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OBJECTIVE: To describe Syrian refugee women's experiences of the barriers to access mental health services for postpartum depression (PPD). DESIGN: A descriptive qualitative study was conducted. METHODS: Fifteen purposefully selected Syrian refugee women who scored ≥10 on the Edinburgh Postnatal Depression Scale participated in the semi-structured telephone interviews. Transcripts were coded verbatim and analysed thematically according to the dimensions of Levesque's model of patient-centred access to healthcare. Data were collected between August 2022 and February 2023. RESULTS: Five themes with 14 subthemes were identified: (1) approachability covered lack of knowledge and misconceptions related to PPD and its treatment, lack of awareness of available psychosocial services and perceived need of mental health treatment; (2) acceptability comprised being a refugee, stigma of mental illness, cultural preferences of healthcare provider and language barrier; (3) availability and accommodation encompassed transportation barrier and location of the centre, no support for childcare and lack of time; (4) affordability included financial difficulties and health insurance coverage; (5) appropriateness comprised no screening for PPD and intermittent services with limited focus on mental health. CONCLUSIONS: The findings of this study reveal that Syrian refugee women experienced multi-faceted complex barriers to access mental health services for PPD. It is important for health professionals, including nurses, and policymakers to address the cultural mental health needs of this population and establish strategies to protect their legal and health rights. IMPACT: Our study has important practice and policy implications for establishing strategies designed specifically for refugee mothers to mitigate their perceived barriers to PPD treatment and ultimately improve their mental health. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research was used. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. Participants were Syrian refugee women with PPD symptoms and contributed only to the interviews and member checking.
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INTRODUCTION: Promoting mental health, preventing and treating mental disorders are critically important in public health, and many randomised controlled trials (RCTs) evaluate intervention strategies for these objectives. However, distinguishing promotion from prevention and from treatment RCTs is challenging. A tool to place studies along the promotion-to-treatment continuum in mental health research does not exist, leaving it to researchers and policymakers to decide on how to classify individual RCTs, which hinders evidence synthesis. METHODS AND ANALYSIS: We present a protocol for the development of a new tool to assist researchers in distinguishing RCTs along the promotion-to-treatment continuum. We will establish a Tool Development Group, and use the Population, Intervention, Comparison and Outcome framework to define constructs. We will generate, define, categorise and reduce the items in the tool using qualitative methods, including cognitive interviews and a Delphi exercise. Psychometric evaluation-including unidimensionality, local independence, monotonicity and item homogeneity-will include data collection, scoring, internal consistency checks and factor analysis of the tool's indicators for available RCTs. We will use standard Cohen's kappa statistics to assess the reliability of the tool. ETHICS AND DISSEMINATION: This study involves data collection from the already published literature. However, this protocol has been approved by the ethics committee of the Università della Svizzera Italiana (CE 2024 04). The results of the present project will be disseminated in peer-reviewed journals and at international and national scientific meetings. Training materials for the application of the tool will also be developed and disseminated to the scientific community. The tool and all related implementation materials will be published on a website and will be freely accessible to the public.
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Promoción de la Salud , Trastornos Mentales , Salud Pública , Ensayos Clínicos Controlados Aleatorios como Asunto , Proyectos de Investigación , Humanos , Trastornos Mentales/terapia , Trastornos Mentales/diagnóstico , Promoción de la Salud/métodos , Salud Mental , Psicometría , Reproducibilidad de los Resultados , Técnica DelphiRESUMEN
Background: Scalable psychological interventions such as the WHO's Self-Help Plus (SH+) have been developed for clinical and non-clinical populations in need of psychological support. SH+ has been successfully implemented to prevent common mental disorders among asylum seekers and refugees who are growing in number due to increasing levels of forced migration. These populations are often exposed to multiple, severe sources of traumatisation, and evidence of the effect of such events on treatment is insufficient, especially for non-clinical populations.Objective: We aim to study the effect of potentially traumatic experiences (PTEs) and the mediating role of symptoms of posttraumatic stress disorder (PTSD) on the improvement following SH+.Method: Participants allocated to SH+ who received at least three sessions (N = 345) were extracted from two large, randomised, European prevention trials involving asylum seekers and refugees. Measures of distress, depression, functional impairment, and post-traumatic stress symptoms were administered at baseline and 6 months post-intervention, together with measures of well-being and quality of life. Adjusted models were constructed to examine the effect of PTEs on post-intervention improvement. The possible mediating role of PTSD symptoms in this relationship was then tested.Results: Increasing numbers of PTEs decreased the beneficial effect of SH+ for all measures. This relationship was mediated by symptoms of PTSD when analysing measures of well-being and quality of life. However, this did not apply for measures of mental health problems.Conclusions: Exposure to PTEs may largely reduce benefits from SH+. PTSD symptomatology plays a specific, mediating role on psychological well-being and quality of life of participants who experienced PTE. Healthcare professionals and researchers should consider the role of PTEs and PTSD symptoms in the treatment of migrants and refugees and explore possible feasible add-on solutions for cases exposed to multiple PTEs.
