Group problem management plus (PM+) to decrease psychological distress among Syrian refugees in Turkey: a pilot randomised controlled trial

AimsDespite high levels of psychological distress, mental health service use among Syrian refugees in urban settings is low. To address the mental healthcare gap, the World Health Organization developed group problem management plus (gPM+), a scalable psychological intervention delivered by non-specialist peer facilitators. The study aimed to evaluate the effectiveness of gPM+ in reducing symptoms of depression and anxiety among Syrian refugees in Istanbul, Türkiye.MethodsA randomized controlled trial was conducted among 368 distressed (Kessler Psychological Distress Scale, K10 > 15) adult Syrian refugees with impaired functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16). Participants were recruited between August 2019 and September 2020 through a non-governmental organization providing services to refugees. Participants were randomly allocated to gPM+ and enhanced care as usual (gPM+/E-CAU) (184 participants) or E-CAU only (184 participants). Primary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist (HSCL-25)) at 3-month follow-up. Secondary outcomes were post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5; PCL-5), functional impairment (WHODAS 2.0), and self-identified problems (psychological outcome profiles).ResultsIntent-to-treat analyses showed no significant effect of gPM+ on symptoms of anxiety, depression, PTSD and self-identified problems. Yet, there was a significant reduction in functional impairment in gPM+/E-CAU compared to E-CAU at 3-month follow-up (adjusted mean difference 1.66, 95 % CI 0.04, 3.27, p = 0.045, d = 0.19). Post-hoc subgroup analyses among participants with probable baseline depression or anxiety showed that there was a small but significant reduction in depression (adjusted mean difference −0.17, 95 % CI −0.32, −0.02, p = 0.028, d = 0.27) and anxiety (adjusted mean difference −0.21, 95 % CI −0.37, −0.05, p = 0.009, d = 0.30) symptoms comparing gPM+/E-CAU to E-CAU only at 1-week post assessment, but not at 3-month follow-up. There was a significant difference between conditions on functional impairment at 3-month follow-up, favouring gPM+/E-CAU condition (adjusted mean difference −1.98, 95 % CI −3.93, −0.02, p = 0.048, d = 0.26).ConclusionIn this study in an urban setting in Türkiye, gPM+ did not alleviate symptoms of depression and anxiety among Syrian refugees experiencing psychological distress and daily living difficulties. However, participants with higher distress at baseline seemed to benefit from gPM+, but treatment gains disappeared in the long term. Current findings highlight the potential benefit of tailored psychosocial interventions for highly distressed refugees in volatile low-resource settings.

Syrian refugees in Türkiye show a high prevalence of mental health problems but encounter barriers to accessing mental health services. Group Problem Management Plus (gPM+), developed by the World Health Organization, is a low-intensity psychological intervention delivered by nonspecialist facilitators. This qualitative process evaluation explores the acceptability, feasibility and perceived effectiveness of gPM+ for Syrian refugees resettled in Türkiye, as well as facilitating factors and barriers to its implementation. Twenty-three semi-structured interviews were conducted with gPM+ participants, facilitators, drop-outs, relatives of participants and key informants. Findings showed that gPM+ was well-received for its group-based format, which participants felt fostered social support, and for its content, which they reported may have led to improvements in coping skills and family relationships. Facilitators viewed the intervention as feasible to implement. However, barriers such as participants' economic struggles, practical challenges (e.g., childcare and transportation difficulties) and low mental health literacy impeded engagement. Adapting gPM+ to address social determinants like poverty may be beneficial. The need for booster sessions was emphasized to maintain long-term change and provide deeper learning of the strategies. For sustainable scaling up gPM+ within primary health care, key informants highlighted the importance of training and supervising nonprofessional facilitators and securing governmental support.

