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Hunt X, Hameed S, Tetali S, Ngoc LA, Ganle J, Huq L, Shakespeare T, Smythe T, Ilkkursun Z, Kuper H, Acarturk C, Kannuri NK, Mai VQ, Khan RS, Banks LM. Impacts of the COVID-19 pandemic on access to healthcare among people with disabilities: evidence from six low- and middle-income countries. Int J Equity Health 2023; 22:172. [PMID: 37653417 PMCID: PMC10472671 DOI: 10.1186/s12939-023-01989-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 08/14/2023] [Indexed: 09/02/2023] Open
Abstract
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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Affiliation(s)
- Xanthe Hunt
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Room 4009, Education Building, Cape Town, South Africa.
| | - Shaffa Hameed
- International Centre for Evidence on Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Shailaja Tetali
- Indian Institute of Public Health-Hyderabad, Hyderabad, India
| | - Luong Anh Ngoc
- Center for Training and Research on Substance Abuse - HIV, Hanoi Medical University, Hanoi, Viet Nam
| | - John Ganle
- School of Public Health, University of Ghana, Accra, Ghana
| | - Lopita Huq
- BRAC Institute of Governance and Development, BRAC University, Dakar, Bangladesh
| | - Tom Shakespeare
- International Centre for Evidence on Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracey Smythe
- International Centre for Evidence on Disability, London School of Hygiene and Tropical Medicine, London, UK
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Hannah Kuper
- International Centre for Evidence on Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Ceren Acarturk
- Department of Psychology, Koc University, Istanbul, Türkiye
| | | | - Vu Quynh Mai
- Center for Population Health Science, Hanoi University of Public Health, Hanoi, Viet Nam
| | - Rifat Shahpar Khan
- BRAC Institute of Governance and Development, BRAC University, Dakar, Bangladesh
| | - Lena Morgon Banks
- International Centre for Evidence on Disability, London School of Hygiene and Tropical Medicine, London, UK
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Kurt G, Ekhtiari M, Ventevogel P, Ersahin M, Ilkkursun Z, Akbiyik N, Acarturk C. Socio-cultural integration of Afghan refugees in Türkiye: the role of traumatic events, post-displacement stressors and mental health. Epidemiol Psychiatr Sci 2023; 32:e51. [PMID: 37539679 PMCID: PMC10465316 DOI: 10.1017/s204579602300063x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023] Open
Abstract
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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Affiliation(s)
- Gülşah Kurt
- Discipline of Psychiatry and Mental Health, UNSW, Sydney, Australia
| | | | - Peter Ventevogel
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Merve Ersahin
- Department of Clinical Psychology, Erasmus University, Rotterdam, The Netherlands
| | | | - Nuriye Akbiyik
- Faculty of Humanities and Social Sciences, University of Bergamo, Bergamo, Italy
| | - Ceren Acarturk
- Department of Psychology, Koc University, Istanbul, Turkey
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Kurt G, Ventevogel P, Ekhtiari M, Ilkkursun Z, Erşahin M, Akbiyik N, Acarturk C. Estimated prevalence rates and risk factors for common mental health problems among Syrian and Afghan refugees in Türkiye. BJPsych Open 2022; 8:e167. [PMID: 36106400 PMCID: PMC9534906 DOI: 10.1192/bjo.2022.573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Gulsah Kurt
- Department of Psychology, Koc University, Istanbul, Türkiye
| | - Peter Ventevogel
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Maryam Ekhtiari
- Department of Sociology and International Relations, Koc University, Istanbul, Türkiye
| | | | - Merve Erşahin
- Department of Clinical Psychology, Erasmus University Rotterdam, The Netherlands
| | - Nuriye Akbiyik
- Faculty of Humanities and Social Sciences, University of Bergamo, Italy
| | - Ceren Acarturk
- Department of Psychology, Koc University, Istanbul, Türkiye
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de Graaff AM, Cuijpers P, Acarturk C, Akhtar A, Alkneme MS, Aoun M, Awwad M, Bawaneh AY, Brown FL, Bryant R, Burchert S, Carswell K, Drogendijk A, Engels M, Fuhr DC, Hansen P, van 't Hof E, Giardinelli L, Hemmo M, Hessling JM, Ilkkursun Z, Jordans MJD, Kiselev N, Knaevelsrud C, Kurt G, Martinmäki S, McDaid D, Morina N, Naser H, Park AL, Pfaltz MC, Roberts B, Schick M, Schnyder U, Spaaij J, Steen F, Taha K, Uygun E, Ventevogel P, Whitney C, Witteveen AB, Sijbrandij M. Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis. BMJ Open 2022; 12:e058101. [PMID: 35443961 PMCID: PMC9021771 DOI: 10.1136/bmjopen-2021-058101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees. METHODS AND ANALYSIS Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. ETHICS AND DISSEMINATION Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.
