trauma; 2) Assess and screen for mental health burden and needs -

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understanding the mental health burden of children via validated instruments is crucial to
identifying more targeted interventions to support reduction of suffering; 3) Provide evidencebased interventions for groups and individuals - easily accessible interventions for low priority
cases to more individualized and specialized treatments for severe categories; 4) Provide
appropriate post-migration infrastructures and social environments that foster mental health -
increasing access to improved living conditions that help students to thrive and regain a sense of
normalcy, for example, activities that increase social interaction and provide educational
experiences; 5) Support parents during and after war - investing in the mediating role of parents
and family will be conducive towards a child’s development and healing; and 6) Support
indirectly affected children - supporting relational bonding and practicing safe and healthy
conversations around distressing topics will support a child’s sense of safety.
El-Khoury, Barkil-Oteo, and Adam (2021) state that international mental health
response in recent conflicts is characterized by a short-term, model relief deployment that
consists of a senior management team composed of mental health professionals that lead a local,
multidisciplinary team. To provide targeted support to persons with severe mental health and/or
substance abuse disorders, “specialist mental health clinicians, primary care doctors with World
Health Organization Mental Health Gap Programme training, accessible referral pathways and
affordable medication protocols” are needed (El-Khoury et al., 2021, p. 3). The layout of these
short-term mental health teams reflects WHO priorities in low-income countries where access
to mental health services, especially for severe cases, is limited. Priority conditions that are
identified and supported through WHO MHGap Program training, which provides training and
resources to support clinical problem solving and decisions making via a non-clinical workforce

56
(WHO, 2022), include psychotic disorders, depression, suicidality, substance abuse, and mental
health disorders in children (WHO, 2008).
Jordans et al. (2013) implemented a community-based, multi-tiered approach to support
the psychosocial functioning and mental health of children between 2004 and 2010 in conflictaffected countries: Burundi, Sudan, Sri Lanka, Indonesia, and Nepal. The five-tier mental care
package consisted of: a) an introduction to the program and assessment of needs; b) a schools’
wide screening of children for psychosocial distress; c) classroom-based intervention (CBI) for
children scoring above cutoff; d) individual or family-based counseling for children with
continued mental health concerns; and e) a mental health specialist referral for children with
identified psychiatric concerns (Jordans et al., 2013).
When comparing the six, multilevel intervention steps for supporting children affected
by war/displacement by Bürgin et al. (2022) with the five-tier mental care package supporting
childhood psychosocial functioning and mental health in conflict-impacted regions by Jordans
et al. (2013), an important distinction between the two is the hierarchy of needs and ecosystemic
focus versus the mental health-based, individualistic approach when supporting children.
Bürgin et al. (2022) accounts for basic needs, including immediate aid, psychological first aid to
minimize the impact of trauma, followed by a mental health screening and intervention process,
and securing services towards improved living conditions and social infrastructures, parent
supports, and aid for children that have been indirectly affected. Jordans et al. (2013) provides a
multi-tiered approach that begins with universal intervention through needs assessments and
school-wide screening, targeted intervention that is classroom-based, and intensive or
individualized intervention, including specialist referrals with identified psychiatric conditions.

57
Both approaches are necessary components and consideration for comprehensive mental service
delivery for children in conflict and war settings.
As shown in Table 1, Wessels (2017) provides a list of commonly utilized MHPSS and
peacebuilding interventions for children impacted by war.
Table 1
Sample of Mental Health and Psychosocial Interventions On Behalf Of War-Affected Children
Note: from Wessels, 2017, p. 5
One intervention option is psychotherapy which may help improve mental health
problems in children in conflict-impacted regions (Burgin et al., 2022; Jayuphan et al., 2020), for
example, via narrative processing techniques or cognitive behavioral therapy (CBT). Also,

58
school-based interventions for children and youth, for example, highlighting the context of
Middle Eastern other socio-cultural contexts, involve coping mechanisms that involve adherence
to regular routines and education (Dimitry, 2011; Kos, 2005), including classrooms that are
structured to support the specific needs of children. A consideration for future application of
intervention and support for children includes that the list provided in Table 1 is non-exhaustive,
with other forms of support not necessarily regarded as an intervention by the target population,
including external or environmental interventions, that is, changes or alterations to the
environment that promote positive mental health and psychosocial outcomes. To meet the urgent
mental health needs in crisis contexts, psychological first aid within an MHPSS framework is an
evidence-informed approach that is suited to leverage resilience and psychosocial support and
reduce psychological distress in trauma-affected populations.
Psychological First Aid
Children are particularly susceptible to various types of disasters as their specific
physiological, anatomical, and behavioral characteristics increase their vulnerability to trauma
(Khorram-Manesh, 2022). Since a critical timeframe may exist for treatment of children
following a traumatic experience, during which interventions are most effective (Schwarz &
Perry, 1994), an important first tier intervention aimed at minimizing the impact of trauma in
children is Psychological First Aid (PFA). PFA is an evidence-informed, disaster response
intervention approach that supports children, youth, adults, and families in distress reduction and
positive, short- and long-term adaptive functioning (Vernberg et al., 2008). It is a central theme
of this approach to comprehensively account for processes and strategies that support stresscoping-adaptation by minimizing physiological stress and its related cognitive and emotional

59
responses, towards decreasing the risk of collateral psychological reactions. Hobfoll (2007)
identified five elements that foster positive social and behavioral adaptation in the immediate and
mid-term time span following mass trauma events that are the guiding principles of PFA. These
evidence-informed intervention principles include: “1) Promote sense of safety, 2) promote
calming, promote sense of self- and collective efficacy, 4) promote connectedness, and 5)
promote hope” (Hobfoll, 2007, pp. 285-286), principles that correspond with resilience research
on the promotion of human adaptation systems involved with fostering resilience (Masten &
Narayan, 2012).
To help mitigate the trauma response, the eight core actions of PFA, which categorize
specific and recommended interventions, are its primary functions that integrate crucial
recommendations that must be closely considered with the survivors’ individualized needs and
the context for service (Vernberg et al., 2008). The goals of each core action include the
following strategies/approaches: 1) Contact and Engagement - responsive, compassionate, and
culturally informed engagement; 2) Safety and Comfort - addressing issues pertaining to
immediate safety concerns, such providing clarifying updates and redirecting to available
resources, locating family members, and allowing space for survivors to serve the needs of their
loved ones; 3) Stabilization - when needed, the use of grounding techniques to help orient
individuals to present time and reality; 4) Information gathering - the foundational core action
that deals with identifying needs, including immediate needs, high-risk monitoring, and
establishing resilience and risk factors; 5) Practical Assistance - supporting steps to a created
action plan to support needs; 6) Connection With Social Supports - increasing access to primary
supportive figures and understanding how to give or receive support from other sources; 7)

60
Information Coping - stress, coping, and adaptation psychoeducation; and 8) Linkage with
Collaborative Services - connecting survivors with resources that are needed currently or in the
future, including supporting continuity of care. Integrating the principles and core actions of PFA
into early intervention efforts will be a step toward delivering comprehensive mental health
services in support of children within contexts of crisis and trauma. Incorporating PFA principles
and actions implemented in a time-sensitive manner is a prospective, critical tool for schools and
educators supporting current and future incidents of childhood trauma in conflict and postconflict affected communities.
Schools as Epicenters for Healing
The United Nations Children’s Fund (UNICEF) highlighted schools as having a
significant role in providing infrastructure and security for children and families (Heath et al,
2009) and are a prime location for mental health care provision (Chemtob, et al., 2002; Ehntholt
et al., 2005; Kern 2017). Schools have the significant role of ameliorating the impact of trauma
for children (Elbedour et al., 1993; Phifer & Hull, 2016), and the early intervention role that
educational programming has on displacement and refugee contexts is suggested to reestablish
predictability of routine and foster social connections (Aguilar & Retamal, 1998; Erdemir, 2022;
Kos, 2005). Within a trauma-informed perspective, infrastructures and social environments that
are developmentally suitable in social interaction, a sense of belonging, education, and
promotion of strengths-based approach are needed to provide children with the opportunity to
develop in a safe environment (Bürgin et al., 2022).
According to WHO (2002), schools are strategically situated to engage in early detection
and intervention of psychological disorders in children because of the ease of access to children

61
and families regularly attending school, their availability on site, reduction of stigmatization
(Pfefferbaum et al., 2003), and mediating role against additional service access gaps, including
poorly situated location and transportation costs. According to Kakuma (2011), the one action
that has the greatest potential to significantly impact mental health in LMICs is integrating
mental health service delivery into existing care systems, such as schools.
Symptoms of traumatic distress can manifest in classrooms, such as compromised
psychosocial functioning and academic progress, and school- and/or classroom-based mental
health interventions that address, for example, knowledge on the impact of stress in conjunction
with appropriate coping skills, help mitigate their progression. Additionally, schools typically
target student programming and support the development of effective social emotional learning
and school climate and culture practices. In doing so, schools may assess, evaluate, and refine
protocols, guidelines, and interventions to build positive, systemic supports that develop a
growth mindset, self-efficacy, self-management, social awareness, and perceptions around
academic support, knowledge on school expectations, safety, and a sense of belonging in
students.
String et al. (2003) asserts that both school-wide and classroom communities are
pathways to a nurturing group atmosphere that facilitates trauma recovery for students. Berger et
al. (2007) distinguishes between targeted and universal school-based interventions, focusing on
the execution of universal program in Israel that helped students cope with the trauma of
violence in the community, abuse, single-moment trauma, the threat of continued acts of
terrorism, and mitigating the traumatic effects of terrorism through self-efficacy work. First,
targeted intervention pinpoints symptomatic students, typically following “trauma-focused

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cognitive-behavioral models,” (Deblinger & Heflin, 1996) and administers a “treatment
package” consisting of: 1) psychoeducation, 2) stress reduction skill-building, 3) management of
trauma activating factors, and 4) correction of distorted trauma-related perceptions (Berger et al.,
2007, p. 542). Second, universal intervention tends to support preventative efforts via support
and programming at the school-wide or classroom level, promoting ongoing, developmentally
appropriate, and positive scholastic experiences for all students. The more selective the needs
that exist within a school system, following a multi-tiered pyramidal framework, the more
specialized the resources needed. It is critical that school systems develop multi-tiered action
plans to support the needs of diverse learners, including those that take multiple domains into
consideration. Mental health service delivery must be integrated into the role and function of
every school system, including its corresponding services, to comprehensively support the
formation of students and promote improved educational outcomes (Kase et al., 2017; WHO,
2021).
Role of Teachers in Supporting Child Victims of Trauma
Because schools are first tier service providers to students, examining the frame and
expertise through which teachers perceive and support childhood trauma in their classrooms is
critical towards effective school-based support. The role that teachers play in the development of
a child, including the amount of time, the breadth of academic and social emotional support and
formation, and the norms and values that are transmitted from educator to learner, place them in
the most versatile and essential stream of service delivery within educational systems. As such,
teachers hold a highly critical role in fostering the mental health of children via continued
support and care towards a spectrum of classroom and individualized needs and goals in multiple

63
domains and tiers. Such goals include, but are not limited to, continued improvement of practice
regarding ongoing classroom management and behavioral supports, catered academic
programming, reinforcement of age-appropriate standards, individualized needs of diverse
learners, school and classroom specific climate and culture, and more. Additionally, teachers are
typically the first point of contact when learning about contextual details or circumstances that
occur in or outside of school, a privileged position to bridge the needs of children facing serious
adversity with pertinent support.
Schools are optimally positioned to administer preventative and responsive mental health
services, indicated by the collective role of compulsory attendance, convenient accessibility to
students and families (Pfefferbaum et al., 2003), and direct engagement with scholastic progress
through ongoing social-emotional and behavior learning support (Crosby, 2015; Ko et al., 2008;
Walter, 2006). Teachers are strategic assets in this student-centered process, for detecting
symptoms and concerns related to childhood trauma and assisting students in their healing
journey, including through reestablishing predictable routines towards a sense of normalcy
(Baum et al., 2009; Brymer et al, 2012). A 2009 school-based survey assessing the psychosocial
well-being of youth in Afghanistan highlighted teachers’ reflections as not having considered the
impact that mental health issues may have on academic performance; teachers were instrumental
in helping identify mental health characteristics and potential for continued exposure in schools
(Panter-Brick et al., 2009), a necessary step towards meeting the psychological needs of students.
Also, teacher-based interventions in classrooms have ameliorated trauma-derived, psychological
distress in children (Berger et al., 2007). Berger et al. (2007) studied the efficacy of a teacherled, classroom-based, eight-week universal intervention for students in a city impacted by

64
multiple acts of terrorism in a brief period in Israel, noting that 45% of Israeli society had been
directly affected by or knew someone who experienced terrorism. The study reported significant
decreases in PTSD, somatic, and anxiety levels, including separation anxiety, and no significant
digression of symptoms highlighting the non-detrimental nature of the methodology (Berger et
al., 2007). Additionally, younger children who had high exposure to terrorism and experienced
more distress due to terrorism were shown to greatly benefit from the classroom intervention
(Berger et al., 2007), a possible indication of the protective or nurturing nature of adults,
including teacher presence and intervention. The role of teachers in the universal and targeted
tiers of mental health support for traumatized students in conflict zones and warzones is pivotal,
requiring ongoing use and support of their capacity, time, and resources.
An important direction is the potential for capacity building with teachers, parents, and
other non-clinical/specialist staff, specifically, by generating local skills as a necessary part of a
comprehensive system to meet the needs or shortages of mental health professionals in war zones
(Kakuma, 2011; Wessells, 2017). According to Kos (2005), “...the school and the teachers have
important psychosocially protective influence on the present well-being, mental health condition
and psychosocial functioning of children…Children damaged by war and exile need warm
human relationships more than techniques” (pp. 5, 11). The same notion of children engaging in
relational and everyday experiences and routines, such physical affection shared between parent
and child and teachers providing encouragement and guidance to students, can have important
psychosocial implications and are ordinary supports and interventions that may not be expressed
with regularity in research (Wessels, 2017). Kos (2005) asserted that the harmful effects of
armed conflict on children can be alleviated by the role and capacity building of teachers,

65
including with empathy and relationship, school- and classroom-based interventions that target
emotional regulation, self-esteem, and other psychosocial domains, and special training that
further expands teachers’ skill sets in expressive, behavioral, and other therapeutic techniques. In
2020, UNESCO executed a teacher-based, multi-district project in Uganda to increase capacity
building in conflict affected regions, resulting in strengthened systems of support that promoted
conflict sensitive education, increased teacher capacity, and produced positive outcomes in wellbeing for students (UNESCO, 2020). Capacity building for teachers and non-specialist personnel
in the education sector would help support the educational needs of developing countries by
providing a higher quality education. The United Nations Sustainable Development Goal (SDG)
4, is to “ensure inclusive and equitable quality education and promote lifelong learning
opportunities for all” (United Nations, n.d.).
Workplace behavior connected to any professional setting is directly related to held
attitudes, and the shifting of attitudes towards a particular aspect of work and may lead to altered
behavior toward that area, for example, client-based support (Traumatic Stress Institute, n.d.).
This concept is important in schools as supportive mindsets and attitudes towards students and
their backgrounds and needs are crucial to providing individualized support that contributes to
students’ personal and academic success. An area of focus that can help facilitate teachers in
meeting the individualized needs of students is to understand teacher perceptions, including how
they perceive students, needs, and contextual background and how they perceive their own roles,
abilities, and needs. It is known that school staff, including teachers, minimally participate in
trauma-informed, professional development opportunities that may provide the necessary
knowledge, skills, and abilities to better support students and improve their educational outcomes

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as learners. Increasing their engagement with professional training is a potential baseline for
schools to more comprehensively respond to the needs of traumatized students (Ko et al., 2008;
SAMHSA, 2014a).
In a 2019 study titled, Teachers’ perceptions of supporting students with trauma in a K-3
setting, I examined the perceptions of teachers and the role of a trauma-informed care
professional training on their needs and capacity on trauma-based awareness, knowledge, skills.
This led to future recommendations for more effectively intervening with students with adversity
and trauma. This single site study of eleven teachers was conducted in San Diego County and
involved a three-part professional development series on trauma informed care that influenced
confidence perception ratings for identifying and managing trauma-related cases in classrooms.
Teachers expressed the following needs at the conclusion of the professional development series:
classroom and individual strategies for supporting students (i.e. individual and environmental),
the significance of self-care, building empathy for the lived and ongoing experiences of students
to better care for and support them, and the impact of adverse childhood experiences on student
behaviors. Per the reflections of the practitioner, structural needs existed around the type and
function of trauma-based supports that teachers need to more effectively meet the diverse needs
of their learners. Teachers' communication on the topic of trauma in the classroom was either
nonexistent or inconsistent, and not from a trauma-informed perspective. Also, teachers preferred
collaborative conversations and opportunities to share personal experiences in the classroom via
a training or workshop setting. Teachers shared that they may benefit from empathy building to
better understand the context and impact of trauma and the shifting population dynamics of their
school community, and to sense support from the school system when meeting their needs

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around student trauma. Adopting a trauma informed care approach that provides teachers with
the knowledge and skills for supporting students with adverse childhood experiences may be a
critical application in trauma-dense environments like conflict and warzones, potentially leading
to more comprehensive services for students via context specific and multi-tiered systems of
support interventions.
Conclusion
As discussed in this chapter, children are vulnerable to trauma and adverse childhood
experiences, with higher exposure to trauma and ACEs leading to negative school outcomes and
negative health and wellbeing issues in adulthood. Living in or near conflict zones, internal
displacement, and the consequence of economic instability, including other factors in war,
increase susceptibility to mental health disorders, with one in five people in conflict-affected
regions having a mental health disorder (Charlson et al., 2019; McDonald, 2021) and only 10%
having access to treatment in LMICs (Sweetland et al., 2014). Approximately 40% of the 108
million people who were displaced by 2022 were children (UNHCR, n.d.-b). To support children
in these volatile environments in LMICs, understanding perceptions of mental health, stigma,
coping, and healing and developing targeted and culturally appropriate, in light of the shortage of
mental health professionals for children, are important considerations. The literature highlighted
that children are facing extreme circumstances and adversity in the Democratic Republic of
Congo and Ethiopia, with armed conflict, displacement, food insecurity and malnutrition,
communicable disease, educational disruptions, and rising grave violations (CFR, 2023; CFR,
2024; EPO, 2023; GCR2P, 2024; HRW, 2024; IMDC, 2024-a; IMDC, 2024-b; Uppsala
University, 2023-a; Uppsala University, 2023-b; UNOCHA, 2022; UNWFP, n.d; USAID, 2024-

68
a; USAID, 2024-b; U.S. Department of State, 2023). Literature suggests developing weak mental
health infrastructures to long-term, comprehensive and robust systems will help close the mental
health gap in conflict-affected regions in LMICs (El-Khoury et al., 2021; Lima, 1987; WHO,
2023) and mitigate the short-term and long-term impact of traumatization in children (Hodes &
Vostanis, 2019). MHPSS, as discussed in the literature review, is a humanitarian intervention
model that is adapted to meet the multi-tiered, mental health and psychosocial support services
needed in conflict settings. Schools are strategic locations to offer preventative and responsive
mental health services to children due its accessibility, early intervention and educational
offerings for displacement and refugee communities, and mitigating role of supporting additional
gaps in service. Further, teachers are first tier providers with an invaluable role in identifying and
supporting existing mental health concerns in complex emergencies (Baum et al., 2009; Brymer
et al, 2012; Panter-Brick et al., 2009; Pfefferbaum et al., 2003; WHO, 2002) and the potential to
increase the scope of mental health practice in schools (Kakuma, 2011; Kase et al., 2017; WHO,
2021) by building capacity to meet the scarcity of mental health professionals in war zones
(Kakuma, 2011; Kos 2005; Wessells, 2017). Chapter three discusses the qualitative methodology
of this study, including the organization overview, selection process, data collection and
instrumentation, data analysis, credibility and trustworthiness, ethics, and role of the researcher.

