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Refugee Emergency: DEFining and Implementing Novel Evidence-based psychosocial interventions

Periodic Reporting for period 2 - RE-DEFINE (Refugee Emergency: DEFining and Implementing Novel Evidence-based psychosocial interventions)

Reporting period: 2019-07-01 to 2020-12-31

There is a growing body of research demonstrating the effectiveness of psychological therapies for refugees and asylum seekers. However, psychological treatments require extensive training and supervision, and sufficient time to be delivered in full. Additionally, most interventions targeted the symptoms of mental disorders, without a specific focus on prevention.

Recently, the World Health Organization (WHO) has developed a novel, low-intensity five-session self-help intervention for managing stress and coping with adversity. This psychosocial intervention, called Self-Help Plus (SH+), is intended to help and support people with and without mental disorders to cope with distress stemming from diverse types of adversity.

RE-DEFINE was developed to test the effectiveness and cost-effectiveness of using SH+ to prevent the onset of mental disorders in refugees and asylum seekers with psychological distress in Western Europe and Turkey. Two prospective, multi-centred, randomized controlled trials took place in seven sites in five Western European countries and Turkey. RE-DEFINE included a total of 1,101 asylum seekers and refugees (Syrians, Afghans, Pakistanis, Iraqis, Nigerians), aged 18+ years old experiencing psychological distress but without a diagnosis of a mental disorder. SH+ was delivered by briefly trained, non-specialist facilitators with refugee or other migrant backgrounds. The trials measured the development of mental disorders, symptoms of psychological distress, functioning, mental well-being, intervention acceptability and economical outcomes.

Main results of REDEFINE research include the following:

• Both the Western European and Turkey studies have shown evidence of an impact of SH+ on preventing mental disorders and reducing stress, but differences were observed between the studies.

• In Turkey providing the SH+ intervention in addition to usual care was found to be highly cost-effective, while in Western European countries there were no differences found in cost-effectiveness.

• RE-DEFINE has shown that SH+ can be effectively delivered in a range of different settings, with groups of different sizes and to people from diverse cultures.

• RE-DEFINE has shown, for the first time, that it is possible to prevent the onset of mental disorders in distressed refugees and asylum seekers.

• RE-DEFINE has shown that it is possible to complete state-of-art randomized controlled trials on preventive mental health interventions.

• Preventive value of RE-DEFINE: Both the Western European and Turkey studies showed evidence of an impact of SH+ on preventing mental disorders and reducing stress. This effect was much more pronounced for the Turkey study where substantial effects were observed at 6 months follow up, compared to the Western European study where effects were only found immediate post-intervention and not at six months follow up. This difference may be explained by differences in context as the participants in Turkey faced many more stressors during the study than the participants in Western Europe.

The RE-DEFINE research has led to the following recommendations for populations affected by adversity, including refugees and asylum seekers:

1. Invest in evidence-based mental health and psychosocial support interventions, such as SH+, along with interventions that support integration and contribute to wider economic benefits.

2. Implement SH+ as intervention for populations exposed to adversity to reduce psychological distress and prevent onset of serious mental illness.

3. Implement SH+ as part of a whole of society approach that also addresses social and economic challenges. SH+ is part of the solution, but it cannot be the only solution.

4. Integrate SH+ and the other low resource intensity interventions, within health and community services to increase accessibility, scalability and sustainability. The best results are likely to be achieved if SH+ is part of an integrated approach with educational, financial legal and social supports.

5. Invest in implementation science to understand the pathways, barriers and facilitating factors to scale up low resource-intensity psychological interventions. Research is needed on implementation; combining SH+ with other key interventions; exploring different delivery approaches; identifying subgroups who will benefit from SH+; and delivering SH+ to groups of people from different cultures together at scale.
The work performed since the beginning of the project is reported below, organized according to the activities planned in each WP:

Work Package 1: Overall project management.
Work package 2: Analysis of migration flows across countries inside and outside Europe, in order to understand the socio-cultural characteristics of asylum seekers and refugees resettled in the countries involved in the project: Italy, Germany, Austria, Finland, the UK (in which there are two sites), and Turkey.
Work package 3: Cultural adaptation of SH+ programme. SH+ consists of a pre-recorded audio course and illustrated book, which contains all of the main messages and information from the SH+ audio. Based on results from WP2, SH+ has been translated and adapted into 3 different languages: Urdu for Pakistani participants, Arabic for Syrian and Iraqi participants, and Dari for Afghan participants. In addition, the SH+ package in English was adapted for use with refugees from Nigeria. This was narrated by a Nigerian voice actor.
Work package 4: Implementation of SH+ programme in European countries. WP4 consisted of a large, pragmatic, multicentre RCT comparing SH+ programme delivered by peer refugee facilitators versus enhanced usual care, in asylum seeker and refugee populations resettled in Europe.
Work package 5: Implementation of SH+ programme in Turkey with same method and approach applied in Work Package 4.
Work package 6: As a common basis for the assessment of the use and costs of health and social care resources in the participating countries, the European version of the Client Socio-Demographic and Service Receipt Inventory CSSRI has been adapted to be applied in asylum seekers and refugees by means of interviews with asylum seekers and refugees and staff members from health and social care facilities providing services for this population.
Work package 7: Development of a detailed dissemination plan related to each phase of the project, and to the reporting of overall results. Many communication activities have been implemented at different levels: video interviews, animated video, press release and a Policy Brief translated in all the languages if the partners and in some of the language of the participants to the Study.
Work package 8 is related to the ethical aspects of the RE-DEFINE project.
As originally stated, we expect that the results obtained will have an enormous impact in terms of availability and access to mental health care and on the quality of evidence-based mental health services for vulnerable populations. RE-DEFINE will have a significant impact on health system and stakeholders, contributing to the equity in preventative interventions for reducing the incidence of mental health diagnoses, promoting health, and providing effective, equitable, and affordable health services.
Graphical representation of the overall project
RE-DEFINE presentation at ENMESH, Lisbon, June 2019
Training of facilitators, Verona, June, 2018
Training of facilitators, Verona, June, 2018
RE-DEFINE presentation at ENMESH, Lisbon, June 2019
RE-DEFINE infographic on results
RE-DEFINE kick-off meeting. Verona, January 15, 2018
Training of Trainers, Verona, May 22-25, 2018
Training of Trainers, Verona, May 22-25, 2018
RE-DEFINE mid-term meeting in Geneva, 4-5 Februaty, 2019