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Affiliation(s)
- Anne M de Graaff
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ceren Acarturk
- Department of Psychology, Koç University, Istanbul, Turkey
| | - Aemal Akhtar
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Mhd Salem Alkneme
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - May Aoun
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Manar Awwad
- Technical Unit, International Medical Corps, London, UK
| | | | - Felicity L Brown
- Research and Development Department, War Child, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Sebastian Burchert
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - Kenneth Carswell
- Department of Mental Health and Substance Abuse, World Health Organization, Geneve, Switzerland
| | | | - Michelle Engels
- International Federation of Red Cross and Red Crescent Societies Reference Centre for Psychosocial Support, Copenhagen, Denmark
| | - Daniela C Fuhr
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pernille Hansen
- International Federation of Red Cross and Red Crescent Societies Reference Centre for Psychosocial Support, Copenhagen, Denmark
| | - Edith van 't Hof
- Department of Mental Health and Substance Abuse, World Health Organization, Geneve, Switzerland
| | | | - Mahmoud Hemmo
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jonas M Hessling
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | | | - Mark J D Jordans
- Research and Development Department, War Child, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Nikolai Kiselev
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christine Knaevelsrud
- Division of Clinical-Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - Gülsah Kurt
- Department of Psychology, Koç University, Istanbul, Turkey
| | - Saara Martinmäki
- ARQ International, ARQ National Psychotrauma Centre, Amsterdam, The Netherlands
| | - David McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Naser Morina
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Hadeel Naser
- Technical Unit, International Medical Corps, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Monique C Pfaltz
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Psychology and Social Work, Mid Sweden University, Sundsvall, Sweden
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthis Schick
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Ulrich Schnyder
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Julia Spaaij
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Frederik Steen
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Karine Taha
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Ersin Uygun
- Trauma and Disaster Mental Health Master Programme, Istanbul Bilgi University, Istanbul, İstanbul, Turkey
| | - Peter Ventevogel
- Public Health, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | | | - Anke B Witteveen
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- Department of Clinical, Neuro- and Developmental Psychology, World Health Organization Collaborating Center for Research and Dissemination of Psychological Interventions, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Acarturk C, Uygun E, Ilkkursun Z, Carswell K, Tedeschi F, Batu M, Eskici S, Kurt G, Anttila M, Au T, Baumgartner J, Churchill R, Cuijpers P, Becker T, Koesters M, Lantta T, Nosè M, Ostuzzi G, Popa M, Purgato M, Sijbrandij M, Turrini G, Välimäki M, Walker L, Wancata J, Zanini E, White RG, van Ommeren M, Barbui C. Effectiveness of a WHO self-help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: a randomized controlled trial. World Psychiatry 2022; 21:88-95. [PMID: 35015365 PMCID: PMC8751562 DOI: 10.1002/wps.20939] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Refugees are at high risk of developing mental disorders. There is no evidence from randomized controlled trials (RCTs) that psychological interventions can prevent the onset of mental disorders in this group. We assessed the effectiveness of a self-help psychological intervention developed by the World Health Organization, called Self-Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two-arm, assessor-masked RCT was conducted in two Turkish areas. Eligible participants were adult Syrian refugees experiencing psychological distress (General Health Questionnaire ≥3), but without a diagnosis of mental disorder. They were randomly assigned either to the Self-Help Plus arm (consisting of Self-Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self-Help Plus was delivered in a group format by two facilitators over five sessions. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview at six-month follow-up. Secondary outcome measures were the presence of mental disorders at post-intervention, and psychological distress, symptoms of post-traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well-being, and quality of life at post-intervention and six-month follow-up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty-four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self-Help Plus (N=322) or ECAU (N=320). Self-Help Plus participants were significantly less likely to have any mental disorders at six-month follow-up compared to the ECAU group (21.69% vs. 40.73%; Cramer's V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408-0.696). Analysis of secondary outcomes suggested that Self-Help Plus was not effective immediately post-intervention, but was associated with beneficial effects at six-month follow-up in terms of symptoms of depression, personally identified psychological outcomes, and quality of life. This is the first prevention RCT ever conducted among refugees experiencing psychological distress but without a mental disorder. Self-Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low-intensity self-help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities.
