Scientific importance of research
Forced displacement is currently one of the most important global challenges. UNHCR data show that over 70 million people are forced to leave their homes due to conflict, war, or oppression. Out of all forced displacements, the number of refugees has risen to a record high of nearly 26 million in the world [22], where the negative effects of wars on civilian populations are already well-known [2,3].
One of the most important public health priorities for international organizations, academia and governments is to detect those who are most vulnerable to the effects of war and resulting forced displacement. It is also of utmost urgency to assess and follow-up refugees’ mental health problems and barriers in accessing health care in host countries, so that evidence-based policymaking and needs-based service provision can be possible.
The results of this study will likely inform the public health authorities, humanitarian and non-governmental organizations in Turkey on how to allocate resources in terms of best management for the mental health problems of refugees in urban settings. Our most interesting finding was that mental disorder rates in urban settings were similar to those found in studies conducted in camps. It is expected that refugees who settled in a large city such as Ankara, rich with opportunities and away from the reminders of the war, should show lower rates of psychopathology. In addition, our study was done much later than the studies done in camps; a decline in mental disorder rates would be expected. This finding points to the need to examine social determinants of mental health and other factors that the refugees go through in the host community in urban settings, which either create new mental problems or prevent the resolution of the existing war-related ones. Through assessments such as the ones used in the present study, it is also possible to learn about resilience to the effects of war. Another potential finding, which may have broader implications, will come from the comparison of the effects of direct exposure to war trauma versus the effects of negative life events imposed by the difficulties during forced displacement and during the adaptation process in the host country. It is generally accepted that war trauma relates more strongly to PTSD, whereas negative life events show stronger correlations with depression. We are in the process of analyzing our data and comparing the effects of two types of events in our respondents.
Although Syrian refugees have been in Turkey since 2011 and the number of refugees has been increasing each year, there were very few studies addressing the mental health status and needs of refugees in urban settings in Turkey. Many studies in other regions of the world have reported low rates of use of mental health services and the common reasons for this were language and cultural barriers, financial constraints, discrimination, negative attitudes of healthcare personnel, and lack of information on how and where to obtain healthcare services [23-28]; the present study also revealed similar findings.
Most of the previous studies conducted in Turkey were limited, because they collected data from camp residents. The current study has overcome those limitations by selecting a community-based urban sample and assessing health services use, in addition to the rates of mental disorders. On another note, the study was conducted in the capital of Turkey, where the health care service provision is expected to be better than most other cities in Turkey.
Nevertheless, this study also has some limitations. First, we did not use a clinical interview, which would make it possible to reach definitive medical diagnoses. On the other hand, our interviewers administered the batch including self-administered scales as an interview, mainly because the education level of the sample was low. Another limitation of the study was that the HTQ version we used assessed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-IV) PTSD instead of DSM-5; this was because a valid and reliable instrument calibrated for DSM-5 was not available at the time of our study. The research team used a quantitative approach to collect data from refugees and a qualitative approach for service providers and decision makers. Although adding a qualitative approach could help with more in-depth data collection from refugees, collecting data in a visual or audio format was not allowed by authorities at the time of the study. Second, our main aim was to administer validated mental health scales in addition to assessing sociodemographic features and services use. The batch including the scales and the questionnaire was already too long and it could be very difficult to have additional qualitative interviews. We therefore decided to use a quantitative approach for refugees and a qualitative approach for service providers and decision makers.
Although we tried to obtain a representative sample, population sizes and distributions according to different neighborhoods were not available and our sample was not random. We had to use snowball sampling to reach respondents and therefore cannot generalize our findings to Syrian refugees in Turkey. We included all adults in the contacted households instead of choosing a random respondent, which may have created a bias in terms of prevalence of mental problems. On the other hand, each household usually had more than one family, sometimes going up to three or four families per household, which may have decreased the aforementioned bias. Despite training of data collectors by senior researchers for data collection to be standardized, there might still be interviewer bias encountered during actual field work.
The present study adds to the literature with its mixed-method approach when assessing services use, which made it possible to learn different points of views from refugees, health authorities and health service providers in a multidimensional manner. The research team disseminated the main findings to a variety of audiences including academia (via conference presentations and scientific publications), public sector, and national and international non-governmental organizations (NGOs and INGOs) (via presentations in health policy-oriented meetings). Our main aim in disseminating the findings was to inform future mental health policy-making and service provision in Turkey, in addition to advocate for increased efforts to promote refugee mental health by a multi-sectoral approach, including targeted interventions to improve social determinants of mental health [23-27].
Challenges faced by researchers
Working with a highly traumatized population: The high prevalence of past and present traumas required better communication skills and resolution of trust issues between the respondents and the interviewers. The interviews lasted longer for those with higher levels of trauma and sometimes caused interviewers to be emotionally affected. At those times, the interviews were supported by senior researchers to decrease the risk of secondary traumatization.
Legal status, lack of data, and high mobility of refugees: Obtaining an appropriate sample to study was problematic and targeting a representative sample was not feasible, because of lack of neighborhood-specific data, the presence of undocumented asylum seekers and high mobility among the registered refugee community. According to official estimates at the time of the study, there were 88.000 Syrian refugees living in Ankara. Since there has been a high mobility among the refugees in Turkey, it was not possible to exactly locate the neighborhoods they lived in. Two neighborhoods, known to be densely populated by Syrian refugees, were targeted for the study. At the time of the study, demographic data were not available at a district level and the research team didn’t know how many Syrians lived in those neighborhoods, because of the lack of publicly available data and the presence of unregistered asylum seekers.
