Periodic Reporting for period 4 - STRENGTHS (Fostering responsive mental health systems in the Syrian refugee crisis)
Periodo di rendicontazione: 2021-07-01 al 2022-12-31
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 and face daily living difficulties. A survey by the STRENGTHS research team in Istanbul, showed that Syrians are at considerable risk of developing common mental disorders. 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 culturally 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 delivered these interventions to Syrian refugees with elevated levels of distress in Europe (The Netherlands, Türkiye, Switzerland, Germany, and Sweden), and the Middle East (Jordan, Lebanon, Egypt), and evaluated their effectiveness. Further, STRENGTHS aimed 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 disseminated 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 culturally 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 delivered these interventions to Syrian refugees with elevated levels of distress in Europe (The Netherlands, Türkiye, Switzerland, Germany, and Sweden), and the Middle East (Jordan, Lebanon, Egypt), and evaluated their effectiveness. Further, STRENGTHS aimed 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 disseminated the evidence base for the WHO scalable programmes across Europe and beyond.
At the beginning of the project, a management structure was set up (WP1) and a Safety Board (SB) that oversees ethics issues was established (WP9).
In WP2, rapid assessments of health system responsiveness and community-level surveys to assess mental health needs were conducted. Barriers and facilitators toward scaling up the WHO programmes were also explored using quantitative data and via qualitative interviews. WP2 also conducted a series of Theory of Change workshops in Istanbul, Amsterdam, and Beirut. In addition, a series of qualitative interviews were conducted in partnership with WP7 on the impact of COVID-19 on the implementation and evaluation of the RCTs.
In WP3, individual and group PM+, EASE, and SbS were translated into Syrian Arabic and culturally adapted to fit the context. Detailed user-stories for SbS were created, as well as protocols for contact-on-demand support. Finally, scalable training materials were developed, and training sessions for local trainers and supervisors in delivery of individual and group PM+ and EASE were conducted.
WP4 successfully completed the pragmatic implementation trial of group PM+ in Jordan and the results showed that three months after the study, participants in group PM+ had greater reductions in depression symptoms, personal problems, and inconsistent disciplinary parenting. Difficulties however arose in relation to the study in Lebanon due to severe political and economic unrest and the COVID-19 crisis. As a result, EASE sessions could no longer be delivered from March 2020 onwards. War Child still managed to enrol 198 children in their implementation study. Despite the reduced sample size, strategies were proposed to maintain the objectives of the project. The results show that both EASE and the one-session psychoeducation home visits (control) showed similar improvements.
The WP5 pragmatic implementation trials evaluating individual PM+ have been completed. In the Netherlands, 206 participants were included and a positive intervention effect was found with reductions in symptoms of depression, anxiety, PTSD, and self-identified problems three months later. In Türkiye, 368 Syrian refugees were included and the main finding was that there was no significant effect of group PM+ in reducing depression and anxiety symptoms at the three-month follow-up assessment. In Switzerland, 54 participants were included. The reduced sample size in Switzerland was due to a change in policy which reduced the number of Syrian refugees that could immigrate to Switzerland. The barriers and facilitators toward scaling up PM+ in Switzerland were thus investigated.
In WP6, the pragmatic implementation trials evaluating SbS in Germany, Sweden, and Egypt have been successfully completed. The analyses resulted in small effect sizes for SbS to improve psychological distress and overall functioning. Additional analyses among participants who had adhered to the programme and completed all SbS sessions showed that effects for SbS were even stronger, with effect sizes approximately double those found in analyses including all participants, irrespective of adherence.
WP7 partners culturally adapted a commonly used resource utilisation tool (the CSRI) which was used in an app for WP6. They analysed the cost-effectiveness results of the WP5 RCTs and completed the economic and implementation evaluation across all study sites. The economic modelling of the scale up of the programmes was conducted and the integrated and validated framework, which looks at the implications for effective scale up and replication, was developed. While the short-term economic case for intervention varies considerably across settings, the integrated framework also highlights the value of using modelling approaches to consider how the economic case for investment will change over the longer term.
WP8 created a Communication and Dissemination Plan, maintained the website, and identified new stakeholders for dissemination. Further, they created a Community of Practice for mental health and psychosocial support trainers where they can find manuals, practical tools, and can join webinars. The Community of Practice will be maintained beyond the lifetime of the project. Finally, WP8 organised two final symposia in 2022: one in Istanbul directed towards practitioners and one in Amsterdam to disseminate the scientific results.
