Executive Summary
Five years into the Syrian Civil War we have seen mass displacement of Syrian Refugees with the most fleeing to neighbouring Turkey and the majority (62%) of these choosing to stay in the South Eastern Provinces of Turkey. There is increasing evidence of the need to respond to Mental Health and Psychosocial Support (MHPSS) as an emergency priority. The World Health Organization recommends not carrying out epidemiological surveys in the first instance because of the difficulties in accurately measuring MHPSS but using projections. For Gaziantep and Hatay it would predict >20,000 Syrian refugees with severe mental disorders 12 months’ post-emergency and a further 100,000 with mild to moderate mental disorders. However, the context means that meeting these needs can be challenging not only because of the language barrier but the complex interplay of factors that determine MHPSS needs. The suggested health promotion activities use Whitehead’s typology of health interventions for addressing health inequalities to describe interventions acting on Individual and Community Strengthening activities, improving living and working conditions and macro-level interventions. Psychological First Aid integrates MHPSS into all service delivery using an individual empowerment approach, Community-based MHPSS utilizing community development theories and Teaching Recovery Techniques is a targeted individual empowerment intervention. The first three interventions align with the IASC pyramid of MHPSS in Emergency settings. The remaining interventions looks at living conditions and macro level policy lobbying the Turkish Government for better access to MHPSS, education and Livelihoods interventions and generally breaking down barriers at a legislative level that could be impacting on MHPSS e.g. the halt on registrations and its knock-on effect on health and health inequalities within Turkey.
Section 1
Population Health Problem to be targeted: Mental Health and Psychosocial Support Needs (MHPSS)
Population at Risk: Syrian Refugees living in the Gaziantep & Hatay, Turkey
Situational Analysis
A. General Context
Turkey is today the largest recipient of Syrian refugees with Turkey as a whole having 2,896,633 registered Syrian refugees (UNHCR, 2017). It is the South East provinces of Turkey that are hosting 62% of Syrian Refugees. The continuing conflict and instability in Syria is increasingly impacting on the internal situation in Turkey, the massive influx of refugees has dramatically modified the demographic structure, 90% of refugees now live outside camps making their identification and consequently their access to MHPSS challenging. Barriers to accessing care persist for refugees mainly related to language, availability of information, lack of confidence in Turkish and international service providers and overstretched public services.
One of the greatest limitations of all the data available is it does not include those that are unregistered which is estimated to be 32% of all Syrian refugees (Erdoğan, 2014). Reasons for not registering include lack of information, language issues, lengthy administrative process or uncertainties regarding future.
B. Factors that influence the situation
1) Demographic factors
Gaziantep and Hatay have a very high number of registered Syrian refugees and there is likely to be many unregistered refugees in need of services in addition to this (Figure 1).
Figure 1. Syrian Refugees registered for Temporary Protection with the Directorate General of Migration Management from the Southeast Child Protection Sub-Working Group. December 2016.
Population
Gaziantep
Hatay
Total number of registered Syrian Refugees
318,595
377,643
Total Number in camps (AFAD, 2016)
44,434 (14%)
36,933 (9.8%)
Estimated Number of Non-Registered Syrian Refugees
32% (Erdoğan, 2014).
Table 1. Syrian Refugees in Gaziantep and Hatay.
Women and children constitute nearly 75 % of the whole refugee population in Turkey (See Figure 2).
Figure 2. Demography of Syrian Refugees in Turkey (UNHCR, 2017)
Disability is not routinely recorded and is felt to be under reported but but disability levels increase to 18-20% in conflict-affected populations and 2-4 % have severe functional difficulties.
2) Socio-cultural factors
Stigma towards mental health problems is an important cultural factor among displaced Syrian populations which is compounded with a language barrier and interaction with the host community especially if of Kurdish ethnicity. Anecdotally, integrated service models are associated with high rates of presentation. Attention to cultural appropriateness for MHPSS is critical to improving access to services (Hassan, 2015).
3) Historical, political, and regulatory and security factors
Insecurity and violence have continuously been causing displacement within Syria and across the Middle East for the past 6 years. By the end of 2016, more than 4.9 million Syrians had fled to neighbouring countries. Government services and local communal services are under strain due to the increased demand, impacting service quality for both refugees and nationals, and threatening social cohesion.
4) Socio-economic factors
It is difficult to work in Turkey. There is a lot of exploitation from the employers as they know the refugees’ very vulnerable situation. When they manage to work, the RAM’s usually have very low income-generating activities.
5) Factors linked to health policy and the organisation of the healthcare system
The healthcare system in Turkey underwent a very ambitious reform in 2003. Access to healthcare in Turkey has greatly increased with the attainment of Universal Health Coverage (covering +/-80% of healthcare expenses) (WHO, 2011). Registered Syrians have theoretical access to the Turkish healthcare system. However, the language barrier and lack of knowledge of their rights prevent refugees from accessing services.
