Scientific Importance of the Research
There is an urgent need for research to advance evidence-based brief psychosocial interventions that can be scaled up during humanitarian crises. The World Health Organization’s Department of Mental Health and Substance Abuse, led by Dr. Mark van Ommeren, has been developing low intensity cognitive behavior therapy (LICBT) to help address refugees’ mental health needs. They developed Problem Management Plus (PM+), which is a brief, basic, one-on-one, paraprofessional-delivered version of LICBT for adults in communities affected by adversity [19–20].
PM + incorporates stress management and individual problem solving . In conflict-affected Pakistan, a pilot comparing PM + to enhanced treatment as usual had high uptake, with 73% completing all sessions, and showed improvement in traumatic stress and functioning . When WHO conducted a larger scale randomized controlled trial (RCT) of PM + in Pakistan, it demonstrated clinically significant reductions in anxiety and depressive symptoms at 3 months among adults impaired by psychological distress .
Psychosocial interventions are needed for refugee families and humanitarian responses, both because parents and children are experiencing common mental disorders (CMD), and because supporting family protective processes and learning self-care strategies can ameliorate the impact of CMD symptoms and stress caused by trauma and displacement. Syrian refugees, like many others, are strongly shaped by the family context. In a receiving country with limited resources for refugees, positive psychosocial outcomes for children and adults depend to a great extent on their families, yet refugee families find few empirically based services geared toward them [21–22]. Refugee families often demonstrate resilience and strengths, but in highly adverse circumstances these processes can be strained or overwhelmed , FS interventions can bolster family protective processes.
We previously developed and evaluated a multiple family support and education group model for Bosnian refugees called Coffee and Families Education and Support (CAFES), which in a US National Institute of Mental Health (NIMH)-funded RCT was shown to have high uptake and to improve mental health help seeking, with depression and family comfort talking about trauma mediating the intervention effect . Based on our community engagement and current study of Syrians, we concluded that the multiple family approaches also fits well with Syrian culture. Of note, this type of family intervention is designed to include adolescents age 12 and above, with time allotted in each session for adolescents and adults to meet in separate breakout groups .
The science of implementation and dissemination (SID) can help address the burden of mental health problems in refugees in LMICs by moving evidence-based interventions from more controlled to naturalistic settings. This is a pressing challenge for studying mental health interventions during humanitarian crises [26–27]. In such settings, SID research is needed to collect information on potential barriers and facilitators to real world implementation, as well as on specific implementation strategies . Regarding PM+, formative research is recommended to help adapt the intervention to the local sociocultural context  and to develop a novel family intervention.
Our plan is to share the research findings through publication in peer-reviewed journals so as to contribute to developing the science in this area. But given the urgency and demands of the humanitarian situation, we also intend to share the research findings through several two-page practically-focused research briefs that accessible and engaging for NGO’s, governments, trans-governmental organizations, and practitioners. Overall, our aim is to increase the awareness of refugee family issues, and to promote interventions that are at the very least family friendly, but also family focused which might be a more feasible approach in specific socio-cultural contexts. We believe that there is a significant shortage in this area, and we would like NGO’s and governments to make this more of a focus.
Family interventions for refugees and migrants are also very relevant in low and middle-income countries that are not facing a humanitarian crisis, and in high-income countries, especially in low resource settings. Thus, we believe that developing the science in the humanitarian emergency will have significance beyond the crisis settings. For example, in the U.S. there are 10.5 million illegal migrants  a large number of migrant families from Mexico and from Latin America who are facing high stress due to the threat of deportation on top of the ordinary exposure to adversity. A family support intervention delivered in community-based organizations, including religious facilities or churches, could be a very good fit to address their capacities to address various stressors and risk for CMD’s. The interventions are held on weekly bases and on weekends when most of the participants especially fathers don’t work. The data collection started in December 2019 and will end by October 2020.
Aim 1 activities included convening the family support design team (FSDT) and drafting the FS manual. Aim 2 involve partnering with the 6 community and clinical sites, training the workers, having each worker administer the intervention to 72 families, and then conducting observations and qualitative interviews to assess implementation issues. Aim 3 involved conducting pre, immediate post, and 3-month post assessments of the 72 families who received the intervention. Regarding Aim 3, our primary hypothesis is that FS primary participants will report fewer symptoms of depression, anxiety, and traumatic stress from baseline to immediate post and 3-month post. Our secondary hypothesis is that FS family members will report improved family members’ knowledge and attitudes regarding responses to adversity, family support, family problem solving, and accessing external resources, and that these will explain improvements in CMD symptoms. In addition, we will also study engagement and retention of families in FS, both as outcomes and as possible determinants of the hypothesized changes. We will conduct analyses: 1) to demonstrate the feasibility of the implementation and evaluation methods; 2) to explore patterns of attendance and retention to FS groups, to inform the researchers in making modifications; 3) to demonstrate the kind of pre-post changes that have been reported for comparable interventions, for both primary participants and family members; 4) to determine key parameters of interest with sufficient accuracy and precision.
Challenges to Research
The researchers faced multiple program development challenges in conducting this research in the humanitarian crisis setting, even beyond those challenges generally encountered in LMICs or low-resource settings.