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CHAPTER THREE: METHODS
The purpose of this study was to explore the perceptions of primary school teachers at
non-governmental organizations (NGOs) in the Democratic Republic of Congo (DRC) and
Ethiopia, including how they make meaning of realities connected to students affected by war,
their own capacity to support the mental health of students, and their current self-supportive and
student-supportive needs in their classroom roles. The following two research questions guided
the research process:
1. How do teachers operating in conflict and post-conflict zones define the experiences of
suffering and healing as it relates to their students?
2. How do teachers operating in conflict and post-conflict zones perceive their capacity to
support the mental health of students impacted by conflict and war?
Qualitative research is based on process theory which emphasizes understanding or
developing non-numerical explanations about the world via an inductive approach (Maxwell,
2013). Since the study was seeking to gain insight about perceptions tied to primary school
teachers at NGO-based schools in conflict and post-conflict contexts, the study pursued a
qualitative approach and utilized purposeful sampling to gain pertinent information about
insights and experiences of interest. A semi-structured interview protocol guided data collection,
and results were analyzed via thematic coding which identified pertinent patterns and themes.
Organization Overview
Organization A (OADRC, a pseudonym) is an international NGO based in the
Democratic Republic of Congo that provides year-round educational services to twenty-three
schools in Eastern Congo, supporting over four thousand students per year. The mission of

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OADRC is to bring transformation to war zones via education, which is driven by the belief that
education builds peace, breaks cycles of war, and every child deserves a high-quality education.
OADRC employs over two hundred staff and faculty members, providing annual staff training
and workshops on the OADRC culture and values, pedagogical framework, teaching approaches,
and classroom management strategies. OADRC has over a 95% pass rate for students on their
national exams, and equal gender representation across their network of schooling. This
organization has schools located throughout the North Kivu region in Eastern DRC, with
additional, partner schools in the Middle East.
OADRC’s community-based programs are geared at building community empowerment.
Leadership opportunities aim at engaging child soldiers and at-risk youth via extracurricular,
recreational offerings, counseling, and group mentorship. Adults who missed out on educational
opportunities during their youth due to war can attend vocational school and receive skills
training to help provide for their families. The United Nations developed a community health
program called water, sanitation, and hygiene (WASH) which educates students on water,
sanitation, and hygiene, and improves access to safe drinking water and sanitation. Finally,
OADRC supports community mental health by engaging in narrative storytelling to help bring
healing to traumatic events.
Organization B (OBE, pseudonym) is a national NGO that focuses on improving
education in Ethiopia. Founded in 2007, its mission and goal are to harness the power of
education to transform Ethiopia, where all Ethiopians can access a nationally funded, highquality education. OBE aims to create sustainable change by building strong partnerships and
empowering its communities. OBE has provided development services to vulnerable populations

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in five regions in Ethiopia, including Amhara, Benishangul Gumuz, Oromia, Southern Nations,
Nationalities, and Peoples (SNNP), and Tigray.
As of today, OBE has built over 185 schools and learning centers, partnered with over
1100 schools, reached almost half a million students with WASH services, provided education in
emergency and child protection services to over 800,000 students, enrolled over 185,000
students who were out of school, and provided capacity building training to almost 750,000
students. This humanitarian organization also provides gender-based violence (GBV) support,
water, sanitation, and hygiene (WASH), and transformational leadership development to the
communities it serves. Additionally, almost 350,000 individuals have received psychosocial
emergency services.
The focus of this research was on the educational experiences and efforts related to the
role of primary school teachers in their conflict and post-conflict contexts, with attention to
teachers’ perceptions on how they make meaning about mental health, trauma, suffering and
healing, their capacity to support the mental health of their children, and their current and future
needs. The teachers are native to their countries and are part of their NGO, working directly at
their NGO-based school site. At the time of the study, certain parts of eastern Democratic
Republic of Congo, in proximity to the city of Goma, were experiencing ongoing violence,
instability, and displacement due to an insurgency militant group. The situation was continuing
to evolve, and many factors were unknown. There were also incidents of conflict and violence
and continued displacement occurring in southern Ethiopia. The changing nature of these
conflicts, their emerging elements, and the extent of their impact are ongoing and not fully
known.

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Selection Process
This section outlines the recruitment process for the target population of this qualitative
study aimed at exploring the perceptions of primary school teachers at NGO-based schools at
OADRC and OBE. The sampling strategy that was utilized was purposeful sampling to ensure
that participants possessed relevant experiences around supporting students via an NGO-based
school in contexts of conflict and war and could provide rich information around their
understanding and insights (Merriam & Tisdell, 2016). Purposeful sampling was the sampling
strategy that allowed for the selection of specific participants given the available access and
connection to OADRC and OBE.
The organization director at both NGOs elected a point of contact to select teachers based
on the following criteria: primary school teachers in grades 1-3, with a minimum of one year of
experience at their current school site, providing educational instruction in their country’s
national language or local/regional dialect, and 18 years old or older. This selection allowed for
both the exploration of teachers’ perceptions and the comparison of individual responses
(Maxwell, 2013) between and across teachers at both NGOs. The cultural perceptions and needs
of teachers around the experience of student adversity and trauma in a conflict and war context
was best understood via a semi-structured interview protocol which enabled the exploration of
questions and probing of directions, nuances, and other meaningful disclosures (Merriam &
Tisdell, 2016).
Communication with directors and elected point of contacts helped answer additional
background questions around the programs offered at the school or organization, including staff
size, student population information, and the educational system’s organizational structure,

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including types of teaching staff available and needed. To best capture a deeper understanding of
the capacity and support systems available to teaching staff in support of conflict and warimpacted students, selection criteria included a sole focus on lead teachers in first to third grade
classrooms, who spoke the country’s national language or the local/regional dialect. This criteria
was prompted by the understanding of local and regional language possibilities that required
translators in various African dialects, including several dialects common to southern Ethiopia,
for example, Konso and Amharic. The language criteria supported conducting the study in the
language of instruction at each school site/region and guided the organization in the selection of
a translator to support the interview protocol process. Considerations for executing sampling and
recruitment procedures included steps taken to minimize the impact of language barriers,
nuanced cultural contexts and dynamics, access to technology, where applicable, and flexibility
with emergent factors including internal or external crises.
Data Collection and Instrumentation
Interviews
The primary data collection tool that was used in this study was semi-structured
interviews with teachers at NGO-based schools at OADRC and OBE. This structure allowed the
respondents to provide open-ended responses, to share additional details that they deemed
relevant to include, and to allow for the exploration, or probing, of participants’ responses
beyond the original set list of interview questions (Maxwell, 2013). The study interviewed
thirteen teachers, seven at OADRC and six at OBE, with each interview lasting between 40-60
minutes and conducted with the help of a translator. The translator was a native speaker provided
by each organization, proficient in English, and had an understanding of education and mental

74
health related concepts. The interviews were conducted in a private space provided by the point
of contact at each organization, whether it was the office headquarters for OADRC for all
interviews, or a classroom space for all interviews at OBE’s school sites.
First, the directors of both organizations, OADRC and OBE, were contacted in August
2023 and were provided with all pertinent information related to this study, including the
information sheet (see Appendix A), interview protocols, and research questions, and were asked
for permission to conduct this research at their organizations with their team of teachers. I asked
the directors if they had any questions, comments, or concerns around the study or on any of the
documents that were shared. Permission was granted by both organizations, and in September
2023, the OADRC director elected a point of contact, the interim deputy director, to help ensure
translation accuracy of the interview protocol to French and to forward recruitment information
to prospective participants for my visit on September 25-29, 2023. The interim deputy director of
OADRC provided a physical copy of the information sheet, translated to French to achieve
cultural equivalency and meaning, to prospective participants. The same steps were taken in
October 2023, where the director of OBE elected a point of contact, a program manager for the
SNNP region, to assist with translation of materials to Konsigna (Ethiopian southern dialect) and
their dissemination to prospective participants for my visit on November 20-22, 2023. Because
the interim deputy director and the southern program manager are authority figures for their
organizations, I reiterated that teachers were to have full permission to choose whether to
participate in this study.
By mid-September 2023, a translation protocol supported attaining the linguistic and
conceptual equivalence of the semi-structured interview guide in the language of interest for

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OADRC: French. To ensure that the interview questions were culturally accurate and appropriate
for the target population, in terms of translation, essence, and applicable to the teaching role or
relevant experience, a two stage, gate-keeping protocol was enacted. Stage one consisted of
providing the interview protocol to the interim deputy director to identify cultural discrepancies,
translation concerns, and reasonableness of questions. The interim deputy director was available
and suited to support in stage one of the gatekeeping protocol. Stage two involved pre-work and
a pre-meeting for this study’s translator on the ground, where the translator was provided with an
explanation of the study, information on the conceptual framework and relevant terminology, the
interview protocols (see Appendices B and C) and information sheet (see Appendix A), and
given ample time to determine the cultural equivalency and meaning for the aspects, concepts,
and protocols related to the study, and ask questions for clarification. The same steps were
completed by the program manager for OBE, with information translated and sent to prospective
teacher participants by mid-November 2023.
One important consideration is the value that community leadership holds within
communal life in Africa. It benefitted the study to present the intention and presence of the
researcher within the community at the time that research was being conducted. This process
included providing the context of the study which involved one-on-one formal sit downs with
teachers to ask questions about their experiences supporting students. The reason for presenting
the intention and presence of the research was two-fold: 1) honoring those in authority as a
cultural value throughout Africa, and 2) connecting with those in authority and gaining valuable
feedback as to how to be in the space that they call home was critical to engaging in appropriate
socio-cultural norms while acting as a researcher and holding a non-native position. Thus, an

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informal interview protocol (see Appendix C) was enacted with local leadership, in this case, the
interim deputy director of OADRC and the director of OBE, during each visit, respectively.
The informal interview protocol was framed by this study’s research questions and
conceptual frameworks and sought to understand the background of OADRC and OBE and
cultural sensitivity within each culture and context. The informal interview, lasting between 30-
45 minutes to allow for introductions, began by stating the purpose of the researcher’s visit,
followed by the interview protocol guide, which informed aspects of the study. Research
methodology was confirmed through the informal interview as more pertinent and contextual
variables were learned about the background of OADRC and OBE, and principles and norms
revealed about cultural sensitivity and the way of life in that region.
During my September visit to OADRC and November visit to OBE, I introduced myself
to all prospective participants, explaining and reviewing the purpose of the study and relevant
information so that participants were informed on all aspects of the study and provided with
copies of the information sheet. The details of the study included its focus on teacher
perceptions, its contribution to research in the areas of school-based mental health support for
traumatized children in conflict and war zones, and eligibility criteria for their participation.
Additionally, the procedures, confidentiality, and potential risks were presented individually with
each prospective participant, including the structure, time, use of recording devices, and all
personally identifiable information removed from data during analysis and reporting. Finally, the
benefits of the study, including contribution to the profession or the field, the status of the study
as approved by an ethics review board, and contact information for additional follow up for
questions, comments, or concerns were provided.

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In-person interviews were conducted with a total of thirteen teachers. The teacher
interview protocol (see Appendix B) questions drew perception insights from teachers and were
based on the research questions and the frameworks for this study: trauma theory, including
adverse childhood experiences (ACEs) trauma-informed care (TIC) with an emphasis on
culturally appropriate, trauma informed support (CA-TIS). The interview questions were aligned
with the study’s focus, providing insight into meaning making, adverse experiences, and conflict
and war-related realities, and the perceived capacities and needs of teachers and students within
the context of an NGO-based schools in both contexts. For example, participants were asked to
define the terms “suffering” and “healing” to provide an open-ended opportunity, with a less
westernized connotation, to interpret their meaning as it relates to their students. The use of these
terms allowed for cultural and contextual knowledge and experience to be revealed without
depending further on mental health terminology that may or may not be within their education or
professional purview. At the conclusion of the interview, respondents were asked to complete a
voluntary, Post-Interview, Participant Demographic Survey (see Appendix D) which acquired
their demographic information, including age, gender, race/ethnicity, religion education level,
and teaching experience. Paper copies of the survey were supplied to teachers, and the translator
and the researcher provided assistance, where needed.
The following materials were available for the interview process in both contexts at
OADRC and OBE: a laptop for field notes and memo reflections, a time-keeping device and an
audio recording device. The field notes served as a record to provide a description of the research
setting, other observations, including non-verbal cues and gestures, interactions, participant
characteristics, quotes and dialogues, reflections, and methodological notes, which included

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challenges, decisions around shifting methodology, ethical considerations, and other reflections
or considerations. Memo reflections supported the data analysis process by capturing a
transparent and analytical account of my thoughts as a researcher and insights through reflexivity
and self-awareness building. Contingent upon the permission given by the participant(s), an
audio recording device tracked start and end times and were used for transcription purposes. All
interviews were recorded with an audio recording device that is password protected. All
participants were thanked for their participation and support of this research. Both organizations
provided translators to develop transcriptions from French for OADRC interviews and from
Konso and Amharic for OBE interviews to English.
Data Analysis
Following the translation of transcripts from French and Konso and Amharic to English, I
began data analysis, relying on coding and thematic analysis and referencing analysis of memos
with information, which included reflections on the comments provided by participants. Coding
is useful for developing theoretical concepts by making comparisons between similar data types
(Maxwell, 2013). I gained familiarity with the interview transcripts by thoroughly reading them
multiple times, at least three total times each. In the initial phase of coding analysis, relevant data
points were identified inductively via open coding, that is, the elements were created directly
from the transcripts (Maxwell, 2013). Next, analysis involved the synthesis or grouping of
empirical codes into axial codes, which reflect an interpretation of the codes developed in the
first phase (Merriam & Tisdell, 2016). Finally, the third phase of analysis involved the
development of patterns or key findings that were based on the theoretical framework and the
research questions guiding the study. The theoretical framework for this study was trauma theory

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with an emphasis on adverse childhood experiences and trauma informed care via culturally
appropriate, trauma-informed support.
Credibility and Trustworthiness
Researchers carry certain biases, assumptions, values, and attitudes to research (Merriam
& Tisdell, 2016), and it is important for the researcher to explore positionality (or reflexivity),
subjectivity (also known as bias), and impact on all aspects of the research process (Maxwell,
2013). Specifically, researcher bias refers to the aspects of the researcher, such as values and
anticipations around the outcomes of the study, that may introduce skewed, non-corrected
findings (Maxwell, 2013). To increase credibility and trustworthiness, and minimize researcher
bias, I maintained disciplined subjectivity and respectful consideration towards respondents
(Merriam & Tisdell, 2016). This will be accomplished in several ways. Reflexivity refers to a
researcher's awareness of the reality that they are part of the world they are studying, and thus,
influence and are influenced within the research space (Maxwell, 2013). I practiced reflexivity
by working through and describing my positionality so that consumers of my study may
understand how certain interpretations or conclusions were made (Merriam & Tisdell, 2016). I
disciplined my subjectivity within the study via reflexivity and working through positionality.
Further, credibility and trustworthiness were based on the experience of the research
participants (Maxwell, 2013), by ensuring accurate storylines, depictions, and disclosures,
according to the feedback of participants. This yielded a higher representation of those
influenced by the topic of interest and minimized harm (Glesne, 2011). Finally, triangulation of
theory supported my view of the context, insights, and perspectives gained from teachers, by

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bringing forward different disciplines, theories, and concepts to describe the fundamental aspects
of perception, adversity and trauma, and multi-tiered supports.
Ethics
According to the American Educational Research Association (AERA) (2002),
educational research is tasked with the highly significant responsibility of respecting the “rights,
privacy, dignity, and sensitivities'' of the target populations and the institutions through which the
work of research is conducted (p. 3). This ethical responsibility, comprised of the interplay
between the researcher’s sense of morality and actual legal duties, is geared towards participants,
colleagues, and society, resulting in protecting participants against harm, upholding trust within
the institution, and considering how the research may impact society at large (Vogt et al., 2012).
The parameters through which ethical research is accomplished include the following five key
principles: a) professional competence, b) integrity, c) professional, scientific, and scholarly
responsibility, d) respect for people's rights, dignity, and diversity, and e) social responsibility
(AERA, 2011).
This qualitative study involved primary school teachers that work at NGO-based schools
in Democratic Republic of the Congo and Ethiopia, and ethical responsibilities were upheld and
guided by ethical principles for research: to protect and respect their dignity, rights, and wellbeing by minimizing harm and maximizing benefits, fairness, inclusivity, and equal opportunity
throughout any and all aspects of the research process (AERA, 2002; AERA 2011). The
information sheet acknowledged the potential risks, as well as benefits, and choice for potential
participants in taking part in the study. Participants were reminded of their voluntary right to
participate or withdraw at any point in the study. Confidentiality, language and meaning, and

81
other pertinent sections of the informed consent process, including the purpose of the study were
discussed. Since this study required a translator (per region) and a recording device, the
participants were given the right to choose whether they wanted to continue participating in the
study or not. They were made aware of how identifiable information was removed or
anonymized when analyzing or reporting this study’s findings.
Prior to leaving the field, I sought the support of a translator to transcribe all interviews to
English, and, afterward, to begin coding and thematic analysis. Since both translators were
provided by the organizations investigated, including the same translator from OADRC and a
separate translator from OBE supporting the transcription processes, they were not required to
sign a confidentiality agreement for the data collection process and research. The identity of the
participants and their disclosures were protected via pseudonyms, and translators were given
access to recordings that supported completing verbatim transcriptions. All materials used for the
interview were kept in locked/protected storage when not in use.
Henderson and Jorm (1994) and Jorm et al. (1990) assert the need to warn participants of
possible distress after noting the reaction in a minority of participants in epidemiological studies.
Stein et al. (2000) presents the ethical dilemma of understanding the needs of survivors and
connecting them with needed intervention, holding that critical factors would need to be
answered before making a determination, for example, of the extent of the trauma and its
psychopathology. Working with vulnerable populations, including individuals or teachers that
have experienced direct or indirect trauma, requires that all participants be informed of the
possible risk of distress (Lochmiller & Lester, 2017) as a factor that may weigh on their decision,

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a notification that was included in this study’s information sheet and presented orally for
prospective participants.
My relationship with OADRC, a non-government organization based in the Democratic
Republic of Congo, is that I joined its ground team for six weeks as a visitor and volunteer
exploring their educational initiatives in the conflict region from February to March 2015.
During this time, I developed friendships and working relationships with participating peers,
organization staff and volunteers, and local children, youth, and adults that participated at or
served alongside OADRC. Due to time passed, it was unknown if any of the aforementioned
individuals or groups continued to serve or participate at OADRC until my visit in September
2023. In August 2023, I re-established communication with the organization’s founder and CEO
via a conversation around my interest to conduct research that would study the avenues of mental
health support for children in conflict zones and warzones. I have maintained occasional contact
with the organization’s founder, who directed me to connect with designated organization staff
that would be able to share their experiences on organization-wide or site-specific mental health
or education initiatives and efforts. Because the study focused on teachers and their perceptions,
and not the perceptions of staff with leadership roles, I did foresee or experience any conflicts of
interest or ethical concern as a non-active affiliate of the organization. I did not have a
relationship with OBE prior to the study being conducted.
Role of Researcher
An important aspect of this research was my role as an instrument of data gathering and
analysis (Merriam & Tisdell, 2016), including the intersection between personal, educational,
professional, and global spheres with a novel, academic experience in a non-native, conflict and

83
war-impacted setting. Although I have short-term experiences developing cultural awareness
across more than 35 countries, including countries with high prevalence of poverty, conflict, and
few infrastructural capabilities to recover from major events, pursuing depth in a particular
context at the research level required me to abide by culturally appropriate expectations that are
still being learned. Brief personal experience and some working knowledge of the intricacies of
the target, cultural context was insufficient to extrapolate on the level of understanding teachers’
perceptions and meaning making, even formulating sound interview questions without an
adequate gate-keeping protocol. It was critical to this study that I continued to build awareness,
rely on mediators and feedback from peers both in the field and colleagues and experts in the
field, and work through my positionality, including how information was gathered, processed,
adaptive to emergent features or unanticipated events, and accurately reflective of the worldview
of the target population (Merriam & Tisdell, 2016).
I also carried personal, educational, professional, and global experience with
understanding and utilized trauma as a frame of reference, including as it pertains to the impact
of trauma in low socioeconomic settings and amongst vulnerable populations (i.e. children). Due
to the greater predisposition to debilitate the human condition, including the short and long-term
effects on the human body and overall quality of life, I may tend to view trauma as more
pathological rather than an opportunity for diverse groupings of strengths within individuals and
collective cultures to exhibit resilience, coping, and growth in the post-traumatic stages. The
perspective I tend to hold as a researcher is that first, all individuals who have experienced war,
rumors of imminent war, and/or civil conflict may benefit to some degree from mental health
intervention, or that mental health professionals with specialized skills in supporting trauma

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victims are ideally suited to support persons, especially in volatile regions. Second, individuals in
low-socioeconomic may not have the resources to seek mental health intervention, potentially,
when other alternative healing approaches may be more culturally acceptable or financially or
proximally feasible. Third, children may be the most vulnerable, and, therefore, the most affected
population group in conflict or war impacted regions. On the one hand, I understand that it is
important to appropriately and ethically consider one’s “social-historical-political location” or
positionality as inseparable from the social process being researched (Holmes, 2020, p. 3). On
the other, it is essential to effectively deal with preconceptions in a way that accurately produces
scientific knowledge that is authentically reflective of the experience and perspectives of the
target population.
According to Hammersley (1993) and Weiner et al. (2012), the responsibility of a
researcher who has worked through positionality entails distinguishing the relationship, or
position, between the researcher and the participants, namely through an insider versus outsider
dialectic, also described as emic versus etic ontological positions. In this research, it was critical
that I understood, with effective competency, the socio-cultural underpinnings of how the target
population conceptualizes suffering, trauma, mental health, and healing. The epistemological
rationale for wanting to accurately and truthfully determine cultural perception, for example, was
that a Western approach to determining needs of any sort, including school-based mental health
needs for students in the context of conflict or war, may be ideologically different for persons
with culturally diverse worldviews. The preceding description is a strength, in my view,
presenting an emic approach to understanding culturally meaningful behavior and action. I
attained culturally meaningful behavior and action by grasping terminology that was reflective of

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the stance of this study’s participants, that is, teachers’ meaning making and perceptions tied to
supporting students at NGO-based schools in volatile regions. As an ultimate objective in this
qualitative study, I provided the ethical conditions necessary that would invite participants as
experts of their own experiences to unravel their own realities in a systematic way.