B. MHPSS as a public health problem for Syrian Refugees
The Syrian conflict has caused unprecedented displacement and exposure to potentially traumatic events. However, MHPSS service provision in Turkey remains patchy and is nowhere near to meeting the need.
Frequency: In this setting the WHO recommends the use of projections rather than epidemiological surveys. Severe Mental disorders in adult populations affected by emergencies is predicted in 3-4% at 12 months’ post-emergency and 15 to 20% mild to moderate mental disorder. Whilst a large percentage will experience normal distress and other psychological reactions (See Table 2.).
For Syrian children, studies have shown a range of psychological symptoms including extreme fear and anxiety; sleeping problems; sadness, grief, and depression; aggression or behavioral problems; hyperactivity; speech language issues and somatic symptoms (Hassan et al, 2016). In a study of 311 Syrian Refugee children, living in camps in Islahiye, Turkey almost half of the children (45%) displayed symptoms of PTSD (Sirin & Rogers-Sirin, 2015). Clinic-reported prevalence rates for mental disorder indicate high levels of psychosocial distress (42%) (Jefee-Bahloul et al, 2014), anxiety and depression among refugees who are living in Turkey and Lebanon. In a more recent camp-based study in Turkey, 33% od refugees showed signs of psychological distress (Alpak et al, 2015). However, caution must be taken with regard to cultural appropriateness and validity of screening tools and diagnosis.
Severity of the problem: Repeated exposure to potentially traumatic situations can result in sequential traumatization impacting on physical, psychological and social wellbeing.
Consequences: Exposure to potentially traumatic events have a cumulative effect, “sequential traumatisation” (Ingelby, 2005), which is associated with PTSD and depressive symptoms. Manifestations of mental health issues reported included: sleep disturbance, depression, anxiety, post-traumatic stress disorder, risk taking behaviour and self-harming but more commonly they impact on relationships, ability to work and can lead to a breakdown in family and social life.
Additional Information Needed
There is a real need for qualitative interviews with refugees and key stakeholders. Collaborating with other actors and stakeholders via coordination mechanisms can allow access to intervention level data and stakeholder mapping and dynamics is essential to ensure that interventions do respond to a need and gap in services. It would also be good to have Mortality data for suicide disaggregated for Syrian refugees within Turkey.
Summary
While considerable relief efforts are deployed by Government of Turkey and its humanitarian partners (UN and NGOs) to support refugees with a wide range of services these are not reaching MHPSS needs.
Section 2
The following health promotion activities aim to address the health impacts and health inequalities generated in association with MHPSS and work at different levels of intervention (see figure 4. IASC, 2007). With reference to the topology of interventions for health promotion (Whitehead, 2007) the first three function at the strengthening individual and community level and the final two are more at the macro-level looking at addressing health inequalities via living and working conditions and social change via healthy Macro policies.
• Strengthening Individuals
o Universal – Psychological First Aid – Consideration of psychosocial aspects in the provision of support to address basic needs, so that is all actors provide Humanitarian aid in a way that preserves and promotes mental health, that is, it is based on community participation and equality – layer 1, IASC pyramid (figure 4)
o Targeted – Teaching Recovery Techniques – Targeted psychosocial support for children – layer 3, IASC pyramid (figure 4)
• Strengthening Communities – Community Based MHPSS – Strengthening of community support by working with the community leaders/representatives – layer 2, IASC pyramid (figure 4)
• Improving Living and Working Conditions – Facilitating access to education and livelihoods programmes to improve MHPSS.
• Promoting Healthy Macro-policies – Lobbying the Turkish Government for better access to multi-sectorial rights via access to healthcare, education and livlihoods for all Syrian Refugees and chanallegning barriers such as halted registration
Figure 3. IASC Pyramid of intervention for MHPSS (IASC, 2007)
Psychological First Aid (PFA)
Activity: PFA is humane, supportive and practical assistance to fellow human beings who recently suffered exposure to serious stressors (WHO, 2011).
Target population: Syrian Refugees
Objectives: To provide non-intrusive, practical care and support, assess needs and concerns, listen and help people connect to information, services and social supports. Ultimatey, protect people from further harm.