Increasing numbers of potentially traumatic experiences can decrease the beneficial effect of a manualized group psychotherapeutic intervention in migrants and refugees across multiple countries.In absence of a full threshold diagnosis of post-traumatic stress disorder, post-traumatic stress symptoms still mediate the relation between potentially traumatic experiences and some outcome improvements at follow-up.While the moderating role of number of potentially traumatic experiences applies to all outcomes (depression symptoms, psychological distress, functional impairment, well-being, and quality of life), the mediating role of post-traumatic stress symptoms in this relation only applies to well-being and quality of life.
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Refugiados , Trastornos por Estrés Postraumático , Humanos , Refugiados/psicología , Trastornos por Estrés Postraumático/terapia , Trastornos por Estrés Postraumático/psicología , Masculino , Femenino , Adulto , Intervención Psicosocial , Calidad de Vida/psicologíaAsunto(s)
Desastres , Terremotos , Trastornos Mentales , Humanos , Salud Mental , Turquía , Trastornos Mentales/terapia , Trastornos Mentales/psicologíaRESUMEN
BACKGROUND: Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project. METHOD: A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress (Professional Quality of Life Scale), perceived injustice, clinical self-efficacy (Counseling Activity Self-Efficacy Scale), service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention. DISCUSSION: There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.
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Agotamiento Profesional , Desgaste por Empatía , Humanos , Salud Mental , Cuidadores , Calidad de Vida , Agotamiento Profesional/prevención & control , Agotamiento Profesional/psicologíaRESUMEN
BACKGROUND: Higher social support protects people from developing mental disorders. Limited evidence is available on the mechanism through which social support plays this protective role. OBJECTIVE: To investigate the stress-buffering process of social support on depressive symptoms using a novel longitudinal dynamic symptom network approach. METHODS: A total of 4242 adult participants who completed the first two waves (from May to October 2020) of the International Covid Mental Health Survey were included in the study. Cross-lagged panel network modelling was used to estimate a longitudinal network of self-reported social support, loneliness and depressive symptoms. Standardised regression coefficients from regularised cross-lagged regressions were estimated as edge weights of the network. FINDINGS: The results support a unidirectional protective effect of social support on key depressive symptoms, partly mediated through loneliness: A higher number of close confidants and accessible practical help was associated with decreased anhedonia (weight=-0.033) and negative self-appraisal symptoms (weight=-0.038). Support from others was also negatively associated with loneliness, which in turn associated with decreased depressed mood (weight=0.086) and negative self-appraisal (weight=0.077). We identified a greater number of direct relationships from social support to depressive symptoms among men compared with women. Also, the edge weights from social support to depression were generally stronger in the men's network. CONCLUSIONS: Reductions in negative self-appraisal might function as a bridge between social support and other depressive symptoms, and, thus, it may have amplified the protective effect of social support. Men appear to benefit more from social support than women. CLINICAL IMPLICATIONS: Building community-based support networks to deliver practical support, and loneliness reduction components are critical for depression prevention interventions after stressful experiences.