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CHAPTER FOUR: FINDINGS
The purpose of this study was to understand the experiences, capacity, and needs of
primary school teachers supporting students in conflict and war zones. The study sought to
understand the cultural and contextual meanings of suffering and healing, the needs that are
present in conflict settings, and teachers’ perceived capacity for supporting student mental
health. Thirteen individual semi-structured interviews were conducted, with seven in the
Democratic Republic of the Congo (DRC) and six in Ethiopia, to gain insight for the following
two research questions:
1. How do teachers operating in conflict and post-conflict zones define the experiences of
suffering and healing as it relates to their students?
2. How do teachers operating in conflict and post-conflict zones perceive their capacity to
support the mental health of students impacted by conflict and war?
This chapter provides an overview of the study’s participants, including a description of their
background and regional context, followed by a detailed presentation of key findings for each
research question.
Overview of Participants
A total of thirteen interviews were conducted with seven teachers interviewed in Goma,
Democratic Republic of Congo, an active conflict zone, in September 2023 and six teachers
interviewed in Konso Zone, a post-conflict zone with risk of armed conflict, in Ethiopia in
November 2023. The seven DRC teachers represent four schools located in either a village or
district in the city of Goma. The six teachers from Ethiopia represent three schools located in two
districts in the Konso Zone in southwestern Ethiopia, districts that have hosted internally

87
displaced persons within their communities. Teacher demographic information and all other data
collected and analyzed reflect information acquired at the time of interviews. Table 2 shows
participant demographics including location, age, gender, background, and number of years
teaching in conflict and war zones. The background information reflects both factual and
experiential information highlighting the journey that teachers have taken to their current
teaching position, including, for example, languages spoken during the interview and/or how
they arrived at their current place of employment.
Table 2
Demographic Information Of Thirteen Teacher Participants in the Democratic Republic of the
Congo and Ethiopia
Participant
Name Location Age/Gender Background
Years
Teaching in
Conflict &
War Zones
DRC1
Kingi
Village,
Masisi
Territory,
DRC
23/Male
-Year Two at current site as a second
grade teacher
-Completed high school degree in general
pedagogy
-Feels he has gained practical knowledge
since starting teaching
-Kingi village is where the war started
1
DRC2
Kingi
Village,
Masisi
Territory,
DRC
21/Female
-Second grade teacher.
-Spoke French and Swahili during the
interview.
-Describes profession as difficult because
of impact of war one year after she was
hired as a teacher.
1
DRC3
Kingi
Village,
Masisi
Territory,
DRC
34/Male
-First grade teacher
-Originally, teaching in Masisi - active
conflict zone
-Due to insecurity, he was relocated to
current site
-Relocation of teachers and students also
occurred
3

88
DRC4
Mgunga
District,
Goma,
DRC
34/Male
-Third grade teacher -Received teaching diploma in 2009, and
teaching with current organization for the
last 5 years -Salary decline and low economic status
prompted the move from previous
organization to the current
3
DRC5
Mgunga
District,
Goma,
DRC
28/Female
-First grade teacher for eight years; six at
Mgunga -Teacher describes difficulties teaching in
region, including managing student safety,
parent conflict, displacement, hunger, and
lack of basic needs
6
DRC6
Mgunga
District,
Goma,
DRC
37/Male
-First grade teacher -Teacher used to work in region of Masisi
before war broke out and was declared a
UN red zone -Through friends, the teacher connected
with this organization and was told it was
a good organization to work for
6
DRC7
Mgunga
District,
Goma,
DRC
27/Male
-Third grade teacher -Teacher has taught at the same school for
several years, experiencing a shift to a
new educational system by the
organizational leadership
5
E1
Konso
Region,
Ethiopia
23/Male
-Teacher joined the organization when it
arrived in the Konso Zone during the
conflict -Organization worked closely with local
administration in Konso and job vacancies
opened for teachers in the region
2.5
E2
Konso
Region,
Ethiopia
22/Male
-Teacher originally worked with the
organization on a project near his village.
When a vacancy in teaching opened, he
applied and received the job -Began work supporting students in 2021
2
E3
Konso
Region,
Ethiopia
26/Male
-Teacher described unemployment,
including his personal experience with not
having a job after finishing college. He is
grateful to the organization for giving him
this teaching opportunity -Teacher’s school belongs to organization
3

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E4
Konso
Region,
Ethiopia
24/Female
-Teacher's journey to teaching was
noticing a vacancy with the organization,
applying for the job, and passing the exam
3
E5
Konso
Region,
Ethiopia
23/Female
-Original profession was computer
science.
-Teacher learned of vacancies with the
organization that described supporting
displaced students
1
E6
Konso
Region,
Ethiopia
23/Female
-Teacher shared interview responses in
Konsigna and Amharic languages.
-Teacher shared her worry about a conflict
that had occurred in the area one week
prior to the interview. Teacher is worried
by this and sees the impact it is having on
the students
5 months
Note: DRC and E are provided as a part of the pseudonyms given to participants working in the
Democratic Republic of Congo and Ethiopia, respectively.
Presentation of Findings
Across the thirteen interviews, analysis of the data yielded six key findings, two for
research question 1 (RQ1) and four for research question 2 (RQ2), described in Table 3 below.
Teachers defined conflict as suffering, where its cascading and traumatic repercussions increased
student vulnerability due to displacement, death, continued violence, access gaps to education
and critical resources, and perpetuated mental health concerns and a continued sense of fear and
insecurity. Conflict was presented as threatening the family system, and suffering contained
nuances based on regional context. Additionally, teachers characterized healing as basic needs
being met, which included peace, safety, and acquiring what is needed to return to a normal life.
The most referenced needs expressed by teachers were peace/security, school supplies, and food,
which highlighted safety, physiological, and basic services needs that would create conditions for
healing. Teachers' perceived capacity to support student mental health revealed the versatility of

90
teachers in cultivating spaces and relationships of safety, trust, peace, hope, and unity while
promoting student learning via unique strategies that were responsive to diverse student needs.
Teachers demonstrated an awareness of their own needs and those of their students, including
recognition of taking care of themselves, the challenges of war and their limited capacity to
support themselves and their students, the role and accessibility of consultation with colleagues,
and the function and significance of human connection for students with trauma. Teachers also
discussed their training and capacity backgrounds, identifying limited capacity, that is,
knowledge and skill, in the work of supporting student mental health, the belief that training
would increase their capacity and scope for helping students, and the types of training they had
received. An interesting finding was that just over half of the respondents expressed needing
training to support students with trauma. Finally, teachers highlighted the importance of
organization leadership and the varied support that teachers received, with the most referenced
services being resources, teachers feeling supported, financial support, strategies, workshops and
training, and learning spaces. In short, teachers are strategic actors operating in conflict and
post-conflict school settings, where they deliver a critical, multidisciplinary educational
experience that preserves life, rebuilds humanity, and offers hope. Teachers are instruments of
their own work, both educational attainment and healing, and further investment in their roles
will bring an even higher caliber of comprehensive support and its outcomes to students in wartorn communities. These key findings will be discussed in greater detail through the perspectives
and voices of teacher participants from conflict and post-conflict zones in the Democratic
Republic of Congo and Ethiopia.
Table 3

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Summary of Key Findings
Summary of Key Findings
RQ1: How do teachers
operating in conflict and postconflict zones define the
experiences of suffering and
healing as it relates to their
students?
RQ2: How do teachers
operating in conflict and postconflict zones perceive their
capacity to support the mental
health of students impacted by
conflict and war?
Key Finding 1
"Conflict is suffering"
→ Sub-finding 1: Conflict
threatens families
→ Sub-finding 2: Suffering
has nuances based on regional
context
Versatility of the teacher role
in conflict zones
Key Finding 2 Healing is basic needs being
met
Teacher awareness of needs:
their students and their own
Key Finding 3 -
Training to support teacher
capacity in mental health
Key Finding 4 -
Importance of organization
leadership
Research Question 1: How Do Teachers Operating in Conflict and Post-Conflict Zones
Define the Experiences of Suffering and Healing As It Relates To Their Students?
The purpose of this research question was to understand the cultural and contextual
experiences of teachers by highlighting their perceptions of meaning to “healing” and “suffering”
as they relate to their students in conflict and post-conflict zones. To answer this research
question, the teachers were asked about the challenges that their students face, their description
of both healing and suffering, and their perceived needs to meet those challenges, including the
challenges of supporting student mental health and those as a result of conflict and war. Two
main findings emerged through the data analysis.
1. Conflict is Suffering

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2. Healing is Basic Needs Being Met
The following discussions provide context to the findings, by describing teachers’ perceptions of
challenges in conflict and post conflict zones, including how conflict threatens families, how
suffering has nuances based on context, and the perceived needs that teachers believe may bring
healing to their region and school communities.
Finding 1: “Conflict Is Suffering”
The study participants shared their experience and descriptions of suffering. Teacher
perceptions of suffering described a reality where the cascading effects of conflict and war have
adversely penetrated aspects of students’ livelihood, circumstances, and education. The
consequences that ensued and the experience of suffering seemed to increase student
vulnerability by limiting access to safety, peace, and assurance that needs would be met. Conflict
is suffering was equated to the threat and/or loss of essential resources and supportive
relationships, and lasting fear, insecurity, and the sense of hopelessness for students.
Teacher E5 in Ethiopia described her experience of conflict and suffering stating,
“Conflict is suffering. People suffer from conflict, people are displaced, hunger is happening,
death, and no school. Everyone is displaced from here in the community. There is no school
anymore, houses and villages are destroyed…” Teacher DRC1 added to the concept of suffering
in the following way, “...as a period of adverse situations and difficulties they face during the
war time including the stress and trauma they get when there’s school lockdown due to
insecurity.” This notion of suffering as a traumatic disruption to normal life, with depictions of
displacement, death, destruction, and access gaps, were consistent across most participants’
experiences. Teacher DRC4 stated that suffering is “...a fact of not finding what someone

93
basically needs to be safe and sound,” a description expounded upon by Teacher DRC6 who
described suffering as the lack of food, peace, family, and an education. Teacher DRC2 further
shared how war produces homelessness, relational attachment problems, and educational barriers
in her community, stating, “Most of them [students] become homeless and can’t feel affection
from their relatives. War affects the education of students by causing school closures, fallen
education standards, trauma diseases, difficulty focusing and more obstacles to learning.”
Teacher E4 expanded on how conflict disrupts relational connection, stating, “There is no love,
they do not see each other, people are hiding themselves. This is affecting us, you know.”
Teacher perceptions of suffering revealed categories of adverse disruption in war-torn
communities.
In both regions investigated, teachers shared experiences that dealt with varying types of
suffering, from active, ongoing conflict and war to dealing with serious and pervasive needs in
their communities. Conflict, as discussed by the participants, is suffering and suffering has
brought death, destruction, and determent to education and the possibility of a normal life. The
sub-findings that emerged from the data analysis were:
1. Conflict Threatens Families
2. Suffering has Nuances Based on Regional Context
Conflict Threatens Families. Conflict threatening families emerged as a sub-finding and
refers to the suffering and outcomes of suffering described through teacher experiences,
including death as the most referenced type of suffering, followed by displacement, insufficient
resources, tribal/ethnic conflict, domestic issues, abandonment, and child soldier recruitment.
This sub-finding of how conflict threatens families was mentioned at least once by each

94
participant, appeared a total of twenty-six times, and diverse responses provided detail as to the
type and degree of suffering experienced by students and families.
Ten out of thirteen teachers alluded to death in students’ families, and seven out of
thirteen teachers alluded to homelessness/displacement. Teacher E3 stated, “Suffering comes
from conflict, ‘mekera/mek’ (Ethiopian dialect term for conflict) …like someone might lose their
family, their parents, someone loses house, someone loses his animals, but you can replace the
house or animals but you cannot replace life.” The loss of life is seen as permanent and life itself
as irreplaceable. Similarly, Teacher E2 shared her depiction of suffering as conflict threatening
families: “... people are displaced, people are dying, and kids are seeing [this] with their eyes.
Kids are suffering from this..." Suffering is not only death and displacement, suffering is also
children witnessing suffering. Teachers DRC4, DRC6, and E3 also shared that loss of family led
to ongoing problems, such as barriers to education. Teacher DRC 4 stated, “One of my students
lost their parents during war. The student couldn’t afford basic needs or school fees payment and
that made the student traumatized…” Similarly, Teacher DRC 6 stated, “A student from my
classroom lost his father and couldn’t study anymore because he didn’t have support from
anyone.” Teacher E3 further highlighted educational disruption as a consequence to loss, stating,
“If their father or if their parents are alive, they have enough to go to school. When they are
living with someone [else], they don’t have the chance.” The vulnerabilities faced in conflict
zones are further exacerbated by loss of relevant support systems such as parents and family, a
notion also shared by Teacher DRC2 who believed conflict leads to significant access issues
related to basic needs, like food. Therefore, conflict is suffering, and it means the loss of family,

95
home, and a support system for students to meet their basic needs and access educational
opportunities.
Suffering Has Nuances Based On Regional Context. Although students and teachers
face many obstacles in conflict and post-conflict zones, it is important to highlight the nuances of
suffering that occur due to regional context, including the situational factors that occurred for
some participants, schools, and communities, such as displacement, ethnic/tribal conflict,
domestic issues, fear of abandonment, and other forms of adversity. In the Goma region in the
Democratic Republic of Congo, teachers made the only references to characteristics of an active
conflict zone, tribal conflict, domestic/family issues, and one instance of child soldier
recruitment by a student’s family to the armed group. In the Konso Zone in Ethiopia, teachers
there made the most frequent references to death, displacement, and their impact on education.
Teacher DRC7 described the context of the schools in this region, stating,
All our schools are located in rural environments and from there our students are victims
of tribal conflicts, parenting problems from home, insecurity, hunger…that put students
in unfavorable conditions especially when the students have been surrounded by corpses
for years, this puts them in scary situations.
Teacher DRC7 also described the active nature of the present conflict by sharing the following
on the day that the interview was conducted: “Today, we heard a bomb bursting that made all the
students scared and they couldn’t focus on the lesson…” Teacher DRC1 also described that both
teachers and students had previously heard bombs bursting from the classroom, and Teacher
DRC3 shared that students are affected by the presence of soldiers, police officers, and gunshots.

96
DRC teachers shared depictions of an active conflict zone and suffering included death/loss,
conflict, insecurity, and domestic concerns.
Tribal conflict had also resulted in fear, prejudiced behavior, and a desire to retaliate due
to the loss of a loved one. Teacher DRC1 shared that a student’s brother was killed by the M23
rebel group in a region outside of Goma, a loss the student attributed to tribal affiliation. The
student’s response was to retaliate against other students who belonged to the tribe that killed his
sibling. Teacher DRC1 stated the following:
One of my students went to Kingi Village looking for his brother who was captured and
killed by the M23 which is an armed group of rebels. When the student found out, he
came back home right away and started to get ready for a strike back against all the other
students who belonged to the tribe where that rebel group is from.
Teacher DRC1 also shared about fear amongst students of being confused for a member of the
rebel group, along with ongoing prejudice and maltreatment between students, and parent
support to engage in prejudiced behaviors by joining against other tribes. Similarly, accusations
of specific tribes causing the war were occurring between students, with Teacher DRC3 citing an
incident one day prior to the interview conducted, “Yesterday during class time some of my
students were accusing some tribe of being among those causing war.” Although these accounts
were shared by two teachers from the DRC region, tribal involvement is affiliated with the
conflict, and its consequences are observed in the divide occurring within school and family
systems, that is, racial/ethnic discrimination between students, along with parent involvement,
based on tribal background. Across teacher interviews in the DRC region, conflict was shown to

97
cause disunity between students of different tribes that attended the same school and lived in the
same community.
Finally, domestic issues were only indicated in teacher responses in the DRC regions.
Teacher DRC5 described suffering as negative conditions experienced in the family. Regarding
suffering at the family level, Teacher DRC7 shared about a student's traumatic response to
domestic violence, after learning that his father remarried resulting in ongoing conflict between
parents. Expounding on domestic issues in the home, Teacher DRC5 believed that violence
interrupted student learning and well-being. The teacher stated,
I had a student in the first grade of primary school whose parents used to fight every day.
During the class the kid interrupted and started to cry and told me that his parents fought
so he didn’t sleep at home. He slept on the street and he had not eaten for two days now.
It hurts me so much when I face such a case within my classroom.
The suffering of children and families as a result of active conflict, tribal conflict, and domestic
conflict was highlighted in this regional context and disrupted student learning and well-being.
Suffering here had consequences at different levels of society, and if students, classroom
communities, or families suffered, the greater community may also suffer, as evidenced by
students and teachers experiencing insecurity, tribal conflict and disunity, and domestic violence.
In Ethiopia, death and displacement occurred with greater frequency and were
consistently mentioned by all six participants in Ethiopia. Death/loss was mentioned twelve
times and homelessness/displacement was mentioned eight times. The nuance of suffering in the
Ethiopian context emphasized how loss of both life and home disrupts education. It is
understandable that displacement was a common topic for a region characterized by a large

98
displacement context and community, as many were forced to flee from their original homes and
villages and resided in designated displacement communities. Teacher E1 described sources of
suffering and their impact on community suffering,
Everyone moves from here. This was sad for the community...if there is conflict, there is
suffering. If someone dies, the kids and family, this is suffering. If there is conflict and
houses are burned down, this is suffering. If you are displaced from this area, it is
suffering.
Teacher E6 also characterized displacement suffering and ongoing conflict, where people
are forced to leave their destroyed homes and villages and lack adequate housing. Teacher E6
shared a conflict that occurred in her area one week prior to the interview, involving the stoning
of an individual and retaliation resulting in the burning down of homes, stating, “A week ago
Thursday, a conflict happened here. This is affecting our work. Maybe we will lose our school
here. We are still worried. After the conflict I have ‘chinket,’ (which means fear), or like I'm
afraid of this [conflict]...” Her students were also affected by this event, believing that conflict
would happen again, and had responded by not coming to school. These experiences highlighted
continued conflict, fear, insecurity, and educational disruption in this regional context.
Another contextual factor that framed the type of suffering experienced in Ethiopia was a
period of drought which occurred simultaneously with the conflict in recent years. Teacher E4
shared how a drought impacted food availability, and how she supported students in her
classroom, stating, “There was conflict and drought, no rain and no food. It was terrible, where
students who were very hungry came to me and told me ‘I am very hungry and give [me] your

99
food.’ I shared my food.” She continued by saying that she cried at the thought of her young,
female student who had lost her parents and came to her hungry.
These regional descriptions in Ethiopia highlighted death, displacement, ongoing
incidents of conflict, drought, and their impact on the community and students. In both DRC and
Ethiopia regions, when there was loss of immediate family, education was disrupted, and
students could not afford school supplies, were less likely to attend school, displayed learning
difficulties, and experienced mental health problems. Also, teachers recognized the occurrence of
fear, insecurity, grief, and other psychological sequelae, and the loss of family to support
educational engagement and attainment of basic needs, areas of need that warrant addressing
further. The next finding addresses healing and what teachers believe are the needs to bring
healing.
Finding 2: “Healing Is Basic Needs Being Met”
Teachers were asked to define healing as it relates to their students to understand the
contextual and cultural meaning within their setting. In the DRC context, teachers characterized
healing as peace and safety, access to basic needs, and the solution to suffering. In the Ethiopian
context, teachers characterized healing as a return to normal life, a return to the original village
and home, and basic needs met. Healing was described by Teacher DRC5 as “the solution to all
aspects of suffering.” This solution-oriented notion was further specified by Teacher DRC3 who
stated, “...anything that would help students meet their basic needs in order to study confidently
and calmly.” When describing healing, DRC teachers described healing as a solution, where one
has access to conditions and resources to experience security and acquire basic needs.