Theoretical underpinning: Individual empowerment
Strengths, Weakness, Opportunities and Threats (SWOT) for PFA
Helpful
Harmful
Internal origin
Strengths
• Can be used by everyone as no training in psychology required
• Standardized and available in multiple languages
• Allows for an integrated approach if all staff are trained in PFA can facilitate access to MHPSS services
Weaknesses
• Need to be careful to control the level of disclosure as can potentially lead to traumatic reliving
• Some people will require a more intense intervention and need to be identified and referred appropriately
External origin
Opportunities
• Easy to implement
• Raising awareness for all service provider on MHPSS
Threats
• Need time and space
• What do you do if you identify someone with needs that there is no service for?
Community-based MHPSS
Activity: This is based on raising community awareness on MHPSS issues, encouraging social support through culturally responsive activities, enhancing the social participation and inclusion of people in need of MHPSS and developing referral pathways to specialised services
Target population: Both Syrian Refugees and Turkish Nationals
Objectives: To reinforce community-based capacities to take into account and to address MHPSS needs of its members and mobilise individual and collective strength and resilience
Theoretical underpinning: This is building the Empowerment Approach (Naidoo, 2009) and Beattie’s model of Health Promotion in terms of Community Development (Beattie, 1991). The WHO rooted health promotion in control (WHO, 1986). In contrast to other approaches this empowerment approach looks at bottom-up strategies rather than expert led interventions. Community development allows populations to set their own priorities that can often come into conflict with practioners predefined notions of priorities. It is time consuming, difficult to measure the impact of and hence more difficult to fund (Naidoo and Wills, 2009, p.73). However, empowerment and participation have played a crucial role in health promotion for people with disabilities (Handicap International, 2014). It also allows for maximum cultural adaption (Kreuter, 2003) using culturally targeted strategies from interpreters (Linguistic strategies) to training community resource persons (Constituent-involving strategies). Therefore, in this setting it makes the the most sense taking a bottom-up approach to responding to MHPSS needs.
SWOT Community-based MHPSS
Helpful
Harmful
Internal origin
Strengths
• Community participation
• Bottom-up empowerment approach
• Culturally Tailored by virtue of the methodology
• Universal policies are more effective than targeted policies (Korpi & Palme, 1998)
Weaknesses
• Can be labour intensive and take a lot of time to set up
• Some people will require a more intense intervention
External origin
Opportunities
• Raising awareness of MHPSS
• Allows exploration of the socio-cultural context and dynamics
Threats
• Difficult to measure impact of so difficult to get funding
Teaching Recovery Techniques (TRT)
Activity: Targeted psychosocial support training community resource people to deliver recovery techniques training for children (Children and War Foundation, 2016). . It teaches children techniques to help them deal with common symptoms of Post-Traumatic Stress. Whilst teaching skills which help them cope with difficulties and prepare for possible future difficulties.
Target population: School Age Children with parallel parent work
Objectives: Designed to prevent as much as possible the need for later psychological treatment.
Theoretical underpinning: This builds on Empowerment approach to health promotion focusing on individual empowerment (Naidoo, 2009). Children learn how to identify their reactions and are taught how they can relax at will. They are encouraged to make use of their own techniques to induce relaxation and where possible bolster these by breathing exercises and muscle relaxation.
SWOT for TRT
Helpful
Harmful
Internal origin
Strengths
• TRT – works with the entire family and provides often very acceptable access to services for adults which may have been otherwise complicated by stigma
• Cost effective
• Creates a network of contacts that gives a strong sense of community, support and reactivity.
• Validated for Syrian refugee children (Oouta et al, 2012) (Barron et al, 2013).
Weaknesses
• Risk of vicarious traumatisation for other children.
• Some children will require a more intense intervention and need to be identified and referred appropriately
External origin
Opportunities
• Access to parents that may be less likely to access mental health services due to associated stigma.
• It recognises that not all children are badly affected by exposure to disasters and war, although a high proportion may be and takes a public health approach
Threats
• The distribution of Syrian Refugees may make it difficult to conduct group work
• Will need to make sure that staff are trained to use the manual and there is a space to conduct the sessions.
Access to Education and Livlihoods
Activity: Facilitate access to education and livelihoods programmes via legislation and refulations that increase access to employment and education for Syrian Refugees.
Target population: All Syrian Refugees
Objectives: Designed to tackle upstream determinants of poor MHPSS outcomes and to build resilience.
Theoretical underpinning: This builds on Social Change approach of health promotion focusing on top-down approachs to health promotion (Naidoo, 2009).
Promoting Healthy Macro-policies
Activity: Lobbying to reduce the barriers to registration for Syrian Refugees in Turkey.
Target population: All Syrian Refugees
Objectives: Designed to tackle barriers to accessing the full remit of rights including the right of access to MHPSS.
Theoretical underpinning: This builds on Social Change approach of health promotion focusing on top-down approachs to health promotion (Naidoo, 2009).
Conclusion
There is a huge unmet need when it comes to MHPSS for Syrian Refugees in Turