Effectiveness and implementation of “Graduation Approach” livelihood programs with displaced populations: A systematic review

Background: Humanitarian actors have widely adopted "Graduation" model programs to support social determinants of health-particularly sustainable livelihoods-among displaced populations. We conducted a systematic review to comprehensively evaluate the evidence regarding Graduation model effectiveness and implementation in displacement contexts. Our objectives were 1) to assess the extent to which Graduation interventions affect food security, employment, living conditions, social wellbeing, poverty, and dependence on humanitarian aid among displaced participants, and 2) to identify barriers and facilitators of implementation in displacement contexts and characterize the model's feasibility and sustainability in such settings. Methods: We reviewed studies conducted from 2002-2024 in the peer-reviewed and grey literature that explicitly described a "Graduation" intervention (comprising at least three typical components) among displaced adult populations. We excluded studies of economic migrants or host communities and studies with inadequate intervention detail. We searched eight databases (EconLit, Academic Search Ultimate, Family & Society Studies Worldwide, APA PsycINFO, PubMed, Web of Science, Global Health, and the Cochrane Library; updated October 2024) and 11 implementing agencies' websites (updated April 2024). We assessed study quality using the Mixed Methods Appraisal Tool for systematic mixed-studies reviews. We screened all articles, reviewed full-text studies, and assessed record quality before narratively synthesizing findings. Results: =28,873 participants). These included randomized trials, program reports, and qualitative studies conducted in Uganda, Mozambique, Colombia, and Costa Rica. Food security outcomes were generally good, but few studies provided quantitative or well-specified estimates. Few employment outcomes were reported; most studies reported improved living conditions. Social wellbeing and poverty outcomes were heterogeneous, with substantial measurement limitations that precluded between-study comparisons. Dependency on humanitarian aid was not directly assessed and mental health outcomes were rarely or vaguely reported. Barriers and facilitators of program implementation were complex, suggesting the importance of comprehensive, community-level support. Program feasibility was best supported by flexible implementation, while sustainability was sensitive to factors such as land tenure and market inter-reliance. Discussion: Most reviewed studies had shortcomings in terms of research rigor and provided insufficient detail to fully assess quality or risk of bias. Findings could not be quantitatively synthesized due to the inconsistency of outcome indicators. While reported findings from these Graduation program evaluations were generally positive, we found little systematic or high-quality evidence for the programs' effectiveness or implementation in displacement settings. Future research should address counterfactuals, long-term outcomes, and implementation issues to assess the fundamental sustainability of these poverty alleviation issues in contemporary displacement contexts. Funding: NIMH grants T32MH103210, T32MH122357, and F31MH136678. Review protocol: PROSPERO CRD42023387899 (May 2023).