100
In Ethiopia, healing was described by five out of six teachers as a “coming back” to
normal life, where a normal life was characterized by peace, the rebuilding of homes, and access
to food. For teachers in Ethiopia, basic needs being met is the process that leads to the
destination. Teacher E3 shared that healing is when people return to their original village,
conflict no longer exists, and people receive what they need to rebuild, stating,
Healing is like when people are displaced and they come back to their original village,
when there is no conflict. People getting help from organizations is healing for them.
Because the conflict is gone, they are coming back to their original village, building their
house, and some people are mentally getting better.
Teacher E5 also referred to healing as receiving external support and returning to school, stating,
“...now, the students are going to school. So, this makes them heal from suffering. So, now they
get food, their houses are already rebuilt.” These accounts describe healing as life with security,
resource support, and the ability to access one’s own home and an education.
Teachers were asked to describe what healing means to them as it relates to their students
and their students’ most important needs from both the school and their teacher that would help
them on the path to healing. Table 4 discusses teacher responses which highlight their
perceptions of what students need in order to heal from their faced circumstances. Additionally,
needs were categorized according to Maslow’s Hierarchy of Needs (Maslow, 1943) and the
Intervention Pyramid for mental health and psychosocial support in emergencies by IASC (2007)
to understand the types of support that teachers described. Their responses are provided, ranked
in order from highest frequency to lowest frequency.

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Table 4
Teacher Descriptions of Healing For Students in Conflict and War Zones
Teacher Descriptions Of Healing For Students in Conflict and War Zones
Need Type Occurrence Region
(DRC/Ethiopia)
Category of
Need (per
Maslow, 1943)
Category of Need
(per IASC, 2007)
Peace/Security 24 (17 in DRC) Both Safety Basic Services &
Security
School Supplies 15 (11 in
Ethiopia) Both Safety Basic Services &
Security
Food 14 Both Physiological Basic Services &
Security
Good
Teacher/Education 10 (8 in DRC) Both
Physiological
Safety
Love
Esteem
SelfActualization
Basic Services &
Security and
Community & Family
Supports
Affection/Compass
ion
7 (6 in
Ethiopia) Both Love
Community & Family
Supports
Joy/Hope 6 Both Safety Community & Family
Supports
Mental Health
Support 6 Both Safety
Focused, nonspecialized supports
and
Specialized Services
Health Care 5 Both Safety Focused, nonspecialized supports
Clothing 5 (4 in
Ethiopia) Both Physiological Basic Services &
Security
Government
Support 5 Both Physiological/
Safety
Basic Services &
Security and
Community & Family
Supports

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Financial Support 4 DRC Physiological/
Safety
Basic Services &
Security
Homes Rebuilt 3
Ethiopia (3
teachers) Safety Basic Services &
Security
Hygiene 2 Ethiopia Physiological/
Safety
Basic Services &
Security and
Community & Family
Supports
Family Support 2 DRC Love
Community & Family
Supports
Clean
Environment 2 Ethiopia Safety
Basic Services &
Security and
Community & Family
Supports
Support for
Disabilities 1 Ethiopia Physiological/
Safety
Basic Services &
Security,
Community & Family
Supports,
Focused, nonspecialized supports,
and
Specialized Services
Transportation 1 Ethiopia Safety Basic Services &
Security
Fun 1 DRC Love Community & Family
Supports
Practical
Knowledge (use of
mosquito net)
1 Ethiopia Safety Basic Services &
Security
Using the assertion made by Teacher DRC 6 that basic needs include food, peace, family,
and education, basic needs in these contexts mean that physiological, safety, and love/belonging
needs must be met in order for healing to occur. The categories of physiological, safety, and love
(belonging) are tiers in Maslow’s original theory of human motivation. The needs described by
teachers all fall within these three categories. Peace/security, a safety category within Maslow’s

103
framework, was referenced the most, a total of 24 times, with 17 references made by DRC
teachers. Higher occurrences in DRC may be attributed to it being an active conflict zone.
Teachers DRC 1 and DRC 4 specifically cited needing government support with a cease fire or
declaration of peace with the opposition group.
The cascading effects of war were alluded to by several teachers. Teacher DRC7 stated
that war leaves a negative impact on minds, education, and employment stating,
We need peace because when war and conflicts don’t end, our mind and even education
will be negatively impacted. We will be jobless and when there’s no job, hunger will hit
people all around. So, as a matter of fact, things don’t move on correctly in war and
conflict time.
Teachers believed peace is needed to bring healing for students. Teacher DRC4 stated, “We want
the government to declare peace with the opponents, to help our kids to study in very good
conditions.” Teachers desired peace/security in their conflict and post-conflict communities.
Second, teachers believed that school supplies, referenced a total of 15 times, were
needed for healing and may be conceptualized as a safety category in Maslow’s framework. The
rationale for the categorization of school supplies as a safety need is because it supports students’
attendance in school, their ability to engage in the classroom environment, and overall, may
prevent students from engaging in at-risk behaviors if school were not accessible. In the
Ethiopian regional context, school supplies were referenced eleven out of the fifteen times, with
four out of six teachers sharing that school supplies arrived late to their school, creating barriers
to learning. This result may be due to regional locations being remote and difficult to reach. The
effect of delayed supplies, including books and classroom materials, was described by Teachers

104
DRC1 and E4. Teacher DRC 1 stated, “I need my students to be provided with more books to
help their proficiency when they are impacted by war, trauma and stress. We want to have our
own books because we’ve been renting books from other schools.” The teacher cited learning
delays caused by conflict and teaching being possible based on book rental availability. Teacher
DRC 6 also shared more on unaffordable schooling,
There was a student who was kicked out from school due to lack of school fees and
supplies. The student went back home to ask for money but unfortunately the parents
couldn’t afford that…I was obliged to use my money and buy some copybooks and other
school supplies for the student.
Unaffordable schooling is a learning constraint for some students, and Teacher E3 further
highlighted how lack of resources may create student safety concerns,
…[I] beg neighborhood families who have enough to help out, telling them this student
does not have school supplies, and we buy them a pen and exercise book. Because some
of the students don't want to share their needs because they’re afraid, we go to their
family and ask them what they need…if material is not on time, this is the moment I help.
These perspectives demonstrate a barrier to both education and healing. School supplies are
considered a basic need that bring healing, where students feel safe to join their school
communities, fostering both learning and attendance.
Third, teachers referenced needing food a total of 14 times, a physiological category in
Maslow’s framework. Teacher DRC7 described that the suffering and trauma of food insecurity
in her school could be healed when the needs of joy, hope, and food are met for students.
Teacher E4 stated that teachers need a feeding program to support attendance,

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A feeding program is helpful because school starts in the morning and students come
back in the evening. So, the whole day the students stay in school. If there is a feeding
program, they will stay…A school feeding program is very good if we work closely with
the organization as it empowers children to continue going to school.
Teacher DRC5 shared about a moment that occurred the morning of the interview,
Today, I had a five-year-old student who came with her mother to the school. When her
mother left, I stayed with the kid in the classroom and the kid was sweating so much.
When I saw that, I immediately noticed that it was due to famine, so I shared a muffin I
had in my purse with the kid and I gave her a cup of water.
Healing in the context of conflict and post conflict zones, as described by teachers, occurs when
the basic need of food is met for students.
On November 22, 2023, while in the southern region of Ethiopia, I wrote a field note
highlighting a thought about conflict zones, which stated, “Without peace, there is no mental
health. Without peace, people will not thrive.” This was the sense that I felt during my time in
Ethiopia, which proved to also be true for my time in the Democratic Republic of Congo. It is
important to note that following the in-person interviews in September and November 2023, the
following messages were conveyed to me. On February 8, 2024, my translator who supported me
in DRC sent me a message on WhatsApp, stating, “We’re in war here. Here in North Kivu
province, 20 miles from Goma. Rebels M23 and Congolese Army. Last Monday the rebels were
at 5 miles from Goma already. But they have just pushed them back.” On 4/15, the interim
deputy director of the organization in DRC who supported this study stated,

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Julian, as you know, Goma is in a war situation, several thousands people who fled the
war are currently living in about ten camps around the city. Every day, bombs from the
enemy fall into these camps and kill innocent people. Imagine the suffering, the fear and
above all, the trauma that these people experience everyday…Dear Julian, I know that
you do not have enough resources to respond to this situation. But perhaps through you,
we can reach individuals or organizations, churches who may be sensitive to this
suffering and who can give something to help.
From the perspectives shared by teachers, and recent messages received from DRC, peace is the
priority needed in these contexts and necessary for healing. Teacher E2 desired peace and a
normal life, stating, “I want my people to have a normal life...for myself I need peace, I want to
continue my life and work.” Therefore, not until basic and survival needs are met, including
peace, security, and access to food and an education, can students be better positioned to heal.
Summary of Findings for Research Question 1
The purpose of the research question was to understand the perceptions that teachers have
of suffering and healing in their cultural context and the needs that exist for students in conflict
and post-conflict zones. “Conflict is Suffering” emerged as the first finding, where suffering was
described according to experience and context, and involved death, destruction, and a deterrent
to education and the prospect of normal life. The first sub-finding that emerged was conflict
threatens families, which was characterized by death, displacement, and insufficient resources,
tribal conflict, domestic issues, abandonment, and child soldier recruitment. Conflict threatens
families and the lack of family support, especially where loss of life occurs, increases student
vulnerability. The second sub-finding that emerged was that suffering has nuances based on

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regional context. In the DRC, teachers referenced suffering as tribal conflict, domestic issues,
and one instance of child soldier recruitment, with a depiction of student mental health and
behavior as being influenced by locality. In Ethiopia, teachers more frequently referenced death
and displacement, which is expected because of the displacement communities they serve, and
shared incidents of ongoing conflict and its impact on the school community and learning. The
second finding that emerged was “Healing is Basic Needs Being Met,” where healing was
described as attaining the basic resources needed, aligned with Maslow’s Hierarchy of Needs,
and a return to a normal life without conflict and with access to sustenance and homes. The most
referenced needs for healing among all teachers in Ethiopia and DRC were peace/security,
school supplies, and food, which are security and physiological needs in Maslow’s Hierarchy
and were responses to questions of defining healing and what students need the most from both
their school and teacher. How teachers perceived their capacity for supporting the mental health
of students impacted by conflict and war will be discussed in the second research question.
Research Question 2: How Do Teachers Operating in Conflict and Post-Conflict Zones
Perceive Their Capacity To Support The Mental Health Of Students Impacted By Conflict
and War?
The purpose of the research question was to understand teacher perceptions of their
student mental health support capacity in the conflict and war context. To answer this question,
teachers were asked to share their perceived capacity to support their students, including their
strengths and areas needing improvement, an example of when they may have supported a
mental health need in their classroom, the supports they received to engage in this type of student
service delivery, including professional development and support from other teachers and school

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leadership, and how they were dealing with conflict and war, including their own needs and
those of their students. Four main findings emerged through the data analysis.
1. Versatility of the Teacher Role in Conflict Zones
2. Teacher Awareness of Needs: Their Students and Their Own
3. Training to Support Teacher Capacity in Mental Health
4. The Importance of Organization Leadership
The following discussions provide evidence and context to the findings.
Finding 1: Versatility Of The Teacher Role in Conflict Zones
Teachers in conflict zones take on multifaceted roles due to high, persistent, and diverse
needs in their environment. The versatility of the teacher role in conflict zones is the first finding
that emerged. This versatility extended beyond strictly an academic role and required support
beyond what the school could provide. In the settings studied, teachers ensured student safety
and trust, promoted peace, hope, and unity, and implemented unique ways to promote student
learning in conflict and war zones. Teachers embraced a role characterized by the belief that they
could help students heal and that they could be changemakers in their communities and regions.
First, teachers created a safe and trusting space for students in conflict and post-conflict
zones, with evidence of this occurring a total of thirty-two times across the interviews. Teacher
DRC2 characterized supporting students with trauma in the following manner,
I actually didn’t receive any type of training to support the mental health of my students
but the only thing I was doing to help is that when students were traumatized, I provided
them with compassion, affection and always was a genuine close friend for them to know
what they feel within them.

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Similarly, Teacher DRC3 ensured student safety and offered care, stating, “I’m able to keep
students safe when there’s a traumatic situation, I can show them affection and make them feel
loved.” These teachers emphasized an ability to understand a student’s state of being and
respond with proximity and care. Teacher DRC4 described a type of special care given to
students who had lost family, citing the approach of presence and sympathy, stating,
During class time there was a student who was crying in my classroom. When I noticed
that, I had a talk with the student and asked him why he was crying. The student told me
he was thinking of his parents who passed away, so I was obliged to stay close to the
student and sympathize with him.
These descriptions showed several ways that teachers supported students' sense of safety,
emotional needs, grieving processes, and other basic needs they had, including after the loss of
their parents. Table 5 further describes the ways teachers fostered student safety and trust in their
classrooms. Teachers predominantly supported safety and trust through varied forms of human
connection and psychosocial support.
Table 5
Ways Teachers Cultivate Safety and Trust For Students in Conflict and War Zones
Participant
Name
Ways Teachers Cultivate Safety and Trust for Students in Conflict and
War Zones
DRC1 1) Demonstrate kindness, respect, and empathy towards the challenges
students face
2) Responsive to students’ real emotions such as fear and worry
3) Ensure the students’ protection and assure the students’ sense of safety
4) Give assurance to students, having grown in capacity to do so through
difficult situations
5) Identify students' feelings/thoughts during war & conflict and help students
regulate and remain calm
6) Protect students and families
7) Remain committed to supporting others during war time

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DRC2 1) Providing compassion, affection, and a close presence
DRC3 1) Help students feel safe, cared for, and loved
DRC4 1) Spending time with students, understanding their feelings, and providing
support within his capacity to do so, such as affection
2) Supporting grieving students with presence and sympathy
3) Supportive and patient with all behaviors of students with trauma
DRC5 1) Provide advice/counsel to students with trauma
DRC6 1) Advice/counsel to students who have lost hope and encouragement through
life’s difficulties
2) Assure student safety and encourage students through worsening situations
DRC7 1) Provide advice/counsel to mitigate stress
2) Improve student mood through games and dance
3) Provide advice/counsel and make students feel loved
4) Not fleeing or running away during war
5) Protect students and assure their safety
E1 1) Provides special care for students who have lost their family, including
school supplies, advice/counsel encouragement, and asking if they have any
additional needs
2) Consistent support to students and motivation to do their best
3) Conduct home visits to identify barriers to student attendance provide
solutions, like, school supplies
E2 1) Support students who have lost family by providing motivation, spending
time with them, and making students laugh through jokes to redirect their
attention off of hardships
2) Providing advice/counsel to students
E3 N/A
E4 1) Offering support via encouragement and love
E5 1) Provide special care to students who have lost family members via presence
and support
2) Teacher provides advice/counsel and encouragement
3) Increasing student awareness/knowledge about the conflict, and playing
with students
E6 1) Responsive support to the unique needs of students
Second, teachers promoted peace, hope, and unity which was referenced a total of 15
times across interviews. Teacher DRC1 shared that teachers received a workshop on sustaining
student hope, stating, “First of all, when we were all displaced, we were at Bulengo Camp. Some
school leaders called us and organized a workshop with us about how to help students maintain
their hope…” Here, during the initial stages of displacement, priority was given to teacher

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training on hope as a possible emphasis on what students urgently need. Teacher DRC2 further
shared how personal endurance through difficulty gives students hope, sharing, “As a teacher of
trauma impacted students, I’ve learned to hang in there and put up with difficult times because
my endurance will still give hope to students.” This teacher’s self-awareness identified
endurance as a trait that students can both identify and depend on to experience hope. Teacher
DRC7 encouraged students to hope in God, who he felt would offer help and stability to their
lives, stating, “My first strength is providing them with pieces of advice, telling them to not to be
stressed because things will be fine as long as we all hope and expect God to help us bring
control to everything.” Teacher DRC7 highlighted the significance he places on spirituality and
its ability to produce hope for him and his students. Finally, Teacher DRC5 shared that despite
the political challenges embedded within conflict, she builds unity among her students,
describing, “...when there’s conflict, I do the best I can to unite students so they live as friends
not as enemies.” Based on political and ethnic affiliations in this context, Teacher DRC5 focused
on building a culture of friendship and unity to minimize conflict in her classroom.
These accounts highlighted the various ways that teachers promoted peace, unity, and
hope in their classrooms and communities. Teacher descriptions demonstrated that teachers
believed promoting these values as necessary and helpful towards minimizing loss of hope or
hopelessness, child soldier recruitment, hostile views or actions of students towards other
students, and participation in conflict. Teachers also believed they had the ability and
responsibility to use their knowledge or their ability to effect change and shift the culture within
their community despite conflict, hopelessness, and disunity occurring.