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Affiliation(s)
- Ceren Acarturk
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Ersin Uygun
- Department of Trauma and Disasters Mental Health, Bilgi University, Istanbul, Turkey
| | - Zeynep Ilkkursun
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Kenneth Carswell
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mine Batu
- Department of Trauma and Disasters Mental Health, Bilgi University, Istanbul, Turkey
| | - Sevde Eskici
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Gulsah Kurt
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Minna Anttila
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Teresa Au
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Josef Baumgartner
- Clinical Division of Social Psychiatry, Medical University of Vienna, Vienna, Austria
| | | | - Pim Cuijpers
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | | | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Michela Nosè
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mariana Popa
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Marit Sijbrandij
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Giulia Turrini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland
| | | | - Johannes Wancata
- Clinical Division of Social Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Elisa Zanini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Ross G White
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Mark van Ommeren
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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6
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Acarturk C, Uygun E, Ilkkursun Z, Yurtbakan T, Kurt G, Adam-Troian J, Senay I, Bryant R, Cuijpers P, Kiselev N, McDaid D, Morina N, Nisanci Z, Park AL, Sijbrandij M, Ventevogel P, Fuhr DC. Group problem management plus (PM+) to decrease psychological distress among Syrian refugees in Turkey: a pilot randomised controlled trial. BMC Psychiatry 2022; 22:8. [PMID: 34983461 PMCID: PMC8728921 DOI: 10.1186/s12888-021-03645-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Syrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul, Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention. METHODS Refugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses. RESULTS There were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementation. The study was not powered to detect an effect. No significant difference between gPM+ and E-CAU group on primary and secondary outcome measures, or in economic impacts were found. CONCLUSIONS gPM+ delivered by non-specialist peer providers seemed to be an acceptable, feasible and safe intervention for Syrian refugees in Turkey with elevated levels of psychological distress. This pilot RCT sets the stage for a fully powered RCT. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03567083 ; date: 25/06/2018.
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Affiliation(s)
- C. Acarturk
- grid.15876.3d0000000106887552Department of Psychology, Koc University, Istanbul, Turkey
| | - E. Uygun
- grid.24956.3c0000 0001 0671 7131Trauma and Disaster, Mental Health, Bilgi University, Istanbul, Turkey
| | - Z. Ilkkursun
- grid.15876.3d0000000106887552Department of Psychology, Koc University, Istanbul, Turkey
| | - T. Yurtbakan
- grid.411781.a0000 0004 0471 9346Department of Psychology, Istanbul Medipol University, Istanbul, Turkey
| | - G. Kurt
- grid.15876.3d0000000106887552Department of Psychology, Koc University, Istanbul, Turkey
| | - J. Adam-Troian
- grid.411365.40000 0001 2218 0143Department of International Studies, American University of Sharjah, Sharjah, United Arab Emirates
| | - I. Senay
- grid.65862.3f0000 0004 0399 5103Department of Psychology, Istanbul Sehir University, Istanbul, Turkey
| | - R. Bryant
- grid.1005.40000 0004 4902 0432School of Psychology, University of New South Wales, Sydney, Australia
| | - P. Cuijpers
- grid.12380.380000 0004 1754 9227Department of Clinical, Neuro and Developmental Psychology and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - N. Kiselev
- grid.7400.30000 0004 1937 0650Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - D. McDaid
- grid.13063.370000 0001 0789 5319Department of Health Policy, Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - N. Morina
- grid.7400.30000 0004 1937 0650Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Z. Nisanci
- grid.16477.330000 0001 0668 8422Department of Applied Sociology, Marmara University, Istanbul, Turkey
| | - A. L. Park
- grid.13063.370000 0001 0789 5319Department of Health Policy, Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - M. Sijbrandij
- grid.12380.380000 0004 1754 9227Department of Clinical, Neuro and Developmental Psychology and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - P. Ventevogel
- grid.475735.70000 0004 0404 6364United Nations High Commissioner for Refugees, Public Health Section, Genève, Switzerland
| | - D. C. Fuhr
- grid.8991.90000 0004 0425 469XDepartment of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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7
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Purgato M, Tedeschi F, Turrini G, Acartürk C, Anttila M, Augustinavicious J, Baumgartner J, Bryant R, Churchill R, Ilkkursun Z, Karyotaki E, Klein T, Koesters M, Lantta T, Leku MR, Nosè M, Ostuzzi G, Popa M, Prina E, Sijbrandij M, Uygun E, Välimäki M, Walker L, Wancata J, White RG, Cuijpers P, Tol W, Barbui C. Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda. Eur J Psychotraumatol 2022; 13:2128270. [PMID: 36237827 PMCID: PMC9553137 DOI: 10.1080/20008066.2022.2128270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Giulia Turrini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Ceren Acartürk