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Depresión , Trastornos Mentales , Masculino , Adulto , Humanos , Femenino , Depresión/prevención & control , Apoyo Social , Soledad/psicología , Red SocialRESUMEN
BACKGROUND: The pandemic has placed considerable strain on health systems, especially in low- and middle-income countries (LMICs), leading to reductions in the availability of routine health services. Emerging evidence suggests that people with disabilities have encountered marked challenges in accessing healthcare services and supports in the context of the pandemic. Further research is needed to explore specific barriers to accessing healthcare during the pandemic, and any strategies that promoted continued access to health services in LMICs where the vast majority of people with disabilities live. METHODS: Qualitative in-depth interviews were conducted with persons with disabilities in Ghana, Zimbabwe, Viet Nam, Türkiye (Syrian refugees), Bangladesh, and India as part of a larger project exploring the experiences of people with disabilities during the COVID-19 pandemic and their inclusion in government response activities. Data were analysed using thematic analysis. RESULTS: This research found that people with disabilities in six countries - representing a diverse geographic spread, with different health systems and COVID-19 responses - all experienced additional difficulties accessing healthcare during the pandemic. Key barriers to accessing healthcare during the pandemic included changes in availability of services due to systems restructuring, difficulty affording care due to the economic impacts of the pandemic, fear of contracting coronavirus, and a lack of human support to enable care-seeking. CONCLUSION: These barriers ultimately led to decreased utilisation of services which, in turn, negatively impacted their health and wellbeing. However, we also found that certain factors, including active and engaged Organisations of Persons with Disabilities (OPDs) and Non-Governmental Organizations (NGOs) played a role in reducing some of the impact of pandemic-related healthcare access barriers.
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COVID-19 , Personas con Discapacidad , Humanos , Países en Desarrollo , Pandemias , Accesibilidad a los Servicios de SaludRESUMEN
AIMS: Socio-cultural integration of refugees has received scant attention in the academic literature. Türkiye hosts the largest number of refugees, including Afghans, as the second largest asylum-seeking group in Türkiye. There is a dearth of research into the mental health and integration of Afghan refugees in Türkiye. The aim of the present study was to investigate socio-cultural integration outcomes among Afghan refugees in Türkiye by considering the role of traumatic events and post-displacement stressors. The role of mental health in integration outcomes was further examined. METHODS: A cross-sectional, web-based survey study with 785 Afghan refugees in Türkiye was conducted between April and June 2021. Data were collected on socio-demographic characteristics, potentially traumatic events (PTEs) (Harvard Trauma Questionnaire), post-displacement stressors (Post-Migration Living Difficulties Checklist), mental health symptoms (Hopkins Symptoms Checklist-25), social integration- social bonds (contact with co-ethnic group members) and social bridges (contact with the host community)- and cultural integration (Vancouver Index of Acculturation). Structural equation modelling was conducted to test the hypothesized relationship between conflict and displacement-related stressors, mental health and socio-cultural integration. RESULTS: Findings showed that conflict-related traumatic events and post-displacement stressors significantly predicted higher mental health symptoms. Experiencing traumatic events significantly predicted higher levels of social bridges, adopting destination culture and lower level of maintaining heritage culture. Mental health problems predicted the relationship between stressors related to forced displacement and integration outcomes-social bridges and adopting destination culture. These findings highlight the role of mental health as an indispensable resource for socio-cultural integration. Further, conflict and displacement-related stressors are important determinants of socio-cultural integration among Afghan refugees in Türkiye. CONCLUSION: Exposure to PTEs and post-displacement stressors were significant risk factors for the mental health and socio-cultural integration of Afghan refugees in Türkiye. These stressful experiences deteriorate refugees' mental health, which hinders their integration into the host society.
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Refugiados , Trastornos por Estrés Postraumático , Humanos , Salud Mental , Trastornos por Estrés Postraumático/psicología , Refugiados/psicología , Estudios Transversales , AculturaciónRESUMEN
QUESTION: Refugees and asylum seekers are at high risk of mental disorders due to various stressors before, during and after forceful displacement. The WHO Self-Help Plus (SH+) intervention was developed to manage psychological distress and a broad range of mental health symptoms in vulnerable populations. This study aimed to examine the effects and moderators of SH+ compared with Enhanced Care as Usual (ECAU) in reducing depressive symptoms among refugees and asylum seekers. STUDY SELECTION AND ANALYSIS: Three randomised trials were identified with 1795 individual participant data (IPD). We performed an IPD meta-analysis to estimate the effects of SH+, primarily on depressive symptoms and second on post-traumatic stress, well-being, self-identified problems and functioning. Effects were also estimated at 5-6 months postrandomisation (midterm). FINDINGS: There was no evidence of a difference between SH+ and ECAU+ in reducing depressive symptoms at postintervention. However, SH+ had significantly larger effects among participants who were not employed (ß=1.60, 95% CI 0.20 to 3.00) and had lower mental well-being levels (ß=0.02, 95% CI 0.001 to 0.05). At midterm, SH+ was significantly more effective than ECAU in improving depressive symptoms (ß=-1.13, 95% CI -1.99 to -0.26), self-identified problems (ß=-1.56, 95% CI -2.54 to -0.59) and well-being (ß=6.22, 95% CI 1.60 to 10.90). CONCLUSIONS: Although SH+ did not differ significantly from ECAU in reducing symptoms of depression at postintervention, it did present benefits for particularly vulnerable participants (ie, unemployed and with lower mental well-being levels), and benefits were also evident at midterm follow-up. These results are promising for the use of SH+ in the management of depressive symptoms and improvement of well-being and self-identified problems among refugees and asylum seekers.