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Third, the versatility of the teacher role included finding and implementing unique
strategies to promote student classroom learning in conflict and war zones. Teachers believed
they could promote learning by offering unique strategies in the classroom that served and
benefited students. Teaching strategies to support students' learning appeared eighteen times in
participant interviews. Most teachers believed that specific and varying types of education can
better support students. Table 6 reviews how strategies, modified learning opportunities, and
teacher attitudes, while taking regional considerations into account, fostered student learning,
including supporting focus, mental capacity and ease, and promoting student mental health and
academic growth and/or accelerated learning.
Table 6
Teaching Strategies For Promoting Student Learning In Classrooms in Conflict and War Zones
Teaching
Strategy
Teaching Strategies For Promoting Student Learning in Classrooms in
Conflict and War Zones
Classroom
Lessons
→ opportunities for individualized learning, finding peace, forgetting difficulty
times, focusing on coursework, and having fun via dance/joking (DRC1)
→ teaching students to forget bad moments and past conflict (E4)
Books and
Reading
→ build mental capacity, help students forget difficulties, keep minds active,
promote mental and emotional capacity (DRC1)
→ increase academic proficiency and help forget difficulties faced (DRC2)
→ sustain focus on learning (DRC3)
Games and
Dance
→ effective for helping students with trauma (DRC5)
→ support learning various subjects and decrease loneliness/support connection
building (DRC6)
→ a refresh or break for students who are experiencing negative thoughts, includes
song, dance, and movement (E5)
Simplified
Teaching
Method
(Ethiopia)
→ make learning easier, help students forget difficulties, support student mental
health (E1)
Teacher
Mindset
Towards
Students
→ joy and hope at improving students mood and the future opportunity afforded
through a quality education and wanting to build a good reputation in the
community (E3)

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and
Teaching
(Ethiopia)
→ full effort and use of everything in their capacity to support students (E4)
Modified
Education
for
Displaced
Students
(Ethiopia)
→ remedial education that helps displaced students gain three grade levels in one
year, uses simple teaching method approach, increases student attendance,
believed (by teachers and students) to bring students to an equal level of
educational attainment as their peers in normal/traditional schooling by program
completion (E5), also described as providing special care for conflict impacted
students between 10-14 years who have typically started their primary education
at 7 years old.
Overall, teachers are versatile actors on educational frontlines in conflict and postconflict settings. Teachers cultivate safety and trust with their students allowing for students to
approach teachers with concerns and feel a sense of safety through adversity. Teachers support
students’ emotional needs, grief, and other diverse needs mainly through human connection and
the psychological and social support it provides. Second, teachers promote peace, hope, and
unity in their classrooms as necessary for child protection and building student hope. Teachers
believe that teaching and ensuring these values are important and that students can carry these
values. Third, teacher versatility was found in the broad scope of duties that support students'
needs, even beyond academic benefits. The education that teachers provided in conflict and post
conflict zones was responsive to student needs, improved student mental health, helped build
academic proficiency and mitigated learning loss, increased student connectedness with the
classroom community, and, through teachers’ mindset, aimed to bring happiness and hope to
students. Teacher identified needs, including their own needs and those of their students will be
discussed in the next finding.
Finding 2: Teacher Awareness Of Needs: Their Students and Their Own
The second finding emerged when teachers were asked how they were dealing with
conflict and war. Teachers described needing to attend to their own needs, which was discussed

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by six out of the thirteen participants. Five of the six were DRC teachers and one was a teacher
in Ethiopia. Teachers were also aware of their own feelings and struggles and those of their
students in light of present hardships. Further, DRC teachers, in particular, recognized the need
to support their colleagues in this work as best as they could, with six out of the seven DRC
teachers sharing how that support was given.
First, teachers recognized the need to take care of themselves and to be responsive to
their own needs, including their mental health needs, to support others. Specifically, four DRC
participants identified the need to support their own self-regulation needs, three DRC
participants alluded to holding onto hope, two of the three referenced their spirituality by hoping
in God, and two participants referenced a need for understanding or identifying the conflict
situation. Teacher DRC 7 reflected on how a past training helped teachers live in a war zone,
I received training on how to deal with living in an area impacted by war and conflict.
Whenever there’s conflict around, as a teacher, I have to find a way to manage that and
bring solutions, positively supporting my mental health and my students’ mental health.
Teacher E1 dealt with conflict by doing research to understand the conflict, stating, “We have to
do research about what caused the conflict, including why they are in conflict, try to understand
what is conflict, and why people are fighting. We have to do research on why they are fighting.”
While two teachers in DRC and Ethiopia referenced the need to understand the conflict, teacher
DRC3 highlighted its personal benefit in helping him overcome difficulty, and Teacher E5
believed it was her strength to provide students with awareness about the conflict in their region.
Thus, a mental health benefit may exist, for both teacher and student, in understanding and
sharing knowledge about the nature of the conflict. More teachers in DRC than in Ethiopia

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responded about their mental health needs with self-awareness, possibly due to having more
experience with decades-long war and conflict. Their experience may have made it essential to
care for their mental health needs in order to deal with the reality and stress of conflict.
Teachers in DRC and Ethiopia recognized that the challenges of war, including student
challenges, were beyond their capacity to support. When asked about their capacity to support
the mental health of students with trauma, teachers responded with diminished or no capacity to
support due to not being able to meet their own needs or student needs. For example, Teacher
DRC 2 believed that it was difficult to help students overcome hardship and engage with
learning, stating, “It’s not easy for me to make my students forget what difficulties have
occurred. Sometimes I can’t even help them be active in the classroom when the situation is
beyond me.” Teacher DRC4 also believed that he lacked mental health support skills, stating,
“My capacity is not strong enough because sometimes I can’t assist students. I had my
expectancy on being supported by the government, and other skilled people in trauma issues.”
Teachers also described having no capacity or resources to support students. Teacher DRC5
lacked support capacity, including to meet his own needs, stating, “I don’t really have what it
takes to do that because, personally, I can’t manage satisfying my needs so it’s hard for me to
support the mental health of my students.” Teacher E4 further described the emotional tension of
not being able to help, even with providing food, stating, “...my heart is broken because of the
kids. If I had, I would give and if I don’t have, this breaks my heart.” Teachers were aware of
their own needs and their limited capacity for supporting their needs and those of students. For
teachers in both regions, emotional capacity to support others was strained by current challenges.

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When asked about how they were supported to meet the needs of students with trauma in
the classroom, five out of the seven teachers in DRC stated that they consulted with one another
on student cases to a degree, demonstrating an awareness to collaborate. Teacher DRC6 shared
that teachers frequently support each other, stating, “We often help one another. When there are
trauma-impacted kids in my classroom, other teachers would tell me to always be kind with the
students and bear their way of being to not add more stress and trauma on them.” Teachers in
Ethiopia, on the other hand, did not discuss engaging in similar consultations. This may be
because teachers in Ethiopia tend to be the sole teacher from the organization at their remote
school location, which may make it more difficult to collaborate with colleagues who are
engaging in the same model of care and educational service delivery. This issue was further
compounded by access issues to transportation, poor road and climate conditions, and conflict
situations in nearby proximity.
This finding demonstrated that teachers recognize the need to be responsive to their own
needs, that the challenges of conflict and war feel beyond their capacity to support, including
their emotional capacity, and the need for collaboration with colleagues on best practices to
support students with trauma. In Ethiopia, some teachers acknowledged the importance of
understanding the conflict, including promoting student awareness, and did not consult with
colleagues, possibly due to barriers like proximity, road access/transportation, and climate that
make it difficult to collaborate. The need for humanity and rebuilding humanity in conflict and
war zones was also clear, and teachers in these settings understood the human need for
connection, especially within their roles and settings. The need for training and the training
received to support student mental health will be discussed in the next finding.

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Finding 3: Training To Support Teacher Capacity in Mental Health
In reflecting on their capacity to support the mental health of students impacted by
conflict and war, seven participants, five from DRC and two from Ethiopia, stated needing
training to support students with trauma, just over half of all participants. The need for training
was expressed more than once for some participants and a total of fifteen times across the seven
participants. Five out of seven teachers believed they needed training to support the mental
health of their students, and three DRC teachers referenced not being able to provide
psychological support to students.
Teacher DRC5 specifically mentioned the need for training in identifying and supporting
the source of trauma, stating, “I haven’t gained a lesson on how to support the mental
psychology (health) of a student,” which may lead to inefficacy in student support. Teacher
DRC2 also stated, “I can’t psychologically help them enough,” with Teacher DRC 5 affirming
this need, stating, “…I’m not a psychologist. It’s a little difficult to help the mental health of
students if I don’t have knowledge in psychology because in psychology there are so many ways
to support the mental health of trauma-impacted students.” Teachers shared a lack of knowledge
and skills to support student mental health and trauma.
Teachers DRC7, E1, E3, and DRC1 specifically expressed that their capacity to support
students was contingent on receiving professional training. Teacher E1 stated, “We have more
strength if we get more training. For mental support, we need more training to be supportive. We
will have more students to support if we will have more training to be strong and supportive.”
Teacher E3 also expressed needing further training, stating, “I need more trainings. This is
creating a lack because if they give more training, I will be successful…They don’t give more

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training anymore.” Teacher DRC1 described his confidence in what more training could
accomplish for students, stating “I can do anything in any field to support the mental health of
the students only if I get trained by skilled people from that field.” These teachers demonstrated
a need, desire, and expectation that receiving additional training would increase their capacity
and scope of practice within their educational roles.
Additionally, teachers were asked to share the type of training or professional learning
opportunities they had received, if any, related to supporting trauma-impacted students and
families. In response, teachers described the training they received to support students with
trauma in Table 7. The table shows descriptions of training received, or not received, and also
sheds light on how the lack of training or the training received led to feelings of need or
empowerment.
Table 7
Teacher Training Received By Region, Source, and Description/Type
Participant
Name Source Teacher Training Received by Description/Type
DRC1 - No Response.
DRC2 - No Response.
DRC3 Unknown Identification of emotions, provision of support and consolation to
redirect attention away from trauma training
DRC4 External &
Internal
Identification of student feelings/emotions and corresponding support
(Source: External - Psychology/Mental Health - several workshops
for teachers). Supporting students training (Source: Internal -
organization/school leadership team - several workshops)
DRC5 Internal -
Organization
Child safety/protection training to understand the root of trauma,
providing support to meet basic needs, and protection of children
DRC6
Internal -
Organization
Leadership
Team
Consultation with colleagues training to share concerns or issues,
including beyond one’s ability to solve

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DRC7
Internal -
Organization
Leadership
Team
Identification of trauma symptoms and minimizing stress training;
how to support students with trauma through a trauma care program
in 2023
E1 Internal -
Organization
Supporting and caring for students in conflict and preparation for
risks of students losing family members and displacement training; a
post-examination, mental health training
E2 Internal -
Organization
Life skills development and social emotional learning for students;
supporting students with trauma, including loss of life, destruction of
homes, and displacement; a mental health and psychosocial support
training
E3 Internal -
Organization
Supporting students suffering from conflict and Accelerated Primary
Learning Program training for student life skills development and
simplified teaching strategies; via pre-teaching trainings
E4 Internal -
Organization
Supporting students, helping students experience happiness, and
simplified teaching methods training; teacher unable to recall name
of training
E5 Internal -
Organization Teaching & student psychosocial support trainings
E6 Internal -
Organization
Supporting student mental health training; training described as
responsive to student needs and trauma
Regarding training received to support students with trauma, teachers described how
training has built capacity for student support. Teacher DRC 4 shared the outcome of trainings
provided by a psychology/mental health team, stating,
I’ve been trained to support trauma-impacted students by making an investigation about
feelings they have or exude within them, and when some analyses have been taken as a
teacher, I have to act compared to what I felt students need to be supported.
Here, training helped the teacher identify student feelings and determine a targeted intervention.
Teacher DRC5 expounded with learning gained in a child protection training, stating, “...when
you have a trauma-impacted kid, you need to talk to them, understand the source of their trauma,
and it’s always better to assist with something to meet the needs of the kids such as food and

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school supplies.” Teacher DRC7 also described a training to identify student trauma symptoms
and minimize stress, stating,
I have learned how to get trauma-impacted students out of stress and there are some
symptoms that may mean there is trauma within the student. Among the symptoms we
have: sleep, crying, troubles, quietness (not talking), and hunger that is detected by sweat.
Teacher E3 further described life skills training through Accelerated Primary Learning Program,
I gave life skills every three months for all students. I am trying my best for students to
come back to their normal life. We are giving them hope that they will be successful
when they finish, grow up, get a job and everything. Also, we give them life skills for
their family lifestyle. This is bad, like early marriage, there are side effects of early
marriage, kidnapping, gender inequality, because as a culture there is something like
early marriage, it is not good for their health. This is my strength, what I got from the
training.
DRC teachers stated that they received training on identifying and supporting student
emotions/feelings, consoling students to redirect attention from trauma and hardship, consulting
with colleagues to share student concerns and find solutions, minimizing student stress, and
serving students with trauma through a novel Trauma Care Program provided to only several
teachers per school site. Because of varied responses, it was unclear if these trainings were
provided to all teacher participants or selectively provided at certain times during their
employment with their organization. Teacher participants from Ethiopia all received mental
health and psychosocial support training via their organization and implemented the Accelerated
Primary Learning Program to students, which teachers described as modified teaching compared

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to traditional education and models in Ethiopia. In this model, teaching was responsive and
simplified to support student mental health needs and life skills were periodically taught to
promote student safety. The finding that teaching was adapted to student mental health needs
seemed to be unique and specialized to how teachers in this context provided educational
services in post-conflict zones. This pre-service training prepared teachers for how to support
students who had suffered the loss of family, destruction of homes, and/or displacement.
Overall, seven teachers expressed needing training to support students with trauma and a
lack of knowledge and capacity for doing so. These teachers also believed that training would
increase their capacity to support students. Teachers who expressed needing training either
received minimal training, no training, or insufficient training on supporting student trauma and
mental health in their careers. For those teachers who did not express needing additional training,
the extent of their learning and application is uncertain, including the efficacy of their training
and educational delivery on students. The next finding will discuss how organization leadership
plays a role in supporting the mental health of students impacted by conflict and war.
Finding 4: The Importance Of Organization Leadership
The fourth finding that emerged related to how organization leadership helped teachers
with various types of needs, including school materials and teacher training to support students
with trauma. Specifically, teachers were asked what school leadership has done to support them
in teaching trauma-impacted students, if anything. Organization leadership supporting teachers
and the work of supporting students, including with trauma, appeared twenty-three times across
twelve of the thirteen participants. Four of twenty-three references were about how other
organizations or partners to their current organizations have supported teachers’ work and are

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indicated in Table 7 as: “*External.” Table 7 features descriptions of the ways organization
leadership supported teachers within their roles at their schools, which indicated: resources,
teachers feeling supported, financial support, strategies, workshops and trainings, learning spaces
provided, specific support to students, specific support to families, mentorship, support from a
mental health professional, work salary, guidelines and instruction, feedback and student
evaluation, and transportation. The types of support received by teachers reflected the ways
teachers felt supported.
Table 8
Organization Leadership Support Provided To Teachers in Conflict and War Zones
Participant
Name Type Organization Leadership Support Provided To Teachers By
Type/Description
DRC1 Feeling
Supported
Feeling supported by organization, including compassion shown to
teachers
DRC2 Books,
Workshops
Provided with books to help increase academic proficiency and
help students forget difficulties they have faced; workshops in
response to traumatic situations at school to help monitor students
assess basic need
DRC3
Books,
Mentorship,
Hope,
Financial
Support, and
Showing
Support
Books and engaging lessons for students; *External organization
provided instruction on how to help students grow in resilience and
endurance; mentorship for teachers, hope to persevere in
supporting students, and financial support to help meet students’
basic needs; organization shows ongoing commitment/support to
teachers
DRC4
Clothes/Food,
Supportive
Response to
Issue (counsel,
financial
support, and
strategies)
*External organization provided clothes and foods supplies to help
improve learning conditions for students; organization response to
teacher notification on traumatic issue in the classroom, which
included counsel, financial support, and strategies to support the
affected student
DRC5
Psychologist
Support,
Resources,
Strategies
Organization provides support from psychologist who provides
support in cases with student trauma; resources support; strategies
for support student cases, including those beyond teacher’s
capacity to solve

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DRC6
Salary,
Financial
Support,
Guidelines,
Support with
workshops
(for families)
Work salary and financial support for students with trauma;
guidelines on supporting students with trauma; permission to host
workshops and conversations with parents of students with trauma
DRC7 Strategies Strategies to support students with trauma
E1
Classroom
Space,
Resources
*External school leadership has provided access to classroom
space and resources when delivery of school materials was delayed
E2
Classroom
Space,
Support (for
affected
students)
Work salary; *External school leadership offers access to
classroom space and support with affected students
E3
Feedback,
Student
Evaluation
Support via feedback/evaluation towards professional development
E4
Building a
School,
Training,
School
Materials
Building a school where teacher works, knowledge/training, and
school materials
E5 No Response. -
E6
Transportation,
School
Materials,
Supporting
Student
Attendance,
and Home
Visit Support
Transportation support to and from school; school materials when
materials are delayed in arriving, and supporting student attendance
by joining teachers in home visits to have conversations with
families to learn about possible needs.
From these responses, resources and financial support were indicated the most out of the
types of support received by teachers, which included financial support to meet the basic needs
of students, such as food, clothes, and school materials, including books and lessons/curriculum.
Supporting basic needs and access to school may be prioritized by organization leadership or are
most notable to teachers among the range of possible ways they have experienced support from

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organization leadership. Teacher DRC3 stated, “School leadership has mentored us morally and
given us hope to keep supporting students. Furthermore, school leaders gave us some money to
continue meeting the basic needs of students.” Additionally, several teachers described how
organization leadership provided strategies, higher tier mental health support, feedback for
professional improvement, and support towards other student and family related needs, such as
attendance. Teacher DRC5 expounds on the impact of school leadership on her role, stating,
“They were always there for us, trying to show us how to deal with cases of trauma within the
classroom and if it’s difficult for us to solve, they call the organization’s psychologist to help us
bring healing.” Teacher E6 also shared how organization leadership supported student attendance
via home visits and conversations that identified family needs, stating, “If one of the students
miss education or school here, we report it, we write down and report it to the school. Then the
school master writes a letter and then goes to the village and talks to the family. We go together
to talk to the family there.” Organization leadership provided a diverse array of teacher supports
that ranged in type and function for teachers, students, and families.
Organization leadership holds a critical role in supporting the capacity of teachers
operating in conflict and post-conflict zones. The services offered by organization leadership
resulted in mental health support for students and teachers, including teachers sustaining hope in
their work. The range of support provided by organization leadership demonstrated the varied
needs that exist in their conflict and post-conflict school communities, from resources supporting
students' needs and learning environments to workshops, training, and strategies for teachers.
Summary of Findings for Research Question 2

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The purpose of the research question was to understand how teachers perceived their
capacity to support the mental health of students impacted by conflict and war. The first finding
that emerged was the “Versatility of the Teacher Role in Conflict Zones.” Teachers' critical roles
are highly versatile in form and function, extending from academic instruction into responsive,
psychosocial support for students, families, and communities. Teachers created safe and trusting
environments for students and promoted peace, hope, and unity. Teachers believed that their
roles involved student healing and positive change and that the education they provided served
multiple functions and benefits for students. “Teacher Awareness of Needs: Their Students and
Their Own” emerged as the second finding. This finding highlighted teachers’ recognition of
self-care to be responsive to student needs, their emotional capacity for dealing with suffering,
teacher consultation and collaboration, and significance for human connection in conflict and
war zones. This need of giving and receiving human connection may point to how families and
communities have been debilitated in their ability to care for their own, an indicator to how
conflict zones impact relationships and require humanity re-construction. Where these fractures
in access to human connection occur, teachers were positioned to be care-takers, mental health
providers, advocates, friends, and, of course, educators, and more. The third finding that emerged
was “Training to Support Teacher Capacity in Mental Health.” Teachers described and
demonstrated their need for training to support student mental health, where needing support was
referenced a total of fifteen times across seven participants. In addition, participants spoke to the
variety of training they had received to support students with trauma, with training received
discussed across eleven participants. Finally, “The Importance of Organization Leadership”
emerged as the fourth finding. The diverse functions that organization leadership hold in

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supporting teachers was referenced twenty-three times across all participants, with resources,
teachers feeling supported, financial support, strategies, workshops and training, and learning
spaces being the most indicated areas where leadership supported teachers. Teachers’
perceptions of their mental health support capacity in conflict zones were, thus, influenced by
their versatile roles, their awareness of critical needs, including the need and role of human
connection, their training received and/or needed, and the role and diverse functions of
organization leadership in the work of facilitating teachers and their work with students and
families.
Conclusion
Based on how teachers create spaces of trust and safety, including how they provide care,
love and affection for students, teachers are aware of the need for human connection in conflict
and war zones. This particular need being met, in conjunction with safety, food, and other
recognized basic needs, serves as a protective factor for students in these contexts, minimizing
risk for students that have been forced to live independently, and who may lack a sense of
belonging to a stable community. Therefore, teachers serve critical functions that sustain the
quality of life extending beyond academic instruction. Teachers are the means by which life is
preserved, nurtured, and stabilized to the degree that their presence is available to students in
conflict and war zones. The measure and quality of their mindsets and behaviors are also
significant for helping meet needs within their school and believing they can bring healing and
effect change, ranging from problem identification, intervention and support capacity, and ability
to demonstrate care and responsiveness in high crisis and needs environments.

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Teachers described conflict as suffering, a suffering that threatened families and was
context specific to the regions investigated. Suffering was a pervasive threat to humanity and
survival, instilling fear, insecurity, and hopelessness through the traumatic experiences of death,
destruction, displacement, and access gaps to resources and education. Healing was described as
basic needs being met, where peace, safety, and needed resources were accessible, and a return
to normal life attainable. Peace/security, school supplies, and food were the most referenced
needs by teachers indicating safety, physiological, and basic services gaps that if met would lead
to healing. Teacher perceptions of their student mental health support capacity revealed their
versatility in fostering safety, trust, peace, hope, unity, and unique and responsive learning
strategies to diverse needs. Teachers demonstrated awareness of their own needs and needs of
students, including the need for self-care, their limited capacity in light of challenges beyond
their scope, the function and availability of case consultation with colleagues, and the critical
role of human connection for traumatized students. Teachers indicated their training contexts and
their capacity for supporting student mental health, sharing the belief that additional training
would strengthen their limited capacity. Finally, teachers expressed the significance of
organization leadership in supporting their capacity within their roles and settings by increasing
mental health services for students and teachers, maintaining teacher hope, and providing a
spectrum of essential services to their conflict and post-conflict school communities. Chapter 5
will discuss findings, recommendations, and future research.