- Department of Psychology, Koc University, Istanbul, Turkey
| | - Minna Anttila
- Faculty of Medicine, Department of Nursing Science, University of Turku, Turku, Finland
| | | | - Josef Baumgartner
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Eirini Karyotaki
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Thomas Klein
- Department of Psychiatry II, Ulm University, Günzburg, Germany
| | - Markus Koesters
- Department of Psychiatry II, Ulm University, Günzburg, Germany
| | - Tella Lantta
- Faculty of Medicine, Department of Nursing Science, University of Turku, Turku, Finland
| | | | - Michela Nosè
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Mariana Popa
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Eleonora Prina
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy
| | - Marit Sijbrandij
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ersin Uygun
- Trauma and Disaster, Mental Health, Bilgi University, Istanbul, Turkey
| | - Maritta Välimäki
- Faculty of Medicine, Department of Nursing Science, University of Turku, Turku, Finland.,Central South University, Changsha, People's Republic of China
| | - Lauren Walker
- Department of Health Sciences, University of York, York, UK
| | - Johannes Wancata
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Ross G White
- School of Psychology, Queen's University Belfast, Belfast, Northern Ireland
| | - Pim Cuijpers
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Wietse Tol
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Verona, Italy.,Cochrane Global Mental Health, University of Verona, Verona, Italy
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8
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Kurt G, Ilkkursun Z, Javanbakht A, Uygun E, Karaoglan-Kahilogullari A, Acarturk C. The psychological impacts of COVID-19 related stressors on Syrian refugees in Turkey: The role of resource loss, discrimination, and social support. Int J Intercult Relat 2021; 85:130-140. [PMID: 34565947 PMCID: PMC8455287 DOI: 10.1016/j.ijintrel.2021.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/10/2021] [Accepted: 09/16/2021] [Indexed: 05/11/2023]
Abstract
COVID-19 does not leave behind refugees. They are disproportionately affected during the current pandemic. The present study aimed to investigate the psychological impacts of COVID-19 related stressors -resource loss and perceived discrimination during the COVID-19 pandemic- on Syrian refugees in Turkey. Further, the buffering role of perceived social support against the detrimental impacts of such stressors was examined. An online cross-sectional study was conducted between September-October 2020. A sample of 345 Syrian refugees in Turkey completed the questions about demographic characteristics, resource loss and perceived discrimination during the pandemic, perceived social support, and depressive and anxiety symptoms. A high level of depressive and anxiety symptoms was reported in our sample. Resource loss and perceived discrimination during the pandemic significantly and positively predicted depressive and anxiety symptoms. Perceived social support acted as a buffer against the detrimental effect of resource loss on mental health. For those with higher perceived social support, resource loss during the pandemic did not significantly predict depressive and anxiety symptoms. The results indicate the detrimental role of COVID-19 related stressors on refugee mental health. Social support is an important protective factor for mental health amidst the pandemic. Our findings highlight the importance of considering the precarious conditions of refugees in all COVID-19 responses and communications.
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Affiliation(s)
- G Kurt
- Department of Psychology, Koc University, Istanbul, Turkey
| | - Z Ilkkursun
- Department of Psychology, Koc University, Istanbul, Turkey
| | - A Javanbakht
- Stress, Trauma, and Anxiety Research Clinic (STARC), Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - E Uygun
- Trauma and Disaster Mental Health, Bilgi University, Istanbul, Turkey
| | | | - C Acarturk
- Department of Psychology, Koc University, Istanbul, Turkey
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9
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Purgato M, Carswell K, Tedeschi F, Acarturk C, Anttila M, Au T, Bajbouj M, Baumgartner J, Biondi M, Churchill R, Cuijpers P, Koesters M, Gastaldon C, Ilkkursun Z, Lantta T, Nosè M, Ostuzzi G, Papola D, Popa M, Roselli V, Sijbrandij M, Tarsitani L, Turrini G, Välimäki M, Walker L, Wancata J, Zanini E, White R, van Ommeren M, Barbui C. Effectiveness of Self-Help Plus in Preventing Mental Disorders in Refugees and Asylum Seekers in Western Europe: A Multinational Randomized Controlled Trial. Psychother Psychosom 2021; 90:403-414. [PMID: 34350902 PMCID: PMC8619740 DOI: 10.1159/000517504] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/29/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress. OBJECTIVE To assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe. METHODS We conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score ≥3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes. RESULTS Four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52-1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29-0.87). CONCLUSIONS This is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified.