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Refugiados , Trastornos por Estrés Postraumático , Humanos , Refugiados/psicología , Trastornos por Estrés Postraumático/terapia , Salud Mental , Conductas Relacionadas con la Salud , Bienestar PsicológicoRESUMEN
BACKGROUND: The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited. OBJECTIVE: To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands. METHODS: We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019-December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat. FINDINGS: Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference -0.25; 95% CI -0.385 to -0.122; p=0.0001, Cohen's d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen's d=0.42), anxiety (p=0.001, Cohen's d=0.27), PTSD symptoms (p=0.0005, Cohen's d=0.39) and self-identified problems (p=0.03, Cohen's d=0.26), but not on impairment (p=0.084, Cohen's d=0.21). CONCLUSIONS: PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit. CLINICAL IMPLICATIONS: Peer-provided psychological interventions should be considered for scale-up in HICs.
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Intervención Psicosocial , Refugiados , Adulto , Masculino , Humanos , Femenino , Depresión/terapia , Refugiados/psicología , Siria , Método Simple CiegoRESUMEN
BACKGROUND: In asylum seekers and refugees, the frequency of mental disorders, such as depression, anxiety and post-traumatic stress disorder, is higher than the general population, but there is a lack of data on risk factors for the development of mental disorders in this population. AIM: This study investigated the risk factors for mental disorder development in a large group of asylum seekers and refugees resettled in high- and middle-income settings. METHODS: Participant-level data from two randomized prevention studies involving asylum seekers and refugees resettled in Western European countries and in Turkey were pooled. The two studies randomized participants with psychological distress, but without a diagnosis of mental disorder, to the Self-Help Plus psychological intervention or enhanced care as usual. At baseline, exposure to potentially traumatic events was measured using the Harvard Trauma Questionnaire-part I, while psychological distress and depressive symptoms were assessed with the General Health Questionnaire and the Patient Health Questionnaire. After 3 and 6 months of follow-up, the proportion of participants who developed a mental disorder was calculated using the Mini International Neuropsychiatric Interview. RESULTS: A total of 1,101 participants were included in the analysis. At 3- and 6-month follow-up the observed frequency of mental disorders was 13.51% (115/851) and 24.30% (207/852), respectively, while the frequency estimates after missing data imputation were 13.95% and 23.78%, respectively. After controlling for confounders, logistic regression analysis showed that participants with a lower education level (p = .034), a shorter duration of journey (p = .057) and arriving from countries with war-related contexts (p = .017), were more at risk of developing mental disorders. Psychological distress (p = .004), depression (p = .001) and exposure to potentially traumatic events (p = .020) were predictors of mental disorder development. CONCLUSIONS: This study identified several risk factors for the development of mental disorders in asylum seekers and refugees, some of which may be the target of risk reduction policies. The identification of asylum seekers and refugees at increased risk of mental disorders should guide the implementation of focused preventative psychological interventions.