Sometimes physical security may come at the cost of ontological security for refugees. They may struggle to develop stable narratives of identity and fail to situate themselves within their new social environments. States often prioritize addressing refugees’ physical security needs to facilitate their integration, but largely overlook the importance of identity security. This study argues that ontological security is crucial to integration processes, and refugees reestablish it by engaging in various forms of identity backlash, lowering their interest in the politics of the host country, and heightening their desire to return home. In other words, identity backlash, political disinterest, and an intensified desire to return home function as ontological security-seeking mechanisms and anxiety responses. The study contributes to ontological security theory (OST) by introducing a novel and nuanced framework that defines a set of indicators for the emotional and narrative-oriented aspects of ontological security among refugees. It takes a micro-level approach examining ontological security at the individual level for Syrian refugees in Turkey and Germany. The specific findings of this study are threefold. First, I find a significantly lower level of narrative-oriented security among Syrian refugees in Turkey than in Germany. Second, the results indicate that narrative-oriented ontological security among Syrian refugees is strongly associated with identity backlash, low political interest, and a willingness to return to the home country. Third, the results show that physical security and ontological security are not always correlated. Overall, this study demonstrates how OST can provide insights into the complex interplay between perceptions of security, identity backlash, political integration, and willingness to return among refugee communities.

Traumatic experiences, acculturation, and psychological distress among Syrian refugees in Turkey: The mediating role of coping strategies

Little is known about whether Syrian refugees intend to return to their origin-country and what affects their return migration intentions. We introduce a theoretical framework for voluntary return, identify the refugees’ decision-making context, and empirically assess the model with a sample of 577 Syrian refugees living in Germany and Turkey in 2018. Three return scenarios were presented in the survey: (i) returning to Syria within two years, (ii) returning when Syria is as safe as before the civil war, and (iii) ever returning. The three scenarios were conceived very differently by the refugees, highlighting the dynamic nature and context dependency of the concept of voluntary return. Syrian refugees in Turkey were more likely to regard their stay as temporary (76 percent), compared to those in Germany (55 percent, p-value of difference = .000). Similarly, structural factors of the origin- and host-countries, that is, the origin-governorate and the current location, were considerably influencing return intentions. Concerning individual factors, female and highly educated refugees had a lower willingness to return. Those who were married were less inclined to return in the short run, yet refugees who self-identified as poor indicated their desired return in the long run. We also analyzed whether random exposure to information regarding return impacted refugees’ intentions. We found a negative, albeit insignificant, impact of information, suggesting that host governments cannot expect (rapid) information dissemination to impact refugees’ decision-making about voluntary return. Our findings underscore that neither proximate nor distant host-countries should bank on the speedy return of the Syrian refugees.

PurposeGovernments can influence entrepreneurial growth through public policy. This paper aims to present critical aspects of entrepreneurship policy design for Syrian refugees in Turkey and evaluate if current policies are effective for Syrian refugees in Istanbul.Design/methodology/approachThe study adopts an explorative phenomenological approach, contextualized within the entrepreneurial behavior literature. The data was collected through semi-structured interviews with fifteen Syrian entrepreneurs residing in Istanbul.FindingsThe results show that Syrian refugees were “pushed” to start new companies. Moreover, the findings suggest that Syrian entrepreneurs could exploit better business opportunities such as targeting international markets or finding competent partners.Research limitations/implicationsThe article offers several practical and social contributions by highlighting how the entrepreneurial behavior of Syrian refugees is driven by their migration or business experiences.Practical implicationsPolicymakers in Turkey need to acknowledge how their entrepreneurial policies regarding innovation and internationalization affect the business success rate among Syrian refugees. In this regard, the Turkish government should adopt new measures that provide Syrian refugees more business flexibility. These policies may include easy access to the Turkish financial system or fewer regulations to obtain work permits. This will encourage refugees to join the formal economy and contribute to the Turkish labor market.Originality/valueThis article adds to the expanding body of knowledge on refugee entrepreneurship by emphasizing the link between refugees' personal experiences and starting new ventures. It also highlights how government policy can be strategically utilized to increase entrepreneurship among Syrian refugees in Turkey.