Safety issues and willingness to participate: Presence of unregistered asylum seekers also led to problems with willingness to participate, since undocumented or unregistered migrants tend to avoid non-essential contact with professionals in host countries because of the fear of deportation. Although non-response rate was very low, some refugees and asylum seekers did not want to participate in the study because of safety concerns and potential research fatigue. Despite numerous measures taken by the research team to increase trust and response rate (training of data collectors, use of name badges, using a peer approach during snowball sampling etc.), 15 households refused to participate in the study and no information could be gathered about their demographic or other characteristics, which could have been different than the study population.
Referral for Services: An additional challenge encountered was related to limited health care access for unregistered asylum seekers. Although respondents with significant psychological symptoms were routinely referred to available mental health services, the research team was not able to do the same for undocumented people, since they did not have free health care coverage and needed other means of support such as psychosocial support delivered by NGOs.
Cultural Barriers: The research team also experienced some cultural and gender-related challenges. For instance, women were reluctant to be interviewed by a male interviewer and it was not easy to find men at home during working hours, as most men were at work during daytime. To avoid bias, necessary measures were taken to end up with a gender-balanced sample (see below).
Resentment from Host Communities: The two neighborhoods where the study was conducted were among the most disadvantaged ones in Ankara and were also home to other (Afghan, Somali) refugees, as well as low-income Turkish families. There was visible animosity towards Syrian refugees by others, fueled by anti-immigrant propaganda (“they are taking up our jobs”, “they receive money from the government, etc.”). This factor did not prevent the research efforts, but may have diminished motivation of others in helping the interviewers find refugees and houses to include in the study.
Language: Language was another important challenge for this specific study topic and the population, since mental health care generally requires more linguistic competence both on the patient and provider side. During the interviews, almost all respondents mentioned the language problem as the main reason for low contact with mental health services. A similar challenge existed for the researchers. First of all, none of the researchers spoke Arabic and most adult refugees did not speak Turkish. The different alphabet (Latin) used in Turkey added to the language barrier. Plus, most of the refugees had very low educational attainment. These factors created several difficulties in conducting the current study. First, the available options for choosing the study measures were limited. The research team had difficulty in finding appropriate depression and PTSD scales validated in Arabic language, mainly because no one in the team could follow the literature in Arabic. Second, bilingual field staff had to be employed in order to translate sociodemographic form (in Turkish) into Arabic. Differing dialects of Arabic posed another challenge in both translation and administration of the scales. Since most of the refugees had low education, self-report questionnaire items needed to be read out and recorded, which led to longer interview durations. Finally, recruiting bilingual and educated interviewers was very difficult.
Strategies used to address the challenges
Training of Data Collectors: Mental health research requires data collection on sensitive issues and data collectors need special communication skills or structured trainings to be able to collect good-quality data and to avoid any conflicts, bias or ethical problems during data collection in the field. Training for mental health research is also necessary to decrease the risk of secondary traumatization among the data collectors. In the present study, strict criteria were set for recruitment of interviewers and standard training sessions were organized before data collection. In parallel to the previously set criteria by the research team, all interviewers had a health science background, had good communication skills, and they were residing in Turkey for at least four years prior to the study. The interviewers were recruited in a two-steps approach; i) an outreach email sent via the e-mail list server of the university, ii) face-to-face interviews with suitable applicants.
Sampling Methodology: The initial approach was to use a probability sampling method to ensure a representative sample for the target group. However, discussions with local authorities showed that this was not feasible due to numerous external factors including lack of publicly available data on a district level, the presence of unregistered asylum seekers and the high mobility among the registered refugee population. The research team therefore decided to work in two neighborhoods, known to be densely populated with refugees and use a snowball sampling technique to be able to reach out to the specific target group, avoiding unnecessary contact with other migrants and non-migrant households.
Cultural Considerations and Gender-Sensitive Approach: Data collection procedure had some cultural and gender-related challenges. For example, women were reluctant to be interviewed by a male interviewer and it was not easy to find men at home during daytime and most days of the week. Therefore, the interviewer team was composed of both genders, and the interviews were conducted with a same-sex interview approach. Also, the field team had to work during several nights and weekends to be able to interview more men and have a gender-balanced sample at the end. Within the mixed model approach, we interviewed several members of health authority and health care staff providing care to the refugees. Those interviews helped us understand the most pressing health care needs of the refugees. Before we started data collection, we interviewed several refugees as part of a pilot study to better understand the context and to finalize the questionnaire. Finally, some of our interviewers themselves were refugees, who greatly contributed to our understanding of the population specific needs and increased the quality of our data collection and analysis.
Safety Considerations: Lastly, several measures were taken to ensure safety of the respondents and the interviewers during household visits and night shifts. First, one of the senior researchers always accompanied and supervised the field team during data collection. Second, all interviewers had clearly visible identification badges with the university logo and carried ethical and institutional approval papers with them at all times. In addition, a WhatsApp group was formed among the field team for better coordination and increased security during data collection. By using digital technologies, the interviewers were able to e-communicate, geolocate themselves and update their location during the household visits.