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Refugiados , Trastornos por Estrés Postraumático , Humanos , Refugiados/psicología , Turquía/epidemiología , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/psicología , Europa (Continente)/epidemiología , Factores de RiesgoRESUMEN
OBJECTIVE: This study aims to determine for Syrian refugee women in Turkey the effectiveness, feasibility, and acceptability of culturally adapted cognitive behavioral therapy (CA-CBT). METHOD: Participants were randomly allocated to receive either CA-CBT (n = 12) or treatment-as-usual (TAU; n = 11). We used the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL) to assess posttraumatic stress symptoms and anxious-depressive distress. CA-CBT was delivered through seven weekly group sessions. RESULTS: CA-CBT had a large effect on PTSD (HTQ d = 1.17) and nearly medium effect sizes for anxious-depressive distress (HSCL d = .40). There were also low drop-out rates and an absence of adverse events. CONCLUSIONS: Because CA-CBT greatly reduced PTSD symptoms as compared with TAU and had a low drop-out rate, no adverse events, and was deliverable in a short treatment frame (seven sessions) and in a group format, we conclude that the treatment is effective, acceptable, and feasible and has the potential for scalability. Clinical Impact Statement: A Syrian version of CA-CBT was effective (large effect sizes for the HTQ), feasible, and potentially scalable (easy application, conducted with trained facilitators, short-term therapy, group format), and acceptable (as evidenced by very low drop out and no adverse events). Thus, the Syrian version of CA-CBT appears to be a valuable psychological intervention for traumatized Syrian refugees, particularly given the lack of effective treatments for this group. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Terapia Cognitivo-Conductual , Refugiados , Trastornos por Estrés Postraumático , Humanos , Femenino , Refugiados/psicología , Turquía , Siria , Ansiedad/terapia , Trastornos por Estrés Postraumático/terapia , Trastornos por Estrés Postraumático/psicologíaRESUMEN
Refugees are at increased risk for developing psychological impairments due to stressors in the pre-, peri- and post-migration periods. There is limited knowledge on how everyday functioning is affected by migration experience. In a secondary analysis of a study in a sample of refugees and asylum seekers, it was examined how aspects of psychological functioning were differentially affected. 1,101 eligible refugees and asylum seekers in Europe and Türkiye were included in a cross-sectional analysis. Gender, age, education, number of relatives and children living nearby, as well as indicators for depressive and posttraumatic symptoms, quality of life, psychological well-being and functioning, and lifetime potentially traumatic events were assessed. Correlations and multiple regression models with World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 12-item version's total and six subdomains' scores ('mobility', 'life activities', 'cognition', 'participation', 'self-care', 'getting along') as dependent variables were calculated. Tests for multicollinearity and Bonferroni correction were applied. Participants reported highest levels of impairment in 'mobility' and 'participation', followed by 'life activities' and 'cognition'. Depression and posttraumatic symptoms were independently associated with overall psychological functioning and all subdomains. History of violence and abuse seemed to predict higher impairment in 'participation', while past events of being close to death were associated with fewer issues with 'self-care'. Impairment in psychological functioning in asylum seekers and refugees was related to current psychological symptoms. Mobility and participation issues may explain difficulties arising after resettlement in integration and exchange with host communities in new contexts.
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Background: Syrian refugees have a high burden of mental health symptoms and face challenges in accessing mental health and psychosocial support (MHPSS). This study assesses health system responsiveness (HSR) to the MHPSS needs of Syrian refugees, comparing countries in Europe and the Middle East to inform recommendations for strengthening MHPSS systems. Methods: A mixed-methods rapid appraisal methodology guided by an adapted WHO Health System Framework was used to assess HSR in eight countries (Egypt, Germany, Jordan, Lebanon, Netherlands, Sweden, Switzerland, and Türkiye). Quantitative and qualitative analysis of primary and secondary data was used. Data collection and analysis were performed iteratively by multiple researchers. Country reports were used for comparative analysis and synthesis. Results: We found numerous constraints in HSR: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services, widening rural-urban inequalities in the distribution of mental health workers; iii) Cultural, language, and knowledge-related barriers to timely care likely caused by insufficient numbers of culturally sensitive providers, costs of professional interpreters, somatic presentations of distress by Syrian refugees, limited mental health awareness, and stigma associated to mental illness; iv) High out-of-pocket costs for psychological treatment and transportation to services reducing affordability, particularly in middle-income countries; v) Long waiting times for specialist mental health services; vi) Information gaps on the mental health needs of refugees and responsiveness of MHPSS systems in all countries. Six recommendations are provided to address these issues. Conclusions: All eight host countries struggle to provide responsive MHPSS to Syrian refugees. Strengthening the mental health workforce (in terms of quantity, quality, diversity, and distribution) is urgently needed to enable Syrian refugees to receive culturally appropriate and timely care and improve mental health outcomes. Increased financial investment in mental health and improved health information systems are crucial.