The world has witnessed a large increase in the number of refugees in the last decade. Today, the highest number of refugees, mainly coming from Syria, live in Turkey, which raises questions about how host society members react to this group of newcomers: whether they offer help and support or whether they reject them. Şenay Yitmen aims to understand and describe attitudes towards Syrian refugees in Turkey by considering the role of various social psychological constructs that might be associated with these attitudes. Based on survey data collected among self-identified Turkish adult citizens, she shows that although feelings towards non-Muslim minorities and Syrian refugees are quite similar, the processes are somewhat distinct as different group identifications - national and religious identification - play different roles in people’s feelings towards these two communities. In relation to attitudes towards Syrian refugees, stronger Turkish national identification is associated with more negative feelings towards these refugees and in addition plays a moderating role in the association between endorsement of multiculturalism and these feelings. Also, Turkish people who have stronger national identification perceive more outgroup threat and as a result have more negative and less positive behavioural intentions towards Syrian refugees. However, perceived threat is translated into less negative, and interestingly, also less positive behavioural intentions among those who endorse humanitarian concerns, which shows that Turkish people make a distinction between positive and negative behavioural intentions towards Syrian refugees and that the processes behind these intentions are different. Additionally, perceived threat is translated into more negative emotions and in return to less support for Syrian refugees’ rights. Further, when Turkish people perceive strong descriptive norms then perceived threat is associated with more negative emotions and less support to Syrian refugees. However, frequency of contact and perceived similarity with Syrian refugees are associated with more social acceptance through lower perceived threat. Yet, perceived similarity is associated less with social acceptance for those who perceive Syrian refugees as permanent settlers in Turkey. Overall, this dissertation illustrates how a very vulnerable group of migrants (Syrian refugees) is perceived and evaluated in an understudied yet geopolitically relevant (Turkish) setting; that similar negative attitudes do not imply similar processes; that positive and negative attitudes are not simply the two sides of the same coin; that key social psychological constructs can be associated directly or indirectly with attitudes towards Syrian refugees, and that these associations may depend on various beliefs and considerations.

Psychological interventions that are brief, acceptable, effective and can be delivered by non-specialists are especially necessary in low- and middle-income countries, where mental health systems are unable to address the high level of psychosocial needs. Problem Management Plus (PM+) is a five-session intervention designed for those impaired by psychological distress while living in communities affected by adversity. Individual PM+ has demonstrated effectiveness in reducing distress in Kenya and Pakistan, and a group version of PM+ (Group PM+) was effective for conflict-affected women in Pakistan. This paper describes a feasibility and acceptability trial of locally adapted Group PM+ for women and men in an earthquake-affected region of rural Nepal. In this feasibility cluster randomised controlled trial, participants in the experimental arm were offered five sessions of Group PM+ and participants in the control arm received enhanced usual care (EUC), which entailed brief psycho-education and providing referral options to primary care services with health workers trained in the mental health Gap Action Programme Intervention Guide (mhGAP-IG). A mixed-methods design was used to assess the feasibility and acceptability of Group PM+. Feasibility was assessed with criteria including fidelity and retention of participants. Acceptability was assessed through in-depth interviews with participants, family members, programme staff and other stakeholders. The primary clinical outcome was depression symptoms assessed using the Patient Health Questionnaire (PHQ-9) administered at baseline and 8-8.5 weeks post-baseline (i.e. after completion of Group PM+ or EUC). We recruited 121 participants (83% women and 17% men), with equal allocation to the Group PM+ and EUC arms (1:1). Group PM+ was delivered over five 2.5-3 hour sessions by trained and supervised gender-matched local non-specialists, with an average attendance of four out of five sessions. The quantitative and qualitative results demonstrated feasibility and acceptability for non-specialists to deliver Group PM+. Though the study was not powered to assess for effectiveness, for all five key outcome measures, including the primary clinical outcome, the estimated mean improvement was larger in the Group PM+ arm than the EUC arm. The intervention and trial procedures were acceptable to participants, family members, and programme staff. The communities and participants found the intervention to be beneficial. Because feasibility and acceptability were established in this trial, a fully powered randomised controlled trial will be conducted for larger scale implementation to determine the effectiveness of the intervention in Nepal.