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CHAPTER FIVE: DISCUSSION AND RECOMMENDATIONS FOR PRACTICE
The purpose of this study was to explore and understand the experiences and needs of
primary school teachers operating in conflict and post-conflict zones in the Democratic Republic
of Congo (DRC) and Ethiopia. The number of studies investigating teacher perceptions of
childhood trauma, including the role of professional development on trauma-informed
approaches in educational settings, has grown in recent years. However, the literature exploring
teacher perceptions of supporting student mental health and trauma in conflict and post-conflict
in settings remains scant, including in the DRC and Ethiopia Further, the organizations
investigated through this study have yet to conduct research on the experiences of their own
teachers. Therefore, this exploration is significant for identifying cultural and contextual factors
and the experience and occurrence of childhood trauma via teachers in school settings, including
teacher meaning making of their own and students’ lived experiences, how they conceptualize
suffering, healing, trauma, mental health, and conflict and war, and their perceived capacities for
supporting the mental health of students. By gaining the insight of teachers working in conflict
and post-conflict education systems, both contextually derived needs and interventions may be
better identified and understood in support of student mental health and the mental health of the
school community in complex, humanitarian emergencies and their aftermath.
This qualitative study was guided by the following research questions:
1. How do teachers operating in conflict and post-conflict zones define the experiences of
suffering and healing as it relates to their students?
2. How do teachers operating in conflict and post-conflict zones perceive their capacity to
support the mental health of students impacted by conflict and war?

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This chapter offers recommendations that are grounded on the findings that childhood
suffering is complex, multi-faceted, and ongoing in conflict and post-conflict zones. Moreover,
teachers take on versatile roles to meet diverse and persistent needs in their school communities,
they are aware of their own needs and the needs of their students, and demonstrate a need for
increased capacity for supporting students with trauma and their mental health. Finally,
organization leadership in these educational spheres are significant for supporting teachers in
their work and meeting the needs of their students.
This chapter begins with a discussion of the findings of the study in relation to previous
research and the theoretical framework of trauma theory, with an emphasis on Adverse
Childhood Experiences (ACEs), and trauma-informed care (TIC) with culturally appropriate
trauma-informed support (CA-TIS). Next, the chapter provides recommendations for practice in
support of developing school-based mental health supports and elevating the stories of those in
conflict and war zones. The recommendations are grounded in the findings that childhood
suffering is complex, multi-faceted, and ongoing in conflict and post-conflict zones. The chapter
ends with a discussion of the limitations and delimitations of the study, proposed areas for
further research, and a conclusion that includes a summary of the study and its impact.
Discussion of Findings
The discussion of findings offers a review of the key findings (Chapter Four) in relation
to scholarly literature and the theoretical framework, trauma theory, guiding the study. Six key
findings emerged from this qualitative study: 1) conflict is suffering, 2) healing is basic needs
being met, 3) versatility of the teacher role in conflict zones, 4) teacher awareness of needs: their
students and their own, 5) training to support teacher capacity in mental health, and 6)

130
importance of organization leadership. This section offers a discussion of key findings and how
trauma theory, including adverse childhood experiences and trauma-informed care and culturally
appropriate support, aids in understanding the traumatic experience of suffering and need in
conflict and post-conflict settings.
Research Question 1 Discussion of Findings
Although some findings were anticipated in this study, based on prior research, others
provided in-depth views on both the uniqueness, complexities, and adversities that teachers and
students face in conflict and post-conflict zones, specifically in the DRC and Ethiopia. Research
question one addressed how teachers defined student suffering and healing in their conflict and
post-conflict contexts. This question in its simplest form deals with what teachers believe
students suffer through in conflict and war zones and what they need in order to heal. Teachers
defined conflict as suffering and healing as basic needs being met. Examining this research
question through the lens of trauma theory points to how teachers are experiencing and
conceptualizing childhood trauma in their school communities and their impact on health and
well-being.
In the realm of trauma and childhood adversity, research outlines traumatic experiences
(NCTSN, 2018; SAMHSA, 2014a), adverse childhood experiences (Centers for Disease Control
and Prevention, n.d ; Felitti et al., 1998), their impact in schools and on learning (Alisic, 2012;
Blodgett & Lanigan, 2018; Crosby, 2015; Fairbank & Fairbank, 2009; Hertel & Johnson, 2013;
Mendelson et al., 2015; McInerney & McKlindon, n.d.), and their prospective for lifelong
impact, including negative health outcomes (Anda et al., 2010; Fairbank & Fairbank, 2009;
Felitti et al., 1998; Orpaas & Varvin, 2015). Teachers and students in the DRC and Ethiopia, as

131
discussed by teachers in the conflict and post-conflict zones, are experiencing the sequelae of
trauma, with students facing many types of adverse childhood experiences that highlight human
suffering and its contextual origins and nuances based on region and experience. The effects of
conflict included death and violence, displacement, destruction of homes, educational disruption,
mental health and psychosocial concerns, and the lack of needs, including safety, peace, food,
family, and education. The types of mental health concerns that were mentioned included
attachment problems, traumatic illness, and stress, which led to access gaps in education and
negatively affected learning experiences in the classroom. Similar was how suffering due to
conflict encompassed the broad range of adversity that characterizes the childhood traumatic
experience.
Based on the findings and the theoretical framework, students and their teachers in both
contexts investigated were experiencing acute, chronic, and complex trauma, with varied forms
of direct or vicarious and perceived or actual psychological or physical exposure (Feriante &
Sharma, 2024). The traumatic experiences ranged from those associated with an active conflict
zone, as noted in Democratic Republic of Congo, including the growing crisis in the eastern
region, characterized by ongoing war, to those associated with Ethiopia’s post-conflict context in
the Konso Zone, characterized by continued insecurity and incidents of conflict. Susceptibility
for mental health disorders, such as anxiety, depression, and post-traumatic stress disorder
(PTSD), increases in resident proximity to war-affected regions (Baker & Shaloub-Kerkovian,
1999; De Jong et al., 2003; Hoppen & Morina, 2019; Hoppen et al., 2021; Jayasuriya et al.,
2016; Karam et al., 1998; Kinzie et al., 1986; Koplewicz et al., 2002; Laor et al., 1997; Morina et
al., 2020; Pat-Horencyk et al., 2007). Therefore, trauma theory provides a critical lens into the

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physical and psychological impact of traumatic experiences as hindering mental health and wellbeing in children and teaching staff in the settings investigated and would place these educational
partners at greater risk for negative life-long outcomes.
While traumatic exposure was discussed as high in both populations, not fully known are
the psychological determinants of mental health and the clinical levels of psychological suffering
affecting teachers and students in these settings. Research indicates that 1 out of 5 people in postconflict settings experience a psychiatric disorder (Charlson, et al., 2019), with approximately
22% for children who experience violence that is not restricted to conflict and war (Panter-Brick
et., 2009). Close to 50% of primary-aged children at a NGO-based school in Syria showed
clinical anxiety and withdrawal, and approximately 62% with fear symptomatology (Cartwright,
et al., 2015). Beyond the scope of the study was the role of possibly concurrent pathways and
outcomes of resilience, individual coping mechanisms, posttraumatic growth, and other cultural,
collective, and individual strengths that may have acted as mitigating factors to traumatic
experiences and individualized responses. As trauma theory indicates, not all traumatic
experiences result in a traumatic response. Nevertheless, the findings for research question 1
indicate occurrence of human suffering in emergency settings via man-made crises, natural
disasters, and complex emergencies, and an unmet level of suffering that will continue as long as
war and conflict are persistent.
Healing was defined by study participants as basic needs being met, needs which are
essential for healing to occur and healing being a desired state, and by one teacher, as a solution
to the problem of suffering. Maslow’s Hierarchy of Needs (Maslow, 1943) and the mental health
and psychosocial support (MHPSS) intervention pyramid (IASC, 2017) are useful models for

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understanding and categorizing the types of critical and foundational needs that will usher
healing to school communities in the war context. For teachers, the most referenced forms of
healing needed were peace and security, school supplies, and food, which not only indicated
safety, physiological, and basic services and security needs per the above models but are also
consistent with current humanitarian aid identified needs and goals in conflict settings (United
Nations, 2023).
Social determinants are known to impact mental health disorders (Lund et al., 2018) and
were ongoing in both contexts, which included conflict and war, displacement, violence, poverty,
trauma and adverse childhood experiences, systemic injustices and economic inequality, food
insecurity, and more. Addressing suffering and the mental health burden of disease in these
settings requires addressing the underlying social determinants of mental health (Lund et al.,
2018). The social determinants of mental health are the factors that form a bridge to suffering
and a gap to healing. Teachers believed that suffering would be alleviated and healing would
come when these determinants were effectively resolved, which is why some had expected
government support, hoped for peace, requested feeding programs for their school communities,
and provided financial assistance to students who had lost families or the means to provide for
their educational needs. The cumulative effect of these social determinants, including trauma
adverse childhood experiences, in the settings investigated hinder healing and exacerbate mental
health disparities, increasing the likelihood of physical and mental issues in adulthood if remain
unmet.
Research Question 2 Discussion of Findings

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Research question two addressed teacher perceptions of their own capacity to support
student mental health, the support or training they have received, and how they were dealing
with conflict, including their own needs and needs of their students. The main findings that
emerged were the versatility of the teacher role, teacher awareness of their needs and those of
their students, mental health training to support teacher capacity, and the importance of
organization leadership. Examining this research question through the lens of trauma theory
points to how teachers are mobilizing their lived experiences in war zones, knowledge, and skills
about trauma and adverse childhood experiences, the needs of students, and assistance from
organization leadership to support their students.
Research demonstrates weak mental health infrastructures with limited access to mental
health services in developing countries (Lima, 1987; WHO, 2023), including a lack of skilled
personnel in LMICs (Mutombo et al., 2024; Sweetland et al., 2014), and a need for trained nonclinical workers in mental health intervention and support (Hamza & Hicks, 2021). Ongoing war
and multisystemic crises are barriers to providing humanitarian support (Camacho et al., 2018;
Kimball & Jumaan, 2020) and the prospect of providing a spectrum of mental health
interventions to children is further hindered, for example, by children with PTSD neglecting
pursuit of support, referrals for therapy unsent by relatives or school personnel, and a lack of an
adequate, locally driven infrastructure for supporting the high prevalence of distress (Berger et
al., 2007). An important reflection for the contexts investigated through this study was the need
to transfer short-term crisis response efforts to long-term, sustainable and adaptable
infrastructural support (El-Khoury et al., 2021, Hamza & Hicks, 2021). WHO (2023) highlights
this possibility through the integration of MHPSS intervention at later stages of the Syrian crisis

135
into health and social care institutions and schools. As is suggested by research, teachers help
mitigate trauma-based distress in children via classroom-based interventions and their strategic
position in identifying mental health symptoms and their prevalence in schools (Berger et al.,
2007; Panter-Brick et al., 2009). In addition, research signals a need to revamp the mental health
infrastructure (Bodas et al., 2015; El-Khoury et al., 2021; Hamza & Hicks, 2021; Lima, 1987;
Murray et al., 2014; WHO, 2023), streamline referral processes for children with moderate to
several mental health conditions (Berger et al., 2007; Gurwitch et al., 2002; Jordans et al., 2013),
and increase caregiver capacity to identify traumatic distress markers and symptoms towards
providing targeted support (Baum et al., 2009; Berger, et al., 2007; Brymer et al, 2012;
Deblinger & Heflin, 1996; Kakuma, 2011; Ko et al., 2008; Panter-Brick et al., 2009;
Pfefferbaum et al., 2003; SAMHSA, 2014a; Wessells, 2017; WHO, 2002).
Research question two findings indicated that teachers inevitably engaged in versatile
aspects of their roles, further illustrating the multifaceted nature and need of trauma and their
cultural and learned aspects of trauma-informed care delivery. Ultimately, teachers served lifepreserving and quality of life improvement functions in education systems in conflict and postconflict zones. By providing safe and trusting spaces and promoting peace, unity, and hope
through persistent adversity characterized by insecurity, fear, and grief, teachers engaged in the
frequent and critical task of mitigating the effects of trauma via psychosocially supporting
children through their love, compassion, presence and responsive support. Teachers operating in
these settings utilized their best understanding and resources to support students with trauma,
though limited in certain resource and training aspects, and believed in their ability to be
changemakers and bring healing to their classrooms. The endurance, stability, and hope that

136
teachers brought in being a positive and caring adult, along with the embedded strategies in their
teaching, helped maintain a sense of security and fostered conditions that allowed students to
access their educational environments, maintain a connection and sense of belonging in their
classrooms, and sustain learning, all of which are forms of school-based mental health services.
Research shows that the protective factor and role of responsive and caring adults helps
to mitigate the trauma stress response for children with adverse childhood experiences (Center
on the Developing Child at Harvard University, 2020). This human intervention is critical in
bridging the gap between students and school, even in displaced or volatile communities where
students may have even less access to a variety of social and educational services and resources
during crises. Teachers demonstrated cultural and experiential knowledge and awareness of what
students are facing, even traumatic suffering in and out of their classrooms, and took proactive
and responsive measures to foster their mental health and well-being and resist the impact of
students’ negative life events. Implementing these trauma-informed principles of understanding,
recognizing, and responding to trauma showed teachers’ personal or cultural characteristics of
humanitarian altruism. Their impact was discussed as having a farther reach based on how
organizational leadership supported teacher capacity, student services, and creating conditions
for teachers to sustain hope in their work.
At the same time, teachers expressed feelings of being overwhelmed and being limited in
their capacity to effectively meet student trauma and mental health needs in their classrooms and,
for some, engage in consultation with colleagues in support of students with trauma. Several
teachers believed they needed to attend to their own mental health, including via self-regulation,
hope building, and understanding the conflict occurring. Ehrlich et al. (2021) highlighted the

137
importance of protecting the mental health and well-being of emergency medical service
personnel as first responders during the onset of the COVID-19 pandemic, raising the concerns
of decreased work productivity due to stress and mental health concerns, obstacles to receiving
mental health support, disposition for increased stress, burnout, depression, and PTSD, and
predisposition to future, chronic mental health problems. The teacher participants conveyed
diminished capacity around helping students meet their personal and learning needs, supporting
student mental health and trauma, and providing resources, all of which were further strained by
ongoing conflict or crises. Additionally, seven teachers, over half of the participants, expressed a
need for mental health training to build their knowledge and skills, with three teachers stating
they were not able to provide psychological support for their students. Teachers cited that
professional training would strengthen their capacity and would lead to an increased scope of
practice and confidence to engage in the work. Some teachers received prior training ranging
from identifying and supporting student emotions and stress to engaging in a more
comprehensive range of mental health and psychosocial support (MHPSS), the latter which was
the case at OBE. Unknown was when and the frequency of training provided, and some teachers
indicated not having received training since prior to the start of their teaching positions within
their organization or not having received any mental health training or lessons to support
students with trauma.
As invaluable caregivers in their schools, teachers operating in conflict and post-conflict
zones have implemented elements of trauma-informed care that are culturally appropriate in
support of a spectrum of adverse childhood experiences occurring in their settings, and
considering prospective vicarious traumatization they are experiencing themselves. Teachers

138
may lack the necessary knowledge about the role, impact, and symptoms of trauma in childhood
and possible task sharing, or non-clinical intervention skills that would increase the quality of
service needed with students with more prominent mental health needs. It was clear that teachers
needed more mental health training, and the training they were provided was not given with
enough frequency to meet the urgent and ongoing demands of mental health in crisis. Leveraging
their accessibility to students, their awareness and expertise of current needs and possible
solutions, and their character and altruistic disposition to the work, investing further in their
capacity and roles would increase the caliber and quality of care to students and families, while
giving them the tools to more effectively meet their own needs and access their support system
via their organization leadership or partners and colleagues.
Recommendations for Practice
The purpose of this study was to explore the experiences of primary school teachers at
NGO-based schools in conflict and post-conflict zones, including their meaning making of
suffering, healing, trauma, and mental health, and their perceived capacity to support student
mental health needs. Recommendations for practice are proposed based on teacher interviews
and the key findings identified in Chapter 4 and discussed in this chapter.
Table 9
Key Findings and Recommendations
Key Findings & Recommendations
RQ1: How do teachers operating in
conflict and post-conflict zones
define the experiences of suffering
and healing as it relates to their
students?
RQ2: How do teachers operating in
conflict and post-conflict zones
perceive their capacity to support the
mental health of students impacted by
conflict and war?
Key Finding 1 "Conflict is suffering" Versatility of the teacher role in

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conflict zones
Key Finding 2 Healing is basic needs being met Teacher awareness of needs: their
students and their own
Key Finding 3 -
Training to support teacher capacity
in mental health
Key Finding 4 - Importance of organization leadership
Recommendation 1 Participatory process to create a school-based mental health program.
Recommendation 2 N/A Build capacity to mitigate stress
responses in the school community.
Recommendation 3 N/A
Teacher/leadership training on
meeting the mental health needs of
students.
Recommendation 4
Elevating stories of students and
teachers from the conflict zone
perspective.
N/A
This section discusses four recommendations for supporting teachers and their school
communities in building the capacity for mental health work in their conflict-affected settings.
Table 9 summarizes the four recommendations for practice that are consistent with the study’s key
findings. The first involves engagement with a participatory process in the design and development
of a school-based mental health program, acknowledging and developing action steps on the
individual and collective voices of educational partners. Given the need to meet the current and
anticipated needs of traumatic stress, the second is to build capacity to mitigate stress response in
the school community. Next, the recommendation involves teacher and leadership training on
supporting student mental health needs that would increase capacity to support student mental
health via a comprehensive, school-based mental health program. Finally, the stories of students
and teachers from the conflict and war zone perspectives need to be elevated to cultivate hope,
solidarity, education, and action.