Background: People who experience war often have increased mental health problems. Those who are forced to flee abroad frequently struggle to access adequate mental health and psychosocial support services. As a result, many refugees often do not seek or use such services.Researchers of the Syrian REfuGees MeNTal HealTH Care Systems (STRENGTHS) consortium carried out rapid appraisals to assess the responsiveness of health systems to the mental health and psychosocial needs of Syrian refugees in eight countries: Egypt, Germany, Jordan, Lebanon, the Netherlands, Sweden, Switzerland, and Türkiye. They used quantitative and qualitative data, including primary and secondary data. This paper summarises and compares findings from the eight countries. What is health system responsiveness?: The ability of a health system to meet the expectations and needs of its people with regards to access, coverage, quality, and safety of services. What are our main findings and recommendations?: We found that all eight host countries struggle to provide responsive mental health and psychosocial support to Syrian refugees. We identified the following key challenges: Insufficient mental health providers and services, including uneven rural-urban distribution;Cultural, language, and knowledge-related barriers to timely care, caused by insufficient culturally sensitive providers and mental health stigma among Syrian refugee communities;Out-of-pocket costs for psychological treatment and transportation to services;Long waiting times for specialist mental health services;Information gaps on the mental health needs of Syrian refugees;We recommend increasing national funding for mental health to help Syrian refugees to receive more culturally appropriate and timely care. Increased funding can reduce out-of-pocket payments by refugees, improve national health information systems, and strengthen the mental health workforce (in terms of quantity, quality, diversity, and distribution). We also recommend investment in cultural competency and mental health training for community-based workers and primary care providers.
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Background: Longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce. Objectives: To investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values. Results: Symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ß = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ß = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ß = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ß = -1.67, 95% CI -3.19 to -0.15), close to death (ß = -1.38, 95% CI -2.70 to -0.06), and being in the host country ≥2 years (ß = -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ß = 2.11, 95% CI 0.58-3.65), and lack of shelter (ß = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ß = -1.36, 95% CI -2.67 to -0.05). Conclusion: Many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories.
Antecedentes: Estudios longitudinales que examinan las trayectorias de la salud mental en los refugiados y solicitantes de asilo son escasos.Objetivos: Investigar las trayectorias de los síntomas psicológicos y el bienestar en refugiados y solicitantes de asilo, e identificar factores asociados a estas trayectorias.Métodos: Se incluyeron 912 solicitantes de asilos y refugiados del brazo control de tres ensayos clínicos en Europa (n = 229), Turquía (n = 320) y Uganda (n = 363). Describimos las trayectorias psicológicas de los síntomas y el bienestar, y utilizamos la exposición traumática, la edad, el estado marital, la educación y el juicio individual como predictores. Después, evaluamos las interacciones bidireccionales entre el bienestar y los síntomas psicológicos, y el efecto de cada uno de los predictores en cada resultado controlando por los valores iniciales.Resultados: Se identificó una mejoría en los síntomas en todos los ensayos, y del bienestar en el 64.7% de los participantes en Europa y Turquía, versus el 31.5% en Uganda. En Europa y en Turquía, la violencia doméstica predijo el incremento de síntomas de después de la intervención (ß = 1.36, 95% CI 0.17 a 2.56), mientras que el homicidio de algún miembro familiar a los 6 meses de seguimiento (ß = 1.23, 95% CI 0.27 a 2.19). Un menor bienestar fue predicho por el homicidio de algún miembro de la familia (ß = −1.69, 95% CI −3.06 a −0.32), haber sido secuestrado (ß = −1.67, 95% CI −3.19 a −0.15), haber estado próximo a la muerte (ß = −1.38, 95% CI −2.70 a −0.06), y estar en el país de acogida ≥2 años (ß = −1.60, 95% CI −3.05 a −0.14). En Uganda, después de la intervención, haber sido secuestrado predijo un aumento de los síntomas (ß =2.11, 95% CI 0.58 a 3.65), y la falta de refugio (ß = −2.51, 95% CI −4.44 a −0.58) y la violencia doméstica predijo un menor bienestar (ß = −1.36, 95% CI −2.67 a −0.05).Conclusión: Muchos participantes se adaptan a la adversidad, pero los factores contextuales juegan un papel crítico en determinar las trayectorias de la salud mental.