In WP2, rapid assessments of health system responsiveness and community-level surveys to assess mental health needs were conducted. Barriers and facilitators toward scaling up the WHO programmes were also explored using quantitative data and via qualitative interviews. WP2 also conducted a series of Theory of Change workshops in Istanbul, Amsterdam, and Beirut. In addition, a series of qualitative interviews were conducted in partnership with WP7 on the impact of COVID-19 on the implementation and evaluation of the RCTs.
In WP3, individual and group PM+, EASE, and SbS were translated into Syrian Arabic and culturally adapted to fit the context. Detailed user-stories for SbS were created, as well as protocols for contact-on-demand support. Finally, scalable training materials were developed, and training sessions for local trainers and supervisors in delivery of individual and group PM+ and EASE were conducted.
WP4 successfully completed the pragmatic implementation trial of group PM+ in Jordan and the results showed that three months after the study, participants in group PM+ had greater reductions in depression symptoms, personal problems, and inconsistent disciplinary parenting. Difficulties however arose in relation to the study in Lebanon due to severe political and economic unrest and the COVID-19 crisis. As a result, EASE sessions could no longer be delivered from March 2020 onwards. War Child still managed to enrol 198 children in their implementation study. Despite the reduced sample size, strategies were proposed to maintain the objectives of the project. The results show that both EASE and the one-session psychoeducation home visits (control) showed similar improvements.
The WP5 pragmatic implementation trials evaluating individual PM+ have been completed. In the Netherlands, 206 participants were included and a positive intervention effect was found with reductions in symptoms of depression, anxiety, PTSD, and self-identified problems three months later. In Türkiye, 368 Syrian refugees were included and the main finding was that there was no significant effect of group PM+ in reducing depression and anxiety symptoms at the three-month follow-up assessment. In Switzerland, 54 participants were included. The reduced sample size in Switzerland was due to a change in policy which reduced the number of Syrian refugees that could immigrate to Switzerland. The barriers and facilitators toward scaling up PM+ in Switzerland were thus investigated.
In WP6, the pragmatic implementation trials evaluating SbS in Germany, Sweden, and Egypt have been successfully completed. The analyses resulted in small effect sizes for SbS to improve psychological distress and overall functioning. Additional analyses among participants who had adhered to the programme and completed all SbS sessions showed that effects for SbS were even stronger, with effect sizes approximately double those found in analyses including all participants, irrespective of adherence.
WP7 partners culturally adapted a commonly used resource utilisation tool (the CSRI) which was used in an app for WP6. They analysed the cost-effectiveness results of the WP5 RCTs and completed the economic and implementation evaluation across all study sites. The economic modelling of the scale up of the programmes was conducted and the integrated and validated framework, which looks at the implications for effective scale up and replication, was developed. While the short-term economic case for intervention varies considerably across settings, the integrated framework also highlights the value of using modelling approaches to consider how the economic case for investment will change over the longer term.
WP8 created a Communication and Dissemination Plan, maintained the website, and identified new stakeholders for dissemination. Further, they created a Community of Practice for mental health and psychosocial support trainers where they can find manuals, practical tools, and can join webinars. The Community of Practice will be maintained beyond the lifetime of the project. Finally, WP8 organised two final symposia in 2022: one in Istanbul directed towards practitioners and one in Amsterdam to disseminate the scientific results.
STRENGTHS has already had a significant impact by scaling up the PM+ and related WHO scalable interventions Step-by-Step and EASE such that a large group of refugees have been able to benefit across the eight selected project countries. 38 scientific publications describing results of STRENGTHS have already been published and the results have been presented at conferences and gatherings worldwide. Various other publications are planned in 2023.
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, the Netherlands, Ukraine, Colombia, and Uganda. Finally, STRENGTHS results have promoted efforts to scale up PM+ widely beyond STRENGTHS, for example in Lebanon, Egypt, Greece, Türkiye, the Netherlands, Iraq, Jordan, 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, the Netherlands, Ukraine, Colombia, and Uganda. Finally, STRENGTHS results have promoted efforts to scale up PM+ widely beyond STRENGTHS, for example in Lebanon, Egypt, Greece, Türkiye, the Netherlands, Iraq, Jordan, and Switzerland.