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These recommendations are interrelated and build on one another. For example, elevating
student and teacher voices may be central and critical for informing all other recommendations,
including the participatory process to create a mental health program, building capacity to mitigate
stress response in the school community, and teacher/leadership training on meeting student
mental health needs. Additionally, a participatory process will be instrumental for delineating the
specific and contextual sources of stress and the current mental health needs. Students and teachers
have a nuanced understanding of experiencing and/or supporting adverse childhood events, which
will contribute to developing culturally appropriate, targeted interventions for building capacity
for stress reduction and student mental health professional development topics and pathways.
These recommendations work in tandem with one another with the prospect of developing
culturally responsive, trauma-informed services to war-affected school communities.
Recommendation #1 - Participatory Process to Create a School-Based Mental Health
Program
The findings demonstrated specific, sociocultural contexts that represent ways of life that
are by villages, ethnic/tribal affiliation, language and dialect, hierarchies of leadership, and
regional communities. In the Democratic Republic of Congo, several hundred thousand people
have been displaced to communities or camps because of conflict and violence. Here, a merging
of people groups inevitably occurs. In Ethiopia, the context investigated in the Konso Zone was
characterized by displaced communities living in host communities, a merging of people groups
that, at the very least, shifts the social fabric of village communities as a direct result of complex
emergencies. This recommendation is based on honoring culture, including acknowledging the
role of customary institutions and systems (Major et al., 2024), and the voices of pertinent

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partners in the work of developing comprehensive, school-based mental health programs. The
practice that is recommended is to engage in a participatory action process to create a schoolbased mental health program.
This recommendation was developed to account for a lack of a comprehensive schoolbased mental health program at both OADRC and OBE in the Democratic Republic of Congo
and Ethiopia, respectively, and the need to account for the role of culture, language, and social
norms, amongst other relevant considerations, in the realm of mental health services for students,
staff, and communities. A critical participatory lens would invite essential conversations and
participation amongst a broad range of community partners, beyond teachers, and be guided by
an equitable process for engaging with representative members of the school community.
Critical participatory action research (CPAR) is a framework for collaborative knowledge
creation, where knowledge is constructed with the marginalized voices of those enduring harm
and injustice (Fine et al., 2021). By centering marginalized voices, their insights, knowledge and
perspectives are highlighted, prioritized, and empowered as this process is carried out not on the
terms of the researcher, but rather on the terms of affected participants, including those most
affected (Fine et al., 2021). The CPAR process incorporates elements of the participatory action
research and checklist, involving continual reflection through a collaborative effort of partners
who identify issues within the community, explore root causes, develop actions steps for selected
solutions or interventions, monitor and evaluate efficacy of interventions, and reflect on learning
and outcomes, engaging in a continual improvement of processes (Center for Community Health
and Development, n.d). The checklist may serve as a guide to make important considerations
when working with the communities and selected partners, which would include students,

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teachers and school staff, parents and guardians, community leaders and local community
members, healthcare professionals, NGOs and aid/relief organizations, government
representatives, international partners, and researchers and academics.
Apple (2018) highlights the significance of critical policy analysis in challenging
traditional notions of knowledge and power in education, understanding the nature of ideological
perceptions of education, acknowledging the role of race and language in strengthening power
dynamics, and highlighting the social justice impact of social mobilizations while adopting a
spectrum of diverse methodologies to provide nuanced views on both actors and dynamics. The
outside inside and inside outside concepts for critical inquiry by Apple (2018) require that
dominant narratives and power structures be examined and that internal processes of an
educational institution as they relate to broader societal contexts be questioned. Using Apple
(2018) as a guide, “outside-inside” questions that are relevant to this recommendation include:
whose knowledge about suffering, healing, and mental health needs is valuable and legitimate,
who would benefit from the installation of a school-based mental health program, how might
language and discourse shape future practice, and which movements are currently influencing
educational and mental health change in each region/context investigated.
When considering language and discourse, including through Andreotti (2012), in the
identification of issues or concerns within the community, even the concepts of trauma and
mental health are placed in the crossfire of cultural relevance and meaning. Not assessing the
impact of language and discourse may inflict the harm of disempowerment at the expense of the
capital and strengths that communities bring. Trauma and mental health and diagnosis and
disorders are Western derived concepts and tend to already carry a deficit-based perspective and

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stereotype rather than a resiliency-informed, strengths-based, and asset-based perception of
community as the premier system of support. Questions that are relevant to consider are how
affected persons conceptualize and define certain experiences, such as suffering, the language of
mental health and trauma according to their cultural contexts, and what they believe are
important solutions to meet the needs they are facing and the steps required to get there.
Furthermore, Andreotti (2012) provides additional layers of critical analysis by also
considering hegemonic, ethnocentric, ahistoric, and depolitical elements regarding the formation
of a policy recommendation, such as related to a mental health program. It is important to further
understand and investigate, for example, the role of ethnic/tribal background in the Democratic
Republic of Congo, where certain ethnic and tribal groups are affiliated with the rebel opposition
groups. Here, teachers who are needed to engage in the work of peace education and conflict
resolution would do so at the expense of appearing to take a political position by virtue of their
position and work in schools, a concept that Hoelscher et al. (2017) calls the “politicization of
humanitarian aid,” which heightens risk for those providing support in emergency settings.
Identifying partners and navigating the prospective solution of a mental health program may
incorporate important considerations that include historical and generational trauma, adverse
factors, events, and conflicts within these regional communities, and the role of political and
ethnocentric viewpoints between rival ethnic and tribal groups and with the historical and current
role of customary institutions in resolving violent conflicts (Major et al., 2024).
Ultimately, although important insights can be gained from adopting a trauma-informed
approach and the theoretical framework of trauma theory for supporting the mental health of
students in schools, a culturally responsive approach that is both critical and participatory is

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necessary to give voice to those in greatest need. The practice of amplifying marginalized voices
is necessary and multifaceted. It brings a level of justice to the status quo by challenging power
dynamics and understanding the nature of the support that is needed, relying on the experiences,
stories, and expertise of the oppressed throughout the process and in the manner and form in
which services are delivered and reflected upon.
It is important to highlight that there exist nuances and challenges in implementing the
critical participatory action process where the communities are located, more so with preexisting challenges in intra-agency collaboration and differing mandates, goals, and objectives.
In the Democratic Republic of Congo, as of February 2024, war broke out as near as five miles
away from the school communities and teacher participants. In Ethiopia, there were recent
incidents of conflict and the students within this remote, post-conflict region were displaced and
living in host communities with community members and leaders that were not from their
original village. The process of bringing pertinent community members and partners to the table
is no small task, for example, in the Democratic Republic of Congo region studied, over 250
organizations existed with different mandates and target areas beyond the major city of Goma in
which the schools are located. Even identifying community leaders in such a close-knit region is
a difficult task, as city authorities and village and tribal leaders, need to be identified at the start
of the process and willing to participate. These challenges need to be reflected upon further and
require collective reflection and brainstorming.
What is expected from the critical participatory process is an activation and
empowerment of community intervention and support, possibly one of the greatest assets in the
village community; the power and capital of the collective, of families also living and serving

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under this protective factor and cover. Here, incorporating a critical participatory action approach
would bring a level of equity and empowerment to students, families, and communities whose
livelihood was stripped away by the horrors of war. It is up to the community to identify and
implement their version or identified course of action for a school-based mental health program
to support schools and their constituents in the aftermath of war and suffering.
Engaging the educational partners that are representative of the community and willing to
participate in this critical participatory action process will allow for actions to move this
recommendation forward. First, a needs assessment can be conducted by identifying issues
within the community and exploring root causes that would lead to the development and
implementation of action steps for selected solutions or interventions. United Nations guidelines
and protocols recommend developing a school mental health team with established connections
within the local community, assess the school’s current needs, assets, and structures, and
collaborate with policymakers and members of the community to sustain mutual engagement in
the work and needs (Margaretha et al., 2023). Following these initial steps, ongoing monitoring
and evaluation of the efficacy of interventions, reflection on learning and outcomes, and
continual improvement of processes will help move the recommendation forward by
empowering and building capacity of participants, strengthening engagement in shared learning
and support while refining the actions needed to support the development of the school-based
mental health program.
Recommendation #2 - Build Capacity to Mitigate Stress Response in the School
Community

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The insecurity, fear, and helplessness of conflict characterizes the contexts investigated
and threatens humanity by prolonging human suffering (de Fouchier & Kedia, 2018). Due to the
prevalence of adversities present in the school communities investigated, not only from past
traumatic events, but those associated with ongoing conflict and resource deprivation, students
and teachers were experiencing varied forms and degrees of stress and trauma that placed them
at risk of anxiety, depression and PTSD. Teachers, who had shared perceptions of being limited
in their emotional capacity to support students, overwhelmed and unable to attend to their own
needs, even self-care needs, also showed secondary exposure to trauma. Research demonstrates
the strong relationship between teacher and student wellness (Harding et al., 2019) including the
importance of teacher self-care, including for colleagues and students, fostering a positive school
atmosphere and for personal equipping with tools to support the mental health of others (RojasAndrade et al., 2024). If unmet, these humanitarian workers, the school teachers, may
experience high attrition and burnout, leading to poor lifelong health (Chemail et al., 2018).
Heightened stress reactions were anticipated to continue as situations deteriorated on the level of
war or continued resource deprivation. An essential target would be to build stress management
capacity in support of students, teachers, and those within the school community.
Developing capacity to mitigate stress response in school communities is multifaceted,
with prospective benefits of supporting mental health, building resilience, improving academic
outcomes, promoting physical health, creating safe and supportive environments, preventing
burnout, and fostering community resilience. Litvak-Hirsch and Lazar (2020) discussed the
effects of a long-term mindfulness stress reduction training on the personal and professional
coping mechanisms of 15 teachers in an Israeli conflict zone, highlighting improvement in their

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self-acceptance, family life, in dealing with life in a conflict zone, and on their role and influence
as teachers. By developing teacher capacity as a starting point in a school-based stress
management program, rooted in mental health principles, teachers would benefit from this
recommendation directly as they are the instruments of their own work with students. Teachers
offered protective and strategic roles in conflict and war zones as caregivers and social service
providers, and supporting their mental health and strengthening their skills would also support
children’s resilience, coping, and mental health status (De Berry et al., 2003). Overall, stress
reduction is crucial and attainable in times of crisis and ongoing adversity via the presence of
supportive adults and intentional intervention processes that practice self-relaxation and selfregulation techniques.
De Fouchier and Kedia (2018) conducted 27, one-session, stress management groups in
Central African Republic in 2014 involving 197 humanitarian workers taking pre-post data
assessing PTSD, depression, and anxiety via the Harvard Trauma Questionnaire (HTQ) and the
Hopkins Symptoms Checklist (HSCL-25). The findings demonstrated the following: 1) seven
average traumatic experiences per participant with 66% exposure to five or more; 2) frequently
reported traumatic events were hiding, witnessing physical assault, living through combat, and
family separation; 3) almost 40% of participants had no social support; and 4) a substantial
reduction in the severity of each psychological factor (de Fouchier & Kedia, 2018). The threehour group interventions consisted of psychoeducation on types of stress, strategies for
supporting traumatic stress reactions in children, and building multi-domain coping strategies,
including through somatic, cognitive-affective, behavioral, and spiritual domains (de Fouchier &
Kedia, 2018). Notable features of this study were its adaptation to the local and cultural context,

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a more specialized and systematic approach than psychological first aid (PFA) with a protocol
situated within PFA and cognitive behavioral therapy (CBT), a realistic and cost-effective
alternative to specialized services lacking in under-resourced settings, and the ability to be
implemented by either a trained professional or a lay support person with adequate training.
Chemali et al. (2019) highlighted the need to support humanitarian fieldworkers
operating regularly in crisis and trauma spaces and developed and adapted the SMART-3RP
training program for language and cultural appropriateness for 120 field and social workers. The
results indicated that mindfulness and self-reflection allowed for greater self- and emotional
awareness, positive thinking, problem solving and interpersonal skills, and patience and empathy
when confronting challenges in the field (Chemali et al., 2019). Notable features of this study
included its cultural adaptation, applicability and high participation rate, its potential for stress
reduction and its benefit for psychosocial support and connection, and its implications for
increasing trusting and connected relationships with target communities and understanding and
communication between host communities and their refugee/displaced persons (Chemali et al.,
2019). Both studies shed light on prospective pathways to deliver needed stress reduction
interventions to school communities in conflict areas.
Actions to move this recommendation forward could include centered efforts on building
stress management capacity via professional training, developing crisis response and operating
procedures, and systematic integration of professional learning into educational offerings for all
partners, including students and families, with auxiliary efforts focused on creating sustainable
solutions to mitigate impact of social determinants of mental health. First, a stress management
intervention or program with standard procedures will be created or adapted for all members of

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the school community. This program will include a needs assessment that will lead to a catered
professional training and ongoing development for teachers and staff on stress management
psychoeducation and multi-domain coping skills building. Taking pre-post data on training
impact via clinical instruments and qualitative self-report data will assess the efficacy of the
psychoeducation and skills building training. This step also involves understanding the
neuroscience of stress response and helps staff identify their preferred coping strategies. Next, a
crisis intervention team will be created to navigate situations or crises that may occur within the
purview of the school system. Finally, a continued focus on developing systems and processes to
meet the social determinants of mental health is crucial to stress management. Creating
sustainable solutions that lead to educational access, positive and supportive relationships, and
basic needs, including clean water, food, housing, and clothes, and more will help this
recommendation move forward because student mental health concerns causing emotional
distress will be more effectively supported via increased capacity to manage stress.
Recommendation #3 - Teacher/Leadership Training on Meeting the Mental Health Needs of
Students
The main goal of this recommendation is to further mobilize educational staff to support
mental health service delivery in conflict and post-conflict zones via mental health training and
development. The findings indicated a student mental health support capacity deficit for teachers
and some supportive measures offered by organization leadership with growing psychological
and resource demands. Teacher DRC5 specifically mentioned the need for training in identifying
and supporting the source of trauma, stating, “I haven’t gained a lesson on how to support the
mental psychology (health) of a student,” which may render other student supports less effective

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or ineffective. Teacher DRC2 also stated, “I can’t psychologically help them enough,” with
Teacher DRC5 affirming this need, stating, “…I’m not a psychologist. It’s a little difficult to
help the mental health of students if I don’t have knowledge in psychology because in
psychology there are so many ways to support the mental health of trauma-impacted students.”
Teachers shared a lack of knowledge and skills to support student mental health and trauma.
Additionally, teachers desired training from skilled professionals. Research shows that
development of teacher capacity is associated with how teachers operate in schools (RojasAndrade et al., 2024). While teachers understood the role of psychologists in supporting student
trauma, teachers were willing and wanted to gain knowledge and skills to better provide
psychological support in their classrooms. They also acknowledged the shortage of trained
psychologists in the areas they were working. The seven teachers, over half of all participants,
expressed needing training to support students and being unsure how to psychologically support
students. Teachers also expressed not receiving help from other teacher colleagues due to lack of
capacity in supporting student mental health.
These findings highlighted a professional development or training need that, if met,
would lead to an increase in knowledge, skills, and abilities in mental health service delivery for
educational leadership and for teaching staff as first tier mental health responders in conflict and
warzones. Teachers were already operating with elements of trauma-informed care principles in
their schools and classrooms via their cultural lens, such as ensuring safety and trust, promoting
and providing individualized support that was responsive to students’ needs, actively
incorporating inclusive practices that built peace and unity and honored culture, history, and
gender, collaborating with educational partners including organizational and school leadership,

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parents and families, students, and community members, and applying previous training on
supporting students’ needs, where applicable. In Ethiopia, teachers implemented components of
MHPSS that included: child protection, aspects of psychological first aid (PFA), such as
providing caring and supportive listening, being informed and informing students about the
conflict, helping students connect to needed services and basic needs, helping students through
distressed moment or hardship, and attempting to engage in self-help or self-care needs; and
school-based supports where teachers provided special care to students who had suffered loss,
responsive support to student needs in the classroom, and an accelerated learning program that
emphasizes a modified education approach for displaced students. Providing ongoing,
specialized, mental health training would also support and increase the efficacy of case
consultation with colleagues on trauma-related issues. Consultation was contingent on training
and understanding how to support student mental health and would be a prospective benefit for
teachers in both contexts investigated.
Hesham et al. (2022) highlighted the strategic importance of schools in promoting
childhood mental health and intervention practice, describing the World Health Organization
(WHO) Mental Health in Schools Training Package developed by the Regional Office for the
Eastern Mediterranean (EMRO). The WHO Mental Health in Schools Program is a multi-tiered
system of support (MTSS) framework to scale up cost-effective, school-based mental health
implementation in LMICs as a priority directive by equipping educators with practical and
responsive, non-specialist skills for provide developmentally appropriate, mental health
interventions (Hesham et al., 2022). By offering this approach to comprehensive, school-based
mental health systems of supports that is adaptable, culturally appropriate, evidence-based, and

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responsive to resources, including mental health child specialist availability and capacity
constraints in LMICs, pilot studies have demonstrated the feasibility of integrating this approach
into schools and catering this prevention and promotion program to meet the existing mental
health needs of students and staff (Hesham et al., 2022). Given the contexts, emerging factors of
crisis, and mental health needs of the settings investigated, integration of a comprehensive,
school-based mental health program at both NGO-based school networks would be a significant
step in leveraging the role of educators to effectively identify and meet student mental health
needs. The development of a comprehensive, school-based mental health program could lead to
addressing trauma and psychological distress, promotion of resilience and coping skills, positive
outcomes in academic achievement, prevention of long-term mental health problems, creation of
safe and supportive environments, empowerment of students and building agency, promoting
social cohesion and community resilience, and reduction of stigma and increase in help-seeking
behaviors.
Actions to move this recommendation forward include developing catered and ongoing
professional development training for teachers and leadership on trauma-informed, school-based
mental health supports that would further build capacity. First, conducting trauma-informed
assessment and screening of staff, parents and families will identify individuals needing
additional support by assessing trauma exposure, symptoms, and resilience factors. Next,
developing individualized support plans (ISP) for identified persons with trauma-related
concerns, will highlight specific goals, interventions, and support that are tailored to the student’s
strengths, abilities, needs and limitations. Also, integrating mental health education and coping
skills training (see Recommendation #2) into school curriculum will increase capacity for stress

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management, emotional regulation, and positive and individualized coping strategies via ageappropriate lessons, activities and group or individual support. This recommendation will move
forward when baseline levels for climate, culture, and school-wide learning environment are
assessed for safety, inclusivity, and positive climate because of the prospect of implementing
culturally attuned, positive behavior support strategies, restorative practices, or other approaches
that will address and mitigate conflict and promote prosocial, peaceful, and positive
relationships. Next, providing parent, family, and community engagement opportunities to
increase support for student mental health, such as psychoeducation, workshops and trainings,
and other modalities will increase their capacity to continue the work of trauma-informed care
and mental health promotion at home and in the community. Developing and training a crisis
intervention team on trauma-informed crisis intervention and establishing standard procedures
for resilience building (ex. stress management intervention/program - see Recommendation #2),
will create readiness for emergency and critical incident response via supportive and empathic
posture. Lastly, ongoing monitoring and evaluation of mental health program effectiveness by
collecting feedback from all educational partners will assess impact and identify areas of
improvement.
Recommendation #4 - Elevating Stories of Students and Teachers From the Conflict Zone
Perspective
Critical to engaging voices from conflict and war zones is the continued effort to elevate
the narratives, stories, and insights of students and teachers. Doing so is a matter of justice and
awareness building, providing an audience, whether regional, national, or global, with the
opportunity to reflect on the insights shared in the war-affected settings (Helbardt et al., 2010).

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Bringing attention to the voices of those in vulnerable contexts and settings not only would add
to the existing knowledge and research base but would re-frame aspirations and hopes by
defining what “a safe and dignified future” should look like (Azzam, 2018), and more accurately
delineate a path to healing that is culture-based (Kanagaratam et al, 2022).
Here, highlighting the work of educators at the intersection of education and conflict and
war would bring a nuanced perspective that gives listeners insight to a literal and metaphorical
frontline in education. Education is offered in how the global community interacts with the
strengths and difficulties that are portrayed through the stories and lives of students and teachers,
their resilience, cultural capital, and their practical successes in the form of personal victories and
educational accomplishments. The practitioner community also benefits from the value of
hearing these stories and understanding contexts on collective values and attributes
(Kanagaratam et al, 2022). Engaging in a participatory process is important for voices to be
accurately represented via active participation in outlining their experiences, priorities, solutions,
and challenging assumptions (Azzam, 2018).
Elevating narratives and the voice of students and teachers in conflict and war zones is
also critical for healing and for others operating in the same work. Teachers can hear tangible
examples of their own stories, and the shared strength, work, and suffering occurring for them
and their students. Healing is possible when narratives are shared, resulting in positive, prosocial
and emotional behaviors that promote mental health and physical health (Harvard Program in
Refugee Trauma [HPRT], 2021).
Actions to move this recommendation forward include establishing conditions for
storytelling and connection building, including adherence to ethical guidelines. First,

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engagement with educational partners to discuss storytelling initiative via a participatory
approach (i.e. teachers, staff, or students/families) may include dialogue about what is
appropriate, ethical, honoring, and conducive to quality of life improvement regarding sharing of
personal/professional experiences around selected topics, for example, school/education in war
zones. Next, utilizing feedback from participatory sessions and abiding by ethical standards,
stories may be shared through appropriate channels in ways that protect anonymity, where
necessary, for example, personal identifiable information (PPI) (see Fisher, 2022). Also,
developing access with peers and colleagues in the field via a local, national, or international
network will promote awareness, relationships, and support around shared experiences or topics.
Periodic meetings in person or via telecommunication platforms to foster dialogue and expand
shared insights and understanding will also help drive this recommendation forward. Finally,
forwarding stories to partners and agencies to highlight the important work being done will
broaden understanding of the successes and the current needs in schools in conflict and postconflict zones.
Limitations and Delimitations
In the field of qualitative research, limitations are forces outside of the control of the
researcher and delimitations are outside of the defined boundaries of the study (Creswell, 2014).
Self-reported data collection method has the embedded limitation of self-report, which may
potentially introduce bias. Although responses are naturally subjective in nature, respondents
may have provided information that was believed to be expected or socially desirable, perhaps
due to an investigation of their role as an educational professional or the role of the investigator
in wanting to understand their perceived capacity, support received, and needs. Additionally,