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Affiliation(s)
- Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Kenneth Carswell
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Ceren Acarturk
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Minna Anttila
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Teresa Au
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Malek Bajbouj
- Department of Psychiatry, Campus Benjamin Franklin, Charité, Universitätsmedizin, Berlin, Germany
| | - Josef Baumgartner
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Massimo Biondi
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Rachel Churchill
- Centre for Review and Dissemination, University of York, York, United Kingdom
| | - Pim Cuijpers
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Zeynep Ilkkursun
- Department of Psychology, College of Social Sciences and Humanities, Koc University, Istanbul, Turkey
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Michela Nosè
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Davide Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Mariana Popa
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Valentina Roselli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marit Sijbrandij
- Department of Clinical, Neuro, and Developmental Psychology, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lorenzo Tarsitani
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Giulia Turrini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Lauren Walker
- Mental Health and Addiction Research Group, University of York, York, United Kingdom
| | - Johannes Wancata
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Elisa Zanini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Ross White
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Mark van Ommeren
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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10
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Wen K, McGrath M, Acarturk C, Ilkkursun Z, Fuhr DC, Sondorp E, Cuijpers P, Sijbrandij M, Roberts B. Post-traumatic growth and its predictors among Syrian refugees in Istanbul: A mental health population survey. J Migr Health 2020; 1-2:100010. [PMID: 34405165 PMCID: PMC8352006 DOI: 10.1016/j.jmh.2020.100010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/26/2020] [Accepted: 11/26/2020] [Indexed: 01/19/2023] Open
Abstract
AIMS The negative mental health effects of exposure to trauma are well-documented. However, some individuals are theorized to undergo post-traumatic growth (PTG) after exposure to trauma, potentially experiencing positive psychological change across five domains: appreciation for life, relationships with others, new possibilities in life, personal strength, and spiritual change. PTG is less studied in forcibly displaced populations in low- and middle-income countries. This study aimed to explore levels of PTG and associated factors among Syrian refugee adults living in Istanbul, Turkey. METHODS A cross-sectional survey was conducted with 1678 respondents. This study analyzed PTG data from 768 individuals as measured by the Post-Traumatic Growth Inventory (PTGI). Descriptive analysis and univariate and multivariate least squares linear regression modeling were used. Factor analysis and Cronbach's alpha tests assessed the psychometric properties of the PTGI. RESULTS The sample exhibited a moderate level of PTG at 55.94 (SD=22.91, range 0-105). Factor analysis of PTGI revealed only four factors instead of five, and the PTGI yielded high internal reliability (Cronbach's α=0.90). PTG and post-traumatic stress disorder (PTSD) had a curvilinear relationship, with the highest PTG levels experienced by those with moderate PTSD levels. Five other variables were significantly associated with PTG: older age, less education, somatic distress, and history of an overnight stay at a health facility for mental health care were associated with lower PTG, while more years of education were associated with higher PTG. CONCLUSIONS This study identified the role of the sociodemographic and psychological determinants that influence post-traumatic growth among Syrian refugees in Istanbul. These findings could be used to inform future research and programs seeking to understand PTG in refugees.