Non-Existent or Weak Partnerships
We were able to identify both academic centers and humanitarian organizations, but it was difficult to find those academic centers that had partnerships with humanitarian organizations, or vice versa. Syrian refugees were generally not a focus of interest for service or research by academic medical centers in Istanbul. It was difficult to identify local academic partners who had research capacity in mental health, including implementation science, which would be necessary for investigating family support interventions. However, we found that the Turkish Red Crescent (TRC) was interested in building mental health research and implementation science capacity in the Turkish Red Crescent, so we focused the supplement award on the TRC.
Lack of Focus on Task-Sharing
It was also challenging to find a psychiatrist who would embrace the task-sharing model, which aims to deliver interventions that do not depend upon psychiatrists as the service providers. Over 6 months, the U.S. and Kosovar investigators were able to identify a child and adolescent psychiatrist, Dr. Vahdet Görmez, who is also a certified trainer in cognitive behavioral therapy (CBT), conducted research with Syrian adolescent refugees in school setting in Istanbul [31–32] who became our primary partner. The main argument in deciding to collaborate with Dr. Görmez was his practical experience in working with Syrian refugees in school setting and his interest in refugee mental health. He was identified by conducting literature review on refugee mental health in Turkey, following which he was contacted and included in the project.
Insufficient Language and Cultural Competency
Another important challenge was that both the U.S. investigators and the local Turkish investigators faced limitations of language and cultural competency for the refugee population. Therefore, we hired two Syrian persons as the project manager and assistant who were able to help us to overcome these hurdles due to language and cultural competency, familiarity with the community and the local NGOs. The Syrian project personnel were identified with help of Dr. Görmez who had experience in working with the staff in previous psychosocial projects. During the implementation process of the project we met many other capable persons in the Syrian community within collaborating organizations which further enabled us to overcome the language and cultural gaps.
Fit with Families
One of the major challenges that we faced was planning for a family intervention that would work with families who had cultural values and practices around gender relations that were very strict in terms of women and men interacting and sharing the same space. Another challenge was that these families faced many burdens and priorities and it was difficult to engage them due to high demands on their time. Another major challenge is that the families were still exposed to major social and economic problems that could not be solved, such as child labor. Another challenge was involving fathers in all sessions as they were either working or having other obligations. In addition, most of the families involved in the run through of FS intervention had a child working.
Just prior to the time of implementation in October 2019, the Turkish government began to more strictly enforce policies regarding the residential permits of Syrian refugees. When refugees came to Turkey, they were allowed to live in a particular region where they were registered, but could not move to another, such as Istanbul to get work. Stricter enforcement of policies includes deportation to the city where they are registered or deportation to Syria if they lack documentation, causing fear among refugees.
We tried to develop a shared understanding with the partner organizations and the refugees they served through regular consultations to come up with problem-solving strategies or solutions in the FSDT meetings and in consultation with the partner organizations. This demanded a great deal of flexibility and patience from the research team members. The research process was slowed down at several junctures in order to deal with these sorts of issues. For example, regarding settling on a format for convening both male and female family members which would be acceptable to Syrians with a range of gender-related values and practices.
Addressing the unique challenges faced by the research team, required additional strategies.
First, we built a coalition of academic and humanitarian organization partners and worked on strengthening relations between them. This coalition included an academic medical partner, six small NGO’s working with Syrian refugees and the Turkish Red Crescent, one of the major actors in Turkey in the provision of various services to refugees.
Research Capacity Building of Local Partners
Two, we invested in building the research capacity building of the local partners, both academic and NGOs. Through the research project, we built the research capacity of several faculty members at Medeniyet University in Istanbul. In addition, we developed and were awarded a supplement with TRC to focus on improving their research capacity.
Engaged Multiple Perspectives
Three, we utilized a family support design team to draw upon multiple perspectives and adapt existing interventions and design new components. The FSDT convened twice for three-day face-to-face meetings in Istanbul. The FSDT was co-led by Weine, Arenliu, and Gormez, and included other LMIC researchers as well as 8 additional community advocates, nurses, and physicians.
Flexible Intervention Design
We designed a flexible structure for the intervention to accommodate gender considerations including use of the Internet and mobile technology. For example, to accommodate families who preferred to sit all together rather than to mix with other families we provided sitting arrangements in which families were grouped as in a restaurant. In addition, each group had one male and female facilitator where female facilitators reinforce women participation as we were concerned that women would not speak out in mixed groups or in presence of husbands. Furthermore, we produced easily accessible videos such as stress reduction exercises to be used by members who might have not attended the session and as reminder of exercises to be done at home.
The overall aim was to write a model that was brief and simple enough to be delivered by community workers and nurses. The FSDT first met face-to-face for three days in month 2 in Istanbul, followed by regular Skype calls and ongoing e-mails, and a follow-up three-day meeting in month 6. Draft materials were prepared and distributed in advance, in English and Arabic and decisions were made by consensus after deliberation.
Expand Communication and Collaboration Between Researchers and End Users
Regarding the TRC, to address the needs we jointly identified, we collaboratively developed a plan to foster evidence-based policy and program development in mental health for refugees by expanding communication and collaboration between the researchers and end users, including the TRC and other NGOs, including practitioners, managers, and policy makers. The specific aims are to: 1) Convene a refugee mental health implementation research group composed of researchers and end users in the TRC that will collaboratively: a) conduct trainings on the state-of-the-science in implementation science research (e.g. strategies for implementation, dissemination, and evaluation of effective mental health interventions); b) disseminate research findings on proven mental health assessments and interventions; and c) build a model for best impacting the TRC organizational structure, climate, culture, and processes regarding the implementation, dissemination, and evaluation of effective and evidence based mental health interventions.