Periodic Reporting for period 3 - STRENGTHS (Fostering responsive mental health systems in the Syrian refugee crisis)
Reporting period: 2020-01-01 to 2021-06-30
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 and face daily living difficulties. A survey by the STRENGTHS research team in Istanbul, Turkey, showed that Syrians are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). This study also showed a large mental health treatment gap, with approx. 90% not receiving care for mental health symptoms. Barriers to the delivery and uptake of effective psychological interventions for refugees include waitlists, an exclusive focus on single psychiatric disorders, and a lack of Arabic-speaking mental health 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 healthcare professionals. The most well-known is the Problem Management Plus (PM+) programme that consists of 5 sessions based on cognitive behavioural therapy and problem-solving techniques and can be delivered either in individual face-to-face or group format. Within STRENGTHS, the PM+ programmes have been translated and adapted to the Syrian-Arabic language and culture, 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 evaluates their effectiveness. Further, STRENGTHS aims to identify necessary steps needed to integrate the scalable WHO programmes into the health systems of countries, and to evaluate barriers and facilitators to implementation, as well as the invested cost and effort for effective scaling up. Finally, STRENGTHS will disseminate the evidence base for the WHO scalable programmes across Europe and beyond.
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 healthcare professionals. The most well-known is the Problem Management Plus (PM+) programme that consists of 5 sessions based on cognitive behavioural therapy and problem-solving techniques and can be delivered either in individual face-to-face or group format. Within STRENGTHS, the PM+ programmes have been translated and adapted to the Syrian-Arabic language and culture, 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 evaluates their effectiveness. Further, STRENGTHS aims to identify necessary steps needed to integrate the scalable WHO programmes into the health systems of countries, and to evaluate barriers and facilitators to implementation, as well as the invested cost and effort for effective scaling up. Finally, STRENGTHS will disseminate the evidence base for the WHO scalable programmes across Europe and beyond.
Since its start in 2017, the STRENGTHS project has set up an overall management structure and installed a Safety Board (SB) that oversees ethics issues.
Partners in WP2 have performed desk-based studies to assess the way Syrian refugees with mental health needs navigate the healthcare system. 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 healthcare system to the psychosocial needs of Syrian refugees. Furthermore, W2 partners have performed a survey on mental healthcare use and access in > 1600 Syrian refugees located in Istanbul, Turkey. The planned second survey in Leipzig, Germany was delayed due to COVID-19 to September 2021.
WP3 has translated and culturally adapted the individual and group PM+ programme, the child and adolescent version (EASE), and the e-health version of PM+ (SbS), to the Syrian-Arabic language and culture. Detailed user-stories for SbS were created, and protocols for contact-on-demand support. Finally, scalable training materials have been developed, and trainings of local trainers and supervisors in delivery of individual and group PM+, and EASE have been conducted.
Within WP4 and WP5, partners obtained ethics approval for implementation of the scalable WHO programmes in Jordan, Lebanon (WP4) and the Netherlands, Turkey and Switzerland (WP5). Pilot studies testing study procedures and preliminary effects have been conducted successfully across all study sites in WP4 and WP5, showing that the WHO scalable programmes are safe, feasible, and likely effective. The pilot studies in Jordan and the Netherlands have been published in peer-reviewed international journals. WP4 has successfully completed the pragmatic implementation trial of group PM+ in Jordan and the results have been submitted to an international peer-reviewed journal. Difficulties have however arisen in relation to the study in Lebanon due to severe political and economic unrest and the COVID-19 crisis. As a result, EASE sessions have not been able to be delivered since March 2020. War Child has still managed to enrol 198 children in their implementation study. Despite the reduced sample size, strategies are proposed to maintain the objectives of the project.
The WP5 pragmatic implementation trials evaluating individual PM+ are ongoing in the Netherlands and Switzerland. Recruitment and data collection have been delayed due to the COVID-19 pandemic. The pragmatic implementation trial evaluating group PM+ in Turkey was affected by the COVID-19 lockdown, but has been successfully completed and 369 Syrian refugees have been included.
In WP6, the pragmatic implementation trials evaluating SbS are ongoing in Germany and Sweden, and the trial in Egypt is almost completed.
WP7 partners have culturally adapted a commonly used resource utilisation tool (the CSRI) to the Syrian-Arabic language and culture and to use in an app for WP6. They have analysed the cost-effectiveness results of the pilot studies in the Netherlands, Turkey and Switzerland. The WP7 economic and implementation evaluation across all study sites is scheduled to be completed during the next reporting period. An implementation log containing data relating to steps, resources and time needed to implement STRENGTHS in the different country settings is collected and will be triangulated through interviews on implementation with country teams, analysis of discussions and progress updates. These will be significant inputs in the next reporting period, alongside data collected in the implementation trials for economic modeling of the scale up of STRENGTHS.