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Affiliation(s)
- Karen Wen
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, Public Health and Policy, 15-17 Tavistock Place, London, UK
| | | | - Ceren Acarturk
- Department of Psychology, Koç University, Istanbul, Turkey
| | | | - Daniela C. Fuhr
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, Public Health and Policy, 15-17 Tavistock Place, London, UK
| | - Egbert Sondorp
- KIT Royal Tropical Institute, Amsterdam, the Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, the Netherlands
| | - Marit Sijbrandij
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, the Netherlands
| | - Bayard Roberts
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, Public Health and Policy, 15-17 Tavistock Place, London, UK
| | - STRENGTHS consortium
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, Public Health and Policy, 15-17 Tavistock Place, London, UK
- KIT Royal Tropical Institute, Amsterdam, the Netherlands
- Department of Psychology, Koç University, Istanbul, Turkey
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, and WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, the Netherlands
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11
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Fuhr DC, Acarturk C, Uygun E, McGrath M, Ilkkursun Z, Kaykha S, Sondorp E, Sijbrandij M, Ventevogel P, Cuijpers P, Roberts B. Pathways towards scaling up Problem Management Plus in Turkey: a theory of change workshop. Confl Health 2020; 14:22. [PMID: 32391076 PMCID: PMC7197136 DOI: 10.1186/s13031-020-00278-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022] Open
Abstract
Background A considerable evidence base has been produced in recent years highlighting the effectiveness of brief scalable psychological interventions for people living in communities exposed to adversity. However, practical guidance on how to scale up these interventions to wider populations does not exist. In this paper we report on the use of Theory of Change (ToC) to plan the scale up of the World Health Organization’s flagship low intensity psychological intervention “Problem Management Plus” (PM+) for Syrian refugees in Turkey. Methods We conducted a one-day ToC workshop in Istanbul. ToC is a participatory planning process used in the development, implementation and evaluation of projects. It is similar to driver diagrams or logic models in that it offers a tool to visually present the components needed to reach a desired long-term outcome or impact. The overall aim of ToC is to understand the change process of a complex intervention and to map out causal pathways through which an intervention or strategy has an effect. Results Twenty-four stakeholders (including governmental officials, mental health providers, officials from international/national non-governmental organisations, conflict and health researchers) participated in the ToC workshop. A ToC map was produced identifying three key elements of scaling up (the resource team; the innovation and the health system; and the user organisation) which are represented in three distinct causal pathways. Context-specific barriers related to the health system and the political environment were identified, and possible strategies for overcoming these challenges were suggested. Conclusion ToC is a valuable methodology to develop an integrated framework for scaling up. The results highlight that the scaling up of PM+ for Syrian refugees in Turkey needs careful planning and investment from different stakeholders at the national level. Our paper provides a theoretical foundation of the scaling up of PM+, and exemplifies for the first time the use of ToC in planning the scaling up of an evidence-based psychological intervention in global mental health.
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Affiliation(s)
- Daniela C Fuhr
- 1Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine; Public Health and Policy, 15-17 Tavistock Place, London, UK
| | - Ceren Acarturk
- 2Department of Psychology, Koc University Istanbul, Istanbul, Turkey
| | - Ersin Uygun
- Refugee Mental Health Branch Outpatient Clinic of Bakirkoy Mental Health Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Michael McGrath
- 1Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine; Public Health and Policy, 15-17 Tavistock Place, London, UK.,4KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Zeynep Ilkkursun
- 2Department of Psychology, Koc University Istanbul, Istanbul, Turkey
| | - Sadaf Kaykha
- War Trauma Foundation, Amsterdam, The Netherlands
| | - Egbert Sondorp
- 4KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- 6Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Peter Ventevogel
- 7Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Pim Cuijpers
- 6Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bayard Roberts
- 1Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine; Public Health and Policy, 15-17 Tavistock Place, London, UK
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12
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McGrath M, Acarturk C, Roberts B, Ilkkursun Z, Sondorp E, Sijbrandij M, Cuijpers P, Ventevogel P, McKee M, Fuhr DC. Somatic distress among Syrian refugees in Istanbul, Turkey: A cross-sectional study. J Psychosom Res 2020; 132:109993. [PMID: 32172038 DOI: 10.1016/j.jpsychores.2020.109993] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/08/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022]
Affiliation(s)
- M McGrath
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
| | - C Acarturk
- Department of Psychology, Koç University, Istanbul, Turkey.
| | - B Roberts
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
| | - Z Ilkkursun
- Department of Psychology, Koç University, Istanbul, Turkey
| | - E Sondorp
- KIT Royal Tropical Institute, Amsterdam, The Netherlands.
| | - M Sijbrandij
- Department of Clinical, Neuro and Developmental Psychology, Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - P Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - P Ventevogel
- Public Health Section, Division of Programme Management and Support, United Nations High Commissioner for Refugees, Geneva, Switzerland.