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Refugiados , Trastornos por Estrés Postraumático , Europa (Continente)/epidemiología , Humanos , Refugiados/psicología , Trastornos por Estrés Postraumático/diagnóstico , Turquía , Uganda/epidemiologíaRESUMEN
BACKGROUNDS: Individuals with chronic medical conditions are considered highly exposed to COVID-19 pandemic stress, but emerging evidence is demonstrating that resilience is common even among them. We aimed at identifying sustained resilient outcomes and their predictors in chronically ill people during the first year of the pandemic. METHODS: This international 4-wave 1-year longitudinal online survey included items on socio-demographic characteristics, economic and living situation, lifestyle and habits, pandemic-related issues, and history of mental disorders. Adherence to and approval of imposed restrictions, trust in governments and in scientific community during the pandemic were also investigated. The following tools were administered: the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the PTSD Checklist DSM-5, the Oslo Social Support Scale, the Padua Inventory, and the Portrait Values Questionnaire. RESULTS: One thousand fifty-two individuals reporting a chronic condition out of 8011 total participants from 13 countries were included in the study, and 965 had data available for the final model. The estimated probability of being "sustained-resilient" was 34%. Older male individuals, participants employed before and during the pandemic or with perceived social support were more likely to belong to the sustained-resilience group. Loneliness, a previous mental disorder, high hedonism, fear of COVID-19 contamination, concern for the health of loved ones, and non-approving pandemic restrictions were predictors of not-resilient outcomes in our sample. CONCLUSIONS: We found similarities and differences from established predictors of resilience and identified some new ones specific to pandemics. Further investigation is warranted and could inform the design of resilience-building interventions in people with chronic diseases.
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COVID-19 , Pandemias , Ansiedad , Enfermedad Crónica , Depresión , Humanos , Soledad , Masculino , Estudios ProspectivosRESUMEN
BACKGROUND: Türkiye hosts 4 million refugees and asylum seekers, with Syrians and Afghans being among the largest refugee groups in country. There are limited comparative data on the conflict- and displacement-related experiences of these groups and the relation with mental health status. AIMS: To assess the mental health status of Syrians and Afghans in Türkiye, identify risk factors and explore to what extent differences in mental health conditions are related to potentially traumatic events and post-displacement stressors. METHOD: Two parallel online survey studies were conducted between April and June 2021 among 798 Syrians and 785 Afghans in Türkiye. Data were collected on sociodemographic characteristics, traumatic events (Harvard Trauma Questionnaire), post-displacement stressors (Post-Migration Living Difficulties Checklist), symptoms of depression and anxiety (Hopkins Symptoms Checklist-25) and post-traumatic stress disorder (PTSD) (Post-Traumatic Stress Disorder Checklist for DSM-5, short form). RESULTS: For Syrian and Afghan participants respectively, estimated prevalence rates were: 41.1% and 50.3% for depression; 39.6% and 41% for anxiety; and 41.6% and 46.5% for PTSD. In both groups, significant predictors were female gender, exposure to potentially traumatic events, and structural and socioeconomic post-displacement stressors. Additional risk factors were older age for Afghans and higher education for Syrians. CONCLUSIONS: Self-reported symptoms of common mental health problems are highly prevalent among Syrian and Afghan refugees and associated with a wide range of risk factors. After controlling for conflict- and displacement-related experiences, Afghans reported higher anxiety symptoms than Syrians, which is likely related to their legal status in Türkiye.
RESUMEN
BACKGROUND: Little is known about changes of mental health during the COVID-19 pandemic in potentially disadvantaged groups. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in six European countries and Australia by prior mental disorders and migration status. METHODS: Overall, 4674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021. Information on psychosocial, financial and demographic, living conditions, prior mental disorders, depression and anxiety symptoms during the pandemic and migration status was collected. Weighted general estimation equations modelling was used to investigate the association between prior mental disorders, migration status, and symptoms over time. RESULTS: Most participants were <40 years old (48%), women (78%) and highly educated (62%). The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35%, respectively. In most countries, prevalence rates remained unchanged throughout the pandemic and were higher among people with prior mental disorders than without even after adjustment for several factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in two countries. No difference by migration status was noted. LIMITATIONS: Convenience sampling limits generalizability. Self-assessed symptoms of depression and anxiety might involve some misclassification. CONCLUSIONS: Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of worsening mental health in the observed groups during the observed period.
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COVID-19 , Pandemias , Adulto , Ansiedad/epidemiología , Ansiedad/psicología , Trastornos de Ansiedad/epidemiología , COVID-19/epidemiología , Depresión/epidemiología , Depresión/psicología , Femenino , HumanosRESUMEN
Importance: The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear. Objective: To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey. Design, Setting, and Participants: This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group. Interventions: The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees. Main Outcomes and Measures: The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021. Results: Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14â¯831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone. Conclusions and Relevance: This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.