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Fostering responsive mental health systems in the Syrian refugee crisis

Periodic Reporting for period 2 - STRENGTHS (Fostering responsive mental health systems in the Syrian refugee crisis)

Reporting period: 2018-07-01 to 2019-12-31

Since the outbreak of the Syrian civil war in 2011 over 12 million Syrians have been displaced. Syrian refugees may have been exposed to multiple war stressors such including sexual violence and destruction of their homes and livelihoods/ Once arrived in the country of resettlement, refugees may face daily living difficulties, such as uncertainty about their asylum applications, loss of social networks, worries about family in the region of origin, and restricted economic opportunities. A survey by the STRENGTHS research team in Istanbul, Turkey, showed that Syrians are at considerable risk to develop common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). This study also showed that approx.90% of these refugees did not seek care for their symptoms, showing that there are numerous barriers to the delivery and uptake of effective psychological interventions for refugees. These barriers include waitlists, and an exclusive focus on single psychiatric disorders (such as PTSD) instead of multiple psychological problems, and a lack of Arabic speaking mental health care professionals.

To address the mental health treatment gap, the World Health Organization (WHO) has developed brief, scalable, transdiagnostic multimodal psychological interventions to reduce psychological distress. These interventions may be delivered by non-professional trained helpers, under supervision of locally trained mental health care professionals. The most well-known is the Problem Management Plus (PM+) programme, that consists of 5 sessions based on cognitive behavioral therapy and prolem solving techniques, and can be delivered either in individual face-to-face and in group format. Within STRENGTHS, the PM+ programmes have been translated and adapted to the Syrian language and culture. In addition, they are further adapted for use in children and young adolescents (the “EASE” programme) and an e-health app-based variant (the Step-by-Step programme; SbS).

STRENGTHS delivers these interventions to Syrian refugees with elevated levels of distress in Europe (The Netherlands, Turkey, Switzerland Germany, and Sweden), and the Middle East (Jordan, Lebanon, Egypt),and will evaluate their effectiveness.
STRENGTHS has identified necessary steps needed to integrate the scalable WHO programmes into the health systems of implementation countries, and will evaluate whether implementation strengthens the responsiveness of the system. In addition, barriers and facilitators to implementation will be identified, as well as the invested cost and effort for effective scaling-up and the cost-effectiveness of the WHO scalable programmes.
Finally, STRENGTHS will disseminate the evidence-base for the WHO scalable programmes, so that they can be used by others outside of STRENGTHS, and for other populations across Europe and beyond.
Until June 30, 2018 (the first reporting period), a lot has been done within the STRENGTHS consortium.
Firstly, we have set up an overall management structure, and organised two consortium meetings (in January 2017 in Amsterdam and in January 2018 in Copenhagen). Further, WP1 together with the Safety Board (SB) has overseen ethics issues related to SRENGTHS, which has resulted in timely delivery of all the ethics requirements in WP9.
Partners in WP2 have collected specific information to assess the way Syrian refugees with mental health needs navigate the health care system. Desk-based studies were conducted to collect specific information on mental health system inputs and analysis. In addition, qualitative data collected by STRENGTHS partners across project countries (The Netherlands, Turkey, Switzerland, Germany, Lebanon, Jordan, Sweden and Egypt) were used to assess the responsiveness of the health care system to the psychosocial needs of Syrian refugees. In addition W2 partners have performed a survey on mental health care use and access in > 1600 Syrian refugees located Istanbul, Turkey.
WP3 has translated the individual and group PM+ programme, and the children and adolescent version (EASE), and the e-health version of PM+ (SbS), into Syrian-Arabic. Literal translations of all intervention materials were performed which were then evaluated by cognitive interviews to assess appropriateness, relevance and acceptability. For the cultural adaptation the socio-cultural perceptions of Syrian refugees in relation to mental health problems and treatment were assessed in all project countries.
The adaption to an electronic PM+ version (SbS) required desk-research, consultation from experts, and qualitative assessments in Syrian refugees. Detailed user-stories for SbS were created.
In addition, training materials have been developed, and trainings of local trainers and supervisors in delivery of individual and group PM+, and EASE have been conducted between February and July 2018 in Amsterdam, The Netherlands and in Tripoli, Lebanon.
Within WP4 and WP5, partners prepared implementation of the scalable WHO programmes in Jordan, Lebanon (WP4) and the Netherlands, Turkey and Switzerland (WP5) by writing a detailed overall study protocol, which was adapted by partners and used for obtaining ethics approval across project countries. Validated Arabic versions of all study instruments were gathered, or they were translated and adapted when they when unavailable. WP4 and 5 partners have prepared recruitment strategies. In June 2018, pilot studies testing study procedures had started in the Netherlands and Turkey.
WP7 partners adapted a commonly used cost-effectiveness tool for use in STRENGTHS (the CSRI), which was also adapted to Arabic. Further, they adapted the CSRI to administer through the app for the SbS study in WP6.
Partners in WP7 and WP8 preparing log to measure implementation effort and dissemination activities throughout STRENGTHS. WP8 has written a communication and dissemination plan, has launched the website, and has been identifying new stakeholders for dissemination of the results through workshops.
We expect that STRENGTHS will create great impact by scaling up the PM+ and related WHO scalable interventions (e.g. Step-by-Step, EASE) so that a large group of refugees will benefit across the eight selected project countries. We expect that scaling up will have an effect of the health-systems level, and will improve equity and efficiency in delivering effective mental health care to refugee populations.
We expect that implementing the scalable low-intensity WHO programmes will increase the responsiveness of the mental health system for refugees and migrants. Efforts are made to ensure the transferability of these practices for use outside the scope of STRENGTHS, and after STRENGTHS’ lifetime.

Although STRENGTHS is now only 1,5 years underway, and we expect that the impact of STRENGTHS will be most evident at the end of its lifetime, we have already showed impact. There have been multiple requests for additional trainings in PM+ beyond the scope of the STRENGTHS implementation trials in WP4, 5 and 6. STRENGTHS partners have been presenting and disseminating the goals of STRENGTHS worldwide.
We have established a connection with a research team in Paris, France, where we will conduct a pilot study to implement PM+ in France. This additional study will be conducted outside the EU STRENGTHS project but will feed into the STRENGTHS project since study procedures will be aligned with those of STRENGTHS.