| | - M McKee
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
| | - D C Fuhr
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
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13
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Uygun E, Ilkkursun Z, Sijbrandij M, Aker AT, Bryant R, Cuijpers P, Fuhr DC, de Graaff AM, de Jong J, McDaid D, Morina N, Park AL, Roberts B, Ventevogel P, Yurtbakan T, Acarturk C. Protocol for a randomized controlled trial: peer-to-peer Group Problem Management Plus (PM+) for adult Syrian refugees in Turkey. Trials 2020; 21:283. [PMID: 32192539 PMCID: PMC7082999 DOI: 10.1186/s13063-020-4166-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background A large proportion of Syrians have been exposed to potentially traumatic events, multiple losses, and breakdown of supportive social networks and many of them have sought refuge in host countries where they also face post-migration living difficulties such as discrimination or integration problems or both. These adversities may put Syrian refugees at high risk for common mental disorders. In response to this, the World Health Organization (WHO) developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM+) to reduce psychological distress among populations exposed to adversities. PM+ has been adapted for Syrian refugees and can be delivered by non-specialist peer lay persons in the community. Methods A randomized controlled trial (RCT) will be conducted with 380 Syrian refugees in Turkey. After providing informed consent, participants with high levels of psychological distress (scoring above 15 on the Kessler-10 Psychological Distress Scale (K10)) and functional impairment (scoring above 16 on the WHO Disability Assessment Schedule 2.0, or WHODAS 2.0) will be randomly assigned to Group PM+/enhanced care as usual (Group PM+/E-CAU) (n = 190) or E-CAU (n = 190). Outcome assessments will take place 1 week after the fifth session (post-assessment), 3 months after the fifth session and 12 months after baseline assessment. The primary outcome is psychological distress as measured by the Hopkins Symptom Checklist (HSCL-25). Secondary outcomes include functional impairment, post-traumatic stress symptoms, self-identified problems, and health system and productivity costs. A process evaluation will be conducted to explore the feasibility, challenges and success of the intervention with 25 participants, including participants, facilitators, policy makers and mental health professionals. Discussion The treatment manual of the Syrian-Arabic Group PM+ and training materials will be made available through the WHO once the effectiveness and cost-effectiveness of Group PM+ have been established. Trial registration Clinical Trial Registration: ClinicalTrials.gov Identifier NCT03960892. Unique protocol ID: 10/2017. Prospectively registered on 21 May 2019.
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Affiliation(s)
- Ersin Uygun
- Trauma Research Laboratory, Department of Psychology, Istanbul Sehir University, Istanbul, Turkey. .,Refugee Mental Health Outpatient Clinic, Bakırköy Training and Research Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.
| | | | - Marit Sijbrandij
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A Tamer Aker
- Department of Psychiatry, Bilgi University, Istanbul, Turkey
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Daniela C Fuhr
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anne M de Graaff
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joop de Jong
- Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - David McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Naser Morina
- University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - A-La Park
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Ventevogel
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Taylan Yurtbakan
- Trauma Research Laboratory, Department of Psychology, Istanbul Sehir University, Istanbul, Turkey
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14
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Fuhr DC, Ataturk C, McGrath M, Ilkkursun Z, Woodward A, Sondorp E, Roberts B. Treatment gap and mental health service use among Syrian refugees in Turkey. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz185.579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction
Turkey hosts the highest number of Syrian refugees in Europe. Refugees are often vulnerable to situational forms of psychosocial distress as a consequence of exposure to war and violence which may result in more profound mental health problems if no treatment is sought. The aim of this study is to report evidence on mental health and psychosocial support (MHPSS) needs, access and barriers to MHPSS care among Syrians refugees living in Istanbul, Turkey.
Methods
A cross-sectional survey was conducted among Syrian refugees aged 18 years or over in Istanbul (Sultanbeyli) between February and May 2018. Data among 1’678 Syrian refugees were collected on mental health outcomes using the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) and the Hopkins Symptoms Checklist (HSCL-25) for depression and anxiety. We also collected data on health care utilization, barriers to seeking and continuing care as well as knowledge and attitudes towards mental health. Descriptive analyses were used.
Results
The prevalence of PTSD, depression and anxiety was 19.6%, 34.7% and 36.1% respectively. The treatment gap was 89% for PTSD, 90% for anxiety and 88% for depression. 249 respondents (15%) screened positive for either PTSD, depression or anxiety in our survey and self-reported emotional/behavioural problems since arriving in Sultanbeyli. Several structural and attitudinal barriers for not seeking care were reported.
Conclusions
To overcome the treatment gap, mental health care programmes need to be more responsive to the needs of Syrian refugees. Barriers to seeking and continuing care can be overcome by providing MHPSS services in the community which facilitate access to care. Community-based programmes of care should be supported by activities which increase awareness about mental health issues and tackle negative attitudes towards mental illness.
Key messages
This study provides the first nationally representative data on the mental health of Syrian refugees in Turkey, and shows that refugees have high mental health needs. Syrian refugees do not seek mental health care despite availability of mental health services in the community.