Whilst the state of precarity negatively impacts Syrian refugees in Turkey, an increasing number of scholars suggest that Syrians are integrating well in that country due to cultural similarities and relatively ‘liberal’ refugee policies. This paper asks why this discrepancy occurs between studies that depict a positive picture of integration and the reality on the ground that approximately 40% of Syrians in Turkey want to go to a country other than Syria and Turkey. The article explains this contradiction by introducing a new-grounded theory of ‘reluctant local integration’. Based on a sequential research design that is composed of a thematic analysis of original fieldwork with 106 participants in the city of Gaziantep and a follow-up theory-guided process tracing in wider Turkey between 2015 and 2021, the article identifies original links between three intertwined themes that lead to reluctant local integration. These are not only a by-product of temporary protection, and unevenly distributed precarity in the economic milieu, but also a result of similar types of ideological, ethnic and religious sectarianism that is deeply rooted in both refugee and host communities in Turkey.

Turkey is the largest refugee host country in the world with about 3.5 million registered Syrian refugees. In this study, we explored intergroup relations between Syrian refugees and Turks in Turkey. We focused on how Turkish people perceived Syrian refugees in Turkey and how these two groups interacted daily. We used an adaptation of McAdams’ Life Story Interview and asked questions about Syrian refugees in the Turkish context. Using this open-ended, qualitative interviewing technique allowed us to understand how Turks and Syrians interacted on a daily basis and what shaped Turkish people’s perceptions about refugees. We conducted a narrative analysis based on agency and communion themes. Results showed that age of participant was negatively correlated with communion, whereas education of participant was positively correlated with agency. Agency and communion positively correlated with each other. Narratives reflected a range of reflections Turkish citizens had about the large influx of Syrian refugees.

AimsProblem Management Plus (PM+) has been effective in reducing mental health problems among refugees at three-month follow-up, but there is a lack of research on its long-term effectiveness. This study examined the effectiveness of PM+ in reducing symptoms of common mental disorders at 12-month follow-up among Syrian refugees in the Netherlands.MethodsThis single-blind, parallel, controlled trial randomised 206 adult Syrians who screened positive for psychological distress and impaired functioning to either PM+ in addition to care as usual (PM+/CAU) or CAU alone. Assessments were at baseline, 1 week and 3 months after the intervention and 12 months after baseline. Outcomes were psychological distress (Hopkins Symptom Checklist [HSCL-25]), depression (HSCL-25 subscale), anxiety (HSCL-25 subscale), posttraumatic stress disorder symptoms (PCL-5), functional impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS).ResultsIn March 2019–December 2022, 103 participants were assigned to PM+/CAU and 103 to CAU of which 169 (82.0%) were retained at 12 months. Intention-to-treat analyses showed greater reductions in psychological distress at 12 months for PM+/CAU compared to CAU (adjusted mean difference −0.17, 95% CI −0.310 to −0.027; p = 0.01, Cohen’s d = 0.28). Relative to CAU, PM+/CAU participants also showed significant reductions on anxiety (−0.19, 95% CI −0.344 to −0.047; p = 0.01, d = 0.31) but not on any of the other outcomes.ConclusionsPM+ is effective in reducing psychological distress and symptoms of anxiety over a period up to 1 year. Additional support such as booster sessions or additional (trauma-focused) modules may be required to prolong and consolidate benefits gained through PM+ on other mental health and psychosocial outcomes.

