A large number of Syrian refugees have sought refuge in Turkey since the onset of the war in Syria in 2011. Turkey now hosts around 3.6 million Syrian refugees and ranks first as host country for Syrian refugees in terms of its numbers (1, 2). The majority of Syrian refugees live outside camps in economically deprived urban areas across Turkey (2, 3), while around 300,000 live in camps on the Syrian border (4).
Refugees are often vulnerable to situational forms of psychosocial distress as a consequence of exposure to war and violence, potentially traumatic events experienced during the individual’s flight from their home country, and exposure to ongoing daily stressors in their new areas of settlement, such as impoverishment, unemployment, poor living conditions, social isolation and discrimination (5). Some forms of distress may be situational while others may be more profound and can manifest in post-traumatic stress disorder (PTSD), depression and/or anxiety disorder (6). Currently, there are no population wide estimates on the prevalence of mental disorders among refugees in Turkey. Acarturk et al (7) investigated the prevalence of probable PTSD and depression among adult Syrians residing in a camp near the Syrian / Turkish border, and reported that around 83% screened positive for PTSD while around 37% screened positive for symptoms of depression. In a cross-sectional study conducted in a tent city in Gaziantep, Turkey, Alpak et al reported a PTSD prevalence of 33.5% among Syrian refugees (8). Data from our own cross-sectional survey of Syrian refugees in Sultanbeyli, Istanbul revealed a prevalence of symptoms of PTSD, depression and anxiety of 19.6%, 34.7% and 36.1% respectively (9). Variability of prevalence estimates may result from differences in the conditions in which the respondents were living, and methodological differences between the surveys (5).
Mental health services in Turkey are overseen by the Turkish Government’s Ministry of Health (10). A national mental health action plan was developed in 2011 (11). However, budget limitations have hampered the integration of mental health into primary and community care, with most care still delivered by psychiatrists, psychologists and other mental health professionals at the tertiary and secondary care level (12). This form of treatment might be beneficial for more serious cases of mental disorders, and for Turkish residents as treatment is delivered in Turkish. Registered Syrian refugees can formally access the public mental health care health system in Turkey but need to speak Turkish or have an interpreter available in order to benefit from treatment. Structural and attitudinal barriers to accessing the public health care system have been reported for refugees, resulting in unmet need and a large mental health treatment gap for Syrian refugees in Turkey (9, 13). Culturally and linguistically sensitive health services are provided to Syrian refugees through 178 refugee health centres established as part of the WHO Refugee Health Programme (14). These centres are not part of the formal public health care system but are community centres where Syrian doctors provide care for Syrian patients (15); these centres also serve as gateways to health care for Syrian refugees (14). There is also a range of nongovernmental organisations (NGOs) involved in provision of mental health and psychosocial support activities for Syrian refugees in Turkey(16, 17). However, there remains a need for evidence-based, community-based interventions for Syrian refugees in Turkey which addresses Syrian refugees’ mental health needs in a culturally relevant and scalable way.
Problem Management Plus (PM+) in Turkey
Problem Management Plus (PM+) was designed by the World Health Organization (WHO) for adults impaired by distress in communities exposed to adversity (18, 19) (20, 21), and is currently being adapted for Syrian refugees residing in countries neighbouring Syria, including Turkey (22). PM+ is a transdiagnostic intervention (i.e., not condition-specific) to reduce common mental health symptoms such as anxiety, depression and posttraumatic stress and to improve psychosocial functioning. PM+ is a 5-session intervention, comprised of evidence-based techniques for problem solving, stress management, behavioural activation, and accessing social support. (19) In South Turkey, the WHO organized ‘trainings for trainers’ in PM+ for Syrian mental health professionals who subsequently trained psychosocial workers providing individual PM+ for Syrians in North East Syria and South Turkey. In Sultanbeyli/Istanbul, PM+ is provided to Syrian refugees in a group setting. Group PM+ providers are female and male peer-refugees with a background in health care, social work or community care who receive eight days of training, followed by three practice cases, on-the-job training, and close supervision during implementation delivery. PM+ trainers/supervisors are licensed mental health care professionals such as psychologists or psychiatrists.
Objective of this paper
The last decade has seen a rise in the development and evaluation of low-intensity psychological interventions (23). Many have proven effectiveness for improving mild to moderate mental health symptoms; however, population-level coverage remains low, due to a range of implementation challenges related to limited adoption in policies and strategies, insufficient resource allocation, competing national interests, and a lack of planning and guidance regarding how to take psychological interventions to scale (24, 25). In this paper we test the use of Theory of Change (ToC) to plan the scaling up of a low-intensity psychological intervention. ToC is a participatory planning process used in the development, implementation and evaluation of projects (26). To the best of our knowledge, ToC has not been applied to scaling up public health interventions yet. The aim of this paper is to present the ToC map for scaling up group PM+ in Turkey. Our objectives were to (a) investigate the use of ToC methodology in planning the scale up of PM+ for Syrian refugees in Turkey; (b) to explore context-specific pathways of scaling up PM+ for Syrian refugees in Turkey; and (c) to identify barriers and facilitators to scale up.