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Affiliation(s)
- D C Fuhr
- Public Health and Policy, LSHTM, London, UK
| | - C Ataturk
- Public Health and Policy, LSHTM, London, UK
| | - M McGrath
- Department of Psychology, Istanbul Sehir University, Istanbul, Turkey
| | - Z Ilkkursun
- Department of Psychology, Istanbul Sehir University, Istanbul, Turkey
| | - A Woodward
- KIT, Royal Tropical Institute, Amsterdam, Netherlands
| | - E Sondorp
- KIT, Royal Tropical Institute, Amsterdam, Netherlands
| | - B Roberts
- Public Health and Policy, LSHTM, London, UK
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15
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Purgato M, Carswell K, Acarturk C, Au T, Akbai S, Anttila M, Baumgartner J, Bailey D, Biondi M, Bird M, Churchill R, Eskici S, Hansen LJ, Heron P, Ilkkursun Z, Kilian R, Koesters M, Lantta T, Nosè M, Ostuzzi G, Papola D, Popa M, Sijbrandij M, Tarsitani L, Tedeschi F, Turrini G, Uygun E, Välimäki MA, Wancata J, White R, Zanini E, Cuijpers P, Barbui C, Van Ommeren M. Effectiveness and cost-effectiveness of Self-Help Plus (SH+) for preventing mental disorders in refugees and asylum seekers in Europe and Turkey: study protocols for two randomised controlled trials. BMJ Open 2019; 9:e030259. [PMID: 31092670 PMCID: PMC6530324 DOI: 10.1136/bmjopen-2019-030259] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION This article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In these trials SH+ is being tested as a preventative intervention to lower the incidence of mental disorders in asylum seekers and refugees with psychological distress resettled in Europe and Turkey. METHODS AND ANALYSIS Two prospective, multicentre, randomised, rater-blinded, parallel-group studies will follow participants over a period of 12 months. One trial will be conducted in Europe and one in Turkey. In each trial, 600 asylum seekers and refugees screening positive on the General Health Questionnaire (≥3), but without a formal diagnosis of any mental disorders according to the Mini International Neuropsychiatric Interview, will be randomly allocated to SH+or to enhanced treatment-as-usual. The primary outcome will be a lower incidence of mental disorders at 6 month follow-up. Secondary outcomes will include the evaluation of psychological symptoms, functioning, well-being, treatment acceptability and indicators of intervention cost-effectiveness. ETHICS AND DISSEMINATION The two trials received ethical clearance from the local Ethics Committees of the participating sites (seven sites), as well as from the WHO Ethics Committee. All participants will provide informed consent before screening and before study inclusion (a two-step procedure). The results of the trials will be disseminated in agreement with a dissemination plan that includes publication(s) in peer-reviewed journals and presentations at relevant national and international conferences and meetings. TRIALS REGISTRATION NUMBERS NCT03571347, NCT03587896.
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Affiliation(s)
- Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, Verona, Italy
| | - Kenneth Carswell
- Department of Mental Health & Substance Abuse, World Health Organisation, Geneve, Switzerland
| | | | - Teresa Au
- Department of Mental Health & Substance Abuse, World Health Organisation, Geneve, Switzerland
| | - Sena Akbai
- Department of Psychology, Istanbul Sehir Universitesi, Istanbul, Turkey
| | - Minna Anttila
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Josef Baumgartner
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Wien, Austria
| | | | - Massimo Biondi
- Department of Human Neurosciences, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Martha Bird
- IFRC Reference Centre for Psychosocial Support, Danish Red Cross, Copenhagen, Denmark
| | | | - Sevde Eskici
- Department of Psychology, Istanbul Sehir Universitesi, Istanbul, Turkey
| | - Louise Juul Hansen
- IFRC Reference Centre for Psychosocial Support, Danish Red Cross, Copenhagen, Denmark
| | - Paul Heron
- Department of Health Sciences, University of York, York, UK
| | - Zeynep Ilkkursun
- Department of Psychology, Istanbul Sehir Universitesi, Istanbul, Turkey
| | | | - Markus Koesters
- Cochrane Global Mental Health, Verona, Italy
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | - Tella Lantta
- Department of Nursing Science, Turun Yliopisto, Turku, Finland
| | - Michela Nosè
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, Verona, Italy
| | - Giovanni Ostuzzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, Verona, Italy
| | - Davide Papola
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, Verona, Italy
| | - Mariana Popa
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK
| | | | - Lorenzo Tarsitani
- Department of Human Neurosciences, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Federico Tedeschi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Giulia Turrini
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, Verona, Italy
| | - Ersin Uygun
- Trauma and Disaster Mental Health, Istanbul Bilgi Universitesi, Istanbul, Turkey
| | - Maritta Anneli Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Johannes Wancata
- Department of Psychiatry and Psychotherapy, Division of Social Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Ross White
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK
| | - Elisa Zanini
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Cochrane Global Mental Health, Verona, Italy
| | - Mark Van Ommeren
- Department of Mental Health and Substance Dependence, World Health Organisation, Geneva, Switzerland
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