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respondents may have unintentionally introduced bias by providing a response that was
erroneous or incomplete. Although rigorous methodology and transparency was employed to
mitigate limitations within this study, including minimizing language barriers and holding
culturally appropriate practice and considerations, limitations still existed. For example, there
were nuances and complexities in translation and cultural differences in understanding and
interpretation which may have impacted the accuracy of the data collected. This was the case
when both translators sought more understanding of technical terms used in the interview
protocol and several respondents needed additional translation within their own dialect or
language of preference, which the interpreter provided.
A few limitations of my current positionality exist within this study. An aim of this study
was to understand how conflict or war impacts the mental health of victims. A limitation was
lacking a stronger understanding of: 1) non-western or culturally-derived healing practices and
intervention models when supporting mental health; 2) culturally-diverse interpretations and
perspectives on the topics being studied, including suffering, healing, trauma, mental health, and
conflict and war; and 3) further knowledge on current national and international response efforts,
including their role in both settings being investigated. Stronger knowledge and skills in these
areas would have strengthened my competency on the topic and helped me refine the approach I
took in this dissertation process.
Another limitation of this study was its inability to do member checking. Although
member checking would have supported credibility and trustworthiness by sharing the
preliminary interview findings to validate and refine interpretations and seek respondents’
feedback, clarification, or correction on the accuracy and relevance of identified themes and

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conclusions (Merriam & Tisdell, 2016), this study was unable to do so due to remote locations
and contexts explored, including active conflict that arose following the collection of data.
Engaging in this ethical and constructive space to gain critical feedback on the accuracy and
authenticity of the interpretations is a noteworthy consideration for future research.
A delimitation of the study was the way the study was bound by geography, sample
strategy, context, qualitative focus, language, and time. The study focused on two conflict and
post-conflict settings with primary school teachers meeting certain criteria for selection. This
qualitative examination of the teachers’ perspectives on cultural context, experience, and needs
when working with students affected by conflict and war involved an interview that, for some,
was provided in multiple languages due to participant language needs during the interviews, and
several of which included dialects, or tongues, that are common, and possibly, only native, in
certain regions. The length of the study was intentionally brief, or short-term, due to the nature of
the dissertation timeline, which did not take into account the shifts in mindsets or perspectives
that may have occurred if the study were designed at longer intervals of time. While there may
be value in future studies, for example, comparing perceptions of teachers across additional
schools within a region, or across national or additional international conflict zones, the selection
of only primary school teachers at each of the two NGO-based settings investigated allowed
deeper understand of teachers’ meaning making and perceptions as they pertained to the conflict
and post-conflict contexts in and around the surrounding regions of study.
Recommendations for Future Research
Future research that may benefit teachers and students in conflict and post-conflict zones
would include a continued focus on understanding teacher experiences across a larger spectrum

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of NGO-based schools, investigating the efficacy of catered, professional development and
training for teachers and staff on school-based, mental health interventions that are traumainformed, and exploring the experiences and needs of other educational partners, including
students, parents and families, school staff, and community members. First, due to the nature and
nuance of how suffering was contextualized in certain regions, replicating the study to include
more voices and experiences from educators across geographic regions may shed more light on
the impact of culture, ethnic/tribal contextual factors, and stories that are specific to those
regions, though still operating within the scope of the same organizations. Second, investigating
the impact of professional development on teacher efficacy and student outcomes would benefit
teachers as they develop essential knowledge, attitudes, and skills to build their capacity to meet
the mental health needs of students where no specialist/licensed or mental health professionals or
clinicians are accessible. Incorporating an element of task sharing where appropriate mental
health services are lacking or nonexistent is an essential and invaluable function supporting
childhood mental health in volatile settings. Finally, broadening the scope of knowledge and
understanding of stories of other educational partners within these school communities would
provide significant insights into how members of an educational system experience and define
suffering and healing, describe their capacities for supporting childhood mental health or their
experiences receiving catered services, and reflect on their needs at the intersection of their
conflict or post-conflict setting and their culture, value system, and beliefs. Exploring a
participatory approach to understanding problems in conflict and war zones and defining and
developing solutions is critical in this work.

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One limitation that is especially important to address in future research is the role of
language in interpretation, including how cultural meaning is conveyed across cultures and intraculturally. Language focuses, such as communication, expression of intent, interpretation of
meaning, cultural context, clarity, accuracy, and essence, and, overall, facilitating understanding,
are critical for fostering the accurate exchange of cultural information and promotion of
understanding in diverse linguistic contexts. Preparing for possible language differences and
dialects during the data collection process, including in the acquiring and preparation of a
selected translator, would provide for more accuracy in terms of understanding and response. It
is valuable to continue developing culturally competent practices and materials that accurately
reflect the language and context of participants as a paramount ethical responsibility when
conducting research with diverse populations.
Conclusion
In 2022, two-thirds of the global child population (about 1.6 billion) lived in conflictaffected countries and 96 million lived in high-intensity areas within 31 miles from an active
combat zone (Ostby et al., 2023). In the Democratic Republic of Congo, 6 million deaths have
occurred since the start of the conflict in 1996 (CFR, 2024), 6.7 million were internally displaced
by the start of 2024 (IDMC, 2024-a), 1.7 million were internally displaced in Goma by February
2024 (USAID, 2024-a), and over 120 armed militant groups were active in DRC as of May 2024
(GCR2P, 2024). In Ethiopia, 60,000 were internally displaced in the Konso Zone in 2021, and by
2024, almost 3 million were internally displaced (IMDC, 2024-b) and 5.6 million needed
assistance due to drought (USAID, 2024-b). Only 10% of people with mental health conditions
in LMICs receive treatment (Sweetland, et al., 2014), despite 20% of the total population

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experiencing a form of mental disorder and 10% experiencing a moderate to severe mental
disorder (McDonald, 2021).
To understand the experiences and meaning making of suffering, trauma, mental health,
and healing, and the role of teachers and NGO-based school organizations in conflict and postconflict zones, this qualitative study interviewed thirteen primary school teachers in conflictaffected Goma in eastern DRC and post-conflict Konso Zone in southern Ethiopia to gain the
perspective of primary school teachers.
The key findings demonstrate a continued need to prioritize integration of school-based
mental health practices in conflict and post-conflict school settings. For the active conflict zone
investigated in DRC, traumatic experiences and humanitarian crises had greatly increased in the
months following data collection, especially with rebel fighting and several hundred thousand
displaced around the city of Goma. For the post-conflict region investigated in southern Ethiopia,
insecurity, fear is still within reach, and teachers in the Konso Zone, located in a more remote
region, are continuing to serve displacement communities with a history of tribal/ethnic conflict.
Teachers are aware of the suffering and needs that students experience in conflict and
post-conflict settings, recognize what healing looks like for their schools and communities, and
are strategically positioned to support the mental health needs of their students considering
limited or virtually non-existent mental health infrastructures in the LMICs and war-affected
regions they operate in. Suffering includes the lack of safety, physiological and basic services,
that is, the basic needs that are needed in order for healing to come.
This study is important because it illustrates the educational experiences of teachers and
students highlighting settings characterized by the adverse childhood experiences of death,

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displacement, destruction, resource deprivation, and educational disruption. Moreover, teachers
are strategically positioned to provide more comprehensive mental health support to students via
their access, versatility, firsthand knowledge of their own needs and the needs of their students,
their training backgrounds and willingness to learn and increase their scope of practice, and the
level of organization leadership support they receive. Specifically, teachers’ perceptions shed
light on how schools, especially through their own presence and role as educators, safeguard
humanity and sustain the quality of life. Teachers provide psychosocial support that is responsive
to student mental health and support students with varying trauma contexts. This study sheds
light on localized forms of suffering in the communities investigated, highlighting the voices of
teachers on the frontline of highly specific and difficult circumstances. Their access and
expertise on the student impact of suffering and the needed road to healing points the global
audience to urgently needed services and aid and recommendations to further support their
identified areas of need.
The study findings led to several recommendations, including the need to invest in human
resources by building capacity for both educators and school leaders to meet the critical and
contextual mental health needs of students. Related, a participatory process is needed to create a
school-based mental health program, and the stories of students and teachers from conflict and
war zones need to be elevated, heard and shared. These are interrelated to the recommendation to
build capacity to mitigate stress response in the school community. Collaboration with other
humanitarian agencies and national organizations is crucial to providing a more comprehensive,
multi-sectoral service to affected communities. Perhaps, starting with an integration of schoolbased mental health at scalable levels, leveraging research and financial backing, is a beneficial

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beginning to determine efficacy of mental health intervention packages specifically suited to the
communities investigated. From here, more awareness and funding could supplement further
needs while continuing the ongoing work of advocacy from other sectors and disciplines. If the
conditions causing or sustaining the traumatic experience are not effectively dealt with by the
actors that have the power to change them, then mental health interventions may not be as
effective in relieving the local or national mental health burden of disease. Ultimately, schools
are epicenters for healing in conflict affected regions, and closer attention and investment in
these institutions will support NGOs in closing the mental health treatment gap in the lowincome countries.
“Not Losing Hope When Things Feel Hopeless”
There is a tangible and ever-increasing level of human suffering occurring on the ground
in regions known as conflict zones. The aforementioned findings, some of which elicit a stark
and hopeless reality, demonstrate that teachers are committed, growth-oriented, and hopeful
regarding their work with students in war-torn communities. These incredible human beings, on
the frontline of both a literal and metaphorical nature, can easily be overlooked or seen as doing
helpless or hopeless work as they deal with a rapidly growing, multi-generational fallout of war
in their schools. However, teachers in this study did not see it that way. They wanted and
promoted peace and created safety and trust within their classrooms, remaining highly devoted to
their work.
Teachers take on vital, versatile roles that meet physiological, safety, and love and
belonging needs, which show they operate in the arenas of life preservation, humanity
reconstruction, and social welfare. Their perspectives, experiences, and perceptions tell a story of

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what has happened, what is happening, and where avenues of support might focus their attention
moving forward. It is clear that an organization that is solely responsible for the education and
wellness of students is a commendable aspiration. Amid continuing demands to meet urgent,
varying, and complex educational crises and needs of vulnerable student populations, the role of
organization leadership is paramount to teacher resilience, perseverance and hope. However, this
work requires other humanitarian actors to bring the full extent of services that are essential to
see systemic change and a needed transition from short-term crisis response to a long-term,
multi-sectoral, mental health infrastructure that is robust and sustainable. Nevertheless, possibly
the greatest asset in conflict and war zones is the human resource, that is, teachers who are not
only on the forefront of educational attainment but are first responders in mental health service
delivery in regions with limited to no access to mental health providers. It is crucial to leverage
their strategic presence and expertise in schools to further advance their capacity and scope in
more holistic support of student mental health. Where many forms of resources are lacking,
teachers are the most critical and ideally positioned asset for supporting children affected by
trauma and war.

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understanding, new hope. World Health Organization.
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all. https://www.who.int/publications/i/item/9789240049338
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Appendix A
University of Southern California Recruitment Information Sheet
Dear Prospective Participant,
My name is Julian Sesma and I am a doctoral student in Global Education at the
University of Southern California. I also hold a role as a K-12 School Counselor in California. I
am conducting a research study to understand the needs and conditions to best provide mental
health services for children in conflict zones and warzones. The name of this research study is
“Understanding the Needs of Primary School Teachers Operating in International Crisis
Response in Ethiopia and the Democratic Republic of the Congo: Supporting Trauma-Informed,
Emergency Mental Health (MH) Services for Children in Conflict & War Zones”
Your participation is completely voluntary, and I will address your questions or concerns
at any point before or during the study.
You may be eligible to participate in this study if you meet the following criteria:
1. Participants must be primary school teachers
2. Teach Grades 1, 2, or 3.
3. Have at least one year of teaching experience at their current school site.
4. Provide educational instruction in the country’s national language or
local/regional dialect.
5. You are 18 years old or older.
If you decide to participate in this study, you will be asked to do the following activities:
1. Participate in one, 60 minute, in-person, audio recorded interview with the
researcher (myself) and a translator on site. The topics of the interview will

198
include questions about your work-related perspectives on trauma, mental health,
suffering, and healing, and your experiences and needs with supporting students
in conflict and war zones.
a. The risks that are involved with this study include feeling discomfort,
embarrassed, and/or distressed about the sensitive aspects of the topic.
NOTE: You have the freedom to share or not share at any time of the
study.
2. Complete a one, 5 minute demographic survey following the interview.
3. Potential review of your interview transcript via email for 10-15 minutes.
I will publish the result in my dissertation. Participants will not be identified in the
results. I will take reasonable measures to protect the security of all your personal information.
All data will be de-identified prior to any publication or presentations. I may share your data, deidentified with other researchers in the future.
If you have any questions about this study, please contact me: at jsesma@usc.edu or via
WhatsApp at +1 (619) 948-0909. If you have any questions about your rights as a research
participant, please contact the University of Southern California Institutional Review Board at
(323) 442-0114 or email irb@usc.edu. Thank you in advance for your consideration.
NOTE: If you are interested in participating in this study. Please contact me via email,
WhatsApp, or in person when I visit your site on the following dates: September 25-29, 2023
(Democratic Republic of Congo) and November 20-22, 2023 (Ethiopia). I will be more than
happy to review this information with you, answer any questions you may have, and provide you
with any other information you may need to better understand this study and make the most

199
informed decision of whether or not to participate. Thank you very much for your time.
Kind regards,
Julian Sesma

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Appendix B
Formal Interview Protocol - Teacher Interview Guide
Interview Questions Concepts from CF
1. Briefly share your journey to your current position. Rapport Building
2. Tell me about the type of training you have received, if any, to
support trauma impacted students.
TIC (RQ2)
3. If someone asked you to describe the challenges your students
face, what would you say?
PROBE #1: Can you give me a specific example for a specific student?
ACEs (RQ1)
4. Please describe what the following two terms mean to you, as they
relate to your students:
a) suffering
b) healing
TIC - CA-TIS (RQ1)
5. Based on the experiences you described your students face, what
would you say are their three most important needs from the
school to help lead them on the path to healing?
PROBE #1: What would you say are their three most important needs
from you?
CA- TIS (RQ1)
6. How do you perceive your capacity to support the mental health
of your students impacted by conflict and war?
PROBE #1: Where do you feel are your strengths to do this?
PROBE #2: Where do you feel you are lacking the capacity to do this?
What else do you need to know? What else do you need to be able to do?
TIC - CA-TIS (RQ2)
7. Tell me about a time when you were able to support a mental
health need within your classroom.
PROBE #1: How did you respond?
TIC/ACEs (RQ2)
8. Tell me about how you are supported, if at all, to meet the needs
of trauma-impacted students in your classroom.
PROBE #1: What professional learning opportunities have you received,
if at all, about supporting trauma-impacted students and families?
PROBE #2: How, if at all, do other teachers support you in teaching
trauma impacted students, if anything?
TIC (RQ2)

201
PROBE #3: What has school leadership done to support you in teaching
trauma impacted students, if anything?
9. What other supports do you need to meet the mental health needs
of your students?
TIC - CA-TIS (RQ3)
10. As a teacher, how are you dealing with conflict and war? CA-TIS (RQ3)
11. What needs, if any, do you feel like you have as a result of the
conflict and war?
CA-TIS (RQ3)
12. What lessons have you learned about working with students that
have been affected by conflict and war?
CA-TIS (RQ1-3)
13. Is there anything else that I haven’t asked you that you would like
to tell me about.
Closing

202
Appendix C
Informal Interview Protocol - Local Leadership Guide
Interview Questions
Background Information
1. Please briefly share your journey of how you arrived at your current
position.
2. Tell me about how where you are operating, is currently experiencing
conflict and war.
3. What are the challenges that your organization faces in meeting the needs
of students in times of conflict or war?
4. How does your organization seek to address the needs of students in times
of conflict or war?
5. How would you describe the role of the teachers in meeting the needs of
students in times of conflict or war?
Cultural Sensitivity
6. What should I, as a Western person and non-native, know about the cultural
norms here?
7. Regarding your culture, what sorts of things must I do, could do, and should
not do?
PROBE: How might I best honor the culture while I am here?
8. What else is important for me to know or understand as I am interviewing
teachers about their capacity to meet the needs of students in their
classrooms?

203
Appendix D
Post-Interview Participant Demographic Survey
***NOTE: This is a voluntary survey. You DO NOT have to answer any or all of the questions.
If you prefer to skip a question, please continue to the next question. If you prefer not to
complete the survey questions, then your participation in today’s interview is complete.
Demographic Questions
1. What is your age? _____________________________________________________
2. What is your gender? __________________________________________________
3. Race/Ethnicity
a. Please describe your race/ethnicity: ___________________________________
b. Multiracial or Multiethnic (Please describe): ____________________________
c. Other (Please describe): ____________________________________________
4. Religion
a. Please describe your religion: ____________________________
b. Other (Please describe): _________________________________
c. No Religion (Please circle this option if this is your response).
5. Education Level (adapted from World Bank, n.d.) (Please circle your answer).
a. Lower Secondary Education (7-9th grade)
b. Upper Secondary Education (10th-12th grade)
c. Postsecondary non-tertiary education (e.g. vocational training programs, certificate
programs, and diploma programs).

204
d. Short-cycle tertiary education (e.g. associate’s degree, foundation degrees, higher
national diplomas, diplomas of higher education)
e. Bachelor’s degree or equivalent (e.g. BA, BS)
f. Master’s degree or equivalent (e.g. MA, MS, MEd)
g. Doctorate degree or equivalent (e.g. PhD, EdD)
h. Other: _______________________________________________________
6. Overall Teaching Experience (please share the total number of years you have been teaching)
a. _____________________________________________________________
7. Teaching Experience at your organization (please share the total number of years you have
been teaching at your current organization)
b. ______________________________________________________________
8. Teaching Experience in conflict zones or war zones (please share the total number of years
you have been teaching in conflict or war zones)
c. ______________________________________________________________

Abstract (if available)

Abstract Full title: Understanding the needs of primary school teachers operating in international crisis response in the Democratic Republic of the Congo and Ethiopia: supporting trauma-informed, emergency mental health services for children in conflict and war zones. Abstract: Conflict-impacted countries are home to more than two-thirds of the global child population, about 1.6 billion children. In low- and middle-income countries (LMIC), 20% of the population experience a form of mental disorder, and 90% of the population with mental health conditions receive no treatment. In light of weak or strained mental health infrastructures during humanitarian crises, NGOs may be ideally positioned to help reduce the wide mental health treatment gap by providing mental health and psychosocial support. Teachers' perceptions of their experiences supporting students in conflict and war zones helps provide vital information about the context, nature, and impact of traumatic and adverse childhood events in school communities that may inform catered school-based mental health services. Therefore, this study explored the experiences of primary school teachers at NGO-based schools in conflict zones and post-conflict zones in eastern Democratic Republic of Congo (DRC) and southern Ethiopia to understand how they define suffering, healing, trauma, and mental health, their perceived capacity to support the mental health of students, and their identified needs and those of their students. Perception data for thirteen teachers, seven from DRC in September 2023 and six from Ethiopia in November 2023, was collected via a semi-structured interview protocol. The key findings demonstrated that teachers defined conflict as suffering, a suffering that threatens families and has nuances based on regional context, including death, displacement, ethnic/tribal conflict, and disruption to education and other basic needs, and healing as meeting basic needs. Teachers’ capacity was illustrated in the following way: the versatility of the teacher role in conflict zones, teacher awareness of their own needs and their students' needs, training to support teacher capacity in mental health, and the importance of organization leadership. In particular, teachers serve critical functions as frontline service providers that preserve, nurture, stabilize students’ lives and mental health to the measure that their presence is available to students in conflict and war zones. Still, teachers indicated the need for training to support their limited capacity to address the sequelae of trauma and mental health concerns. This study stresses the importance of prioritizing the integration of school-mental health programs and practices in conflict and post-conflict schools in LMICs, and leveraging the strategic role, access, and expertise of teachers by building their student mental health support capacity to respond to humanitarian crises.

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Asset Metadata

Creator Sesma, Julian Thomas Francis (author)

Core Title Understanding the needs of primary school teachers operating in international crisis response in the Democratic Republic of the Congo and Ethiopia…

School Rossier School of Education

Degree Doctor of Education

Degree Program Global Executive

Degree Conferral Date 2024-08

Publication Date 09/04/2024

Defense Date 07/16/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag adverse childhood experiences (ACE),complex emergency,conflict,culturally appropriate,Democratic Republic of Congo (DRC),Ethiopia,Healing,internally displaced persons (IDP),mental health,mental health and psychosocial support (MHPSS),OAI-PMH Harvest,refugee,school-based mental health,Suffering,Trauma,trauma theory,trauma-informed care (TIC),trauma-informed support (CA-TIS),war zone

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Krop, Cathy Sloane (committee chair), Chung, Ruth (committee member), Noveck, Mary Anna (committee member)

Creator Email jsesma@usc.edu,sesmajulian@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC11399AGPL

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Format theses (aat)

Rights Sesma, Julian Thomas Francis

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