WP8 has written a preliminary and final Communication and Dissemination Plan, maintains the website, and has identified new stakeholders for dissemination. Further, they have created a Community of Practice for mental health and psychosocial support trainers where they can find manuals, practical tools, and can join webinars. Finally, WP8 has organised the publication of a special issue in the journal Intervention aimed at mental health and psychosocial support professionals on PM+, including many publications from the STRENGTHS consortium.
Partners in WP2 have performed desk-based studies to assess the way Syrian refugees with mental health needs navigate the healthcare system. 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 healthcare system to the psychosocial needs of Syrian refugees. Furthermore, W2 partners have performed a survey on mental healthcare use and access in > 1600 Syrian refugees located in Istanbul, Turkey. The planned second survey in Leipzig, Germany was delayed due to COVID-19 to September 2021.
WP3 has translated and culturally adapted the individual and group PM+ programme, the child and adolescent version (EASE), and the e-health version of PM+ (SbS), to the Syrian-Arabic language and culture. Detailed user-stories for SbS were created, and protocols for contact-on-demand support. Finally, scalable training materials have been developed, and trainings of local trainers and supervisors in delivery of individual and group PM+, and EASE have been conducted.
Within WP4 and WP5, partners obtained ethics approval for implementation of the scalable WHO programmes in Jordan, Lebanon (WP4) and the Netherlands, Turkey and Switzerland (WP5). Pilot studies testing study procedures and preliminary effects have been conducted successfully across all study sites in WP4 and WP5, showing that the WHO scalable programmes are safe, feasible, and likely effective. The pilot studies in Jordan and the Netherlands have been published in peer-reviewed international journals. WP4 has successfully completed the pragmatic implementation trial of group PM+ in Jordan and the results have been submitted to an international peer-reviewed journal. Difficulties have however arisen in relation to the study in Lebanon due to severe political and economic unrest and the COVID-19 crisis. As a result, EASE sessions have not been able to be delivered since March 2020. War Child has still managed to enrol 198 children in their implementation study. Despite the reduced sample size, strategies are proposed to maintain the objectives of the project.
The WP5 pragmatic implementation trials evaluating individual PM+ are ongoing in the Netherlands and Switzerland. Recruitment and data collection have been delayed due to the COVID-19 pandemic. The pragmatic implementation trial evaluating group PM+ in Turkey was affected by the COVID-19 lockdown, but has been successfully completed and 369 Syrian refugees have been included.
In WP6, the pragmatic implementation trials evaluating SbS are ongoing in Germany and Sweden, and the trial in Egypt is almost completed.
WP7 partners have culturally adapted a commonly used resource utilisation tool (the CSRI) to the Syrian-Arabic language and culture and to use in an app for WP6. They have analysed the cost-effectiveness results of the pilot studies in the Netherlands, Turkey and Switzerland. The WP7 economic and implementation evaluation across all study sites is scheduled to be completed during the next reporting period. An implementation log containing data relating to steps, resources and time needed to implement STRENGTHS in the different country settings is collected and will be triangulated through interviews on implementation with country teams, analysis of discussions and progress updates. These will be significant inputs in the next reporting period, alongside data collected in the implementation trials for economic modeling of the scale up of STRENGTHS.
WP8 has written a preliminary and final Communication and Dissemination Plan, maintains the website, and has identified new stakeholders for dissemination. Further, they have created a Community of Practice for mental health and psychosocial support trainers where they can find manuals, practical tools, and can join webinars. Finally, WP8 has organised the publication of a special issue in the journal Intervention aimed at mental health and psychosocial support professionals on PM+, including many publications from the STRENGTHS consortium.
We expect that STRENGTHS will create great impact by scaling up the PM+ and related WHO scalable interventions Step-by-Step and EASE so that a large group of refugees will benefit across the eight selected project countries. The impact of STRENGTHS will be most evident at the end of its lifetime, though we have already showed impact. 24 scientific publications describing results of STRENGTHS have already been published and the results have been presented at conferences and gatherings worldwide.
Further, STRENGTHS has already led to multiple new “satellite projects” funded by national and international funding bodies building directly upon the STRENGTHS results so far. These include further implementation of the scalable WHO programmes by STRENGTHS partners in Lebanon, Switzerland, France, Netherlands, Ukraine, and Uganda. Finally, STRENGTHS results have promoted efforts to scale up PM+ widely beyond STRENGTHS, for example in Lebanon, Egypt and Switzerland.
Further, STRENGTHS has already led to multiple new “satellite projects” funded by national and international funding bodies building directly upon the STRENGTHS results so far. These include further implementation of the scalable WHO programmes by STRENGTHS partners in Lebanon, Switzerland, France, Netherlands, Ukraine, and Uganda. Finally, STRENGTHS results have promoted efforts to scale up PM+ widely beyond STRENGTHS, for example in Lebanon, Egypt and Switzerland.