BackgroundDigital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations. Our study objective was to evaluate the effectiveness of SbS as self-guided intervention with optional message-based contact-on-demand (COD) support on reducing psychological distress, functional impairment, symptoms of posttraumatic stress disorder (PTSD), and self-identified problems in a sample of Syrian refugees residing in Egypt.Methods and findingsWe conducted a 2-arm pragmatic randomized controlled trial. A total of 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 > 15) and reduced psychosocial functioning (WHODAS 2.0 > 16) were randomized into SbS + CAU (N = 266) or CAU only (N = 272). Primary outcomes were psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO Disability Assessment Schedule 2.0) at 3-month follow-up. Secondary outcomes were symptoms of PTSD (PTSD Checklist for DSM-5 short form, PCL-5 short) and self-identified problems (Psychological Outcomes Profiles Scale, PSYCHLOPS). Intention-to-treat (ITT) analyses showed significant but small effects of condition on psychological distress (mean difference: −0.15; 95% CI: −0.28, −0.02; p = .02) and functioning (mean difference: −2.04; 95% CI: −3.87, −0.22; p = .02) at 3-month follow-up. There were no significant differences between groups on symptoms of PTSD and self-identified problems. Remission rates did not differ between conditions on any of the outcomes. COD was used by 9.4% of participants for a median of 1 contact per person. The main limitations are high intervention dropout and low utilization of COD support.ConclusionsThe trial provides a real-world implementation case, showing small positive effects of a digital, potentially scalable and self-guided mental health intervention for Syrian refugees in Egypt in reducing psychological distress and improving overall functioning. Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability.Trial registrationGerman Register for Clinical Studies DRKS00023505.

Five years ago, the study titled “Biopolitical Problematic: Syrians Refugees in Turkey” was the second chapter of the book, “Turkey’s Syrians, today and Tomorrow” published and its argument was found remarkable and got good feedback. This study aims to update the recent statistics belonging to the Syrian refugees and revise the new developments in connection with the discussed biopolitical perspectives. It is obvious that with its nationalist character, Turkey continues to give its citizens some moral and respectable codes to save and to defend, which also defines civil types of human behavior and relations, which are all the time culturally and politically approved but put a kind of fear inside people. Therefore, nothing has changed on the theoretical ground, but the reader can find out new references problematizing the integration issue. Syrians' noticeable presence in almost every region and mostly negative narratives of the locals, their integration strategies, and the government's policies have been supported by recent literature and, recently most of the reaction appears because of the thought that “they are not actually guests.” However, rising of such a belief is not enough to change the theoretical framework constructed for the previous study: Agamben’s concepts of the camp, bare life, and state of exception, Foucault’s opinions on the relationship between security, territory, and population as associated with the socio-political practices, and Furedi’s culture of fear is still the key concepts of the theoretical process.

Purpose The following question drove this research: Would the pursuit of a rights-based approach, one that considers local dynamics and political sensitivities result in greater economic integration and social inclusion of Syrian refugees in Turkey? The paper aims to discuss this issue. Design/methodology/approach This piece draws on independent research the author conducted in Turkey and other frontline states to the war in Syria from 2016 to 2018. Findings Despite a shift in government policy toward Syrian refugees, without an overarching rights-based approach that includes the participation of all stakeholders and considers local dynamics and political sensitivities, enhancing the livelihood security of Syrian refugees and vulnerable members of host communities remains bleak in Turkey. Originality/value This original paper closely examines the Government of Turkey’s response to the humanitarian crisis that was precipitated by the armed conflict in Syria. The paper also examines the socioeconomic dynamics and increased tensions between the Syrian refugee and host communities.

Building upon empirical research, this study examines the socio-economic impact of the Covid-19 pandemic on Syrian refugees in Turkey by analyzing its implications on employment, livelihood opportunities, and social cohesion. More specifically, it focuses on the experiences of Syrian refugees to examine the ways in which they exert their agency to cope with the structural constraints when faced with ‘multiple crises’ in host countries, intersecting with the dynamics of a ‘normalized refugee crisis’. Our findings from fieldwork conducted in the top six refugee-hosting cities reveal that loss of jobs, limited access to decent work, increased dependency on external financial assistance, and social exclusion have been some of the most acute effects of the pandemic on refugees. Meanwhile, the perceived effects that refugees have on the host community’s welfare trigger problems that impede social cohesion. All in all, the study intends to highlight the far-reaching effects of the pandemic beyond its direct health implications by addressing the structural vulnerability of refugees and the importance of providing an enabling environment for socio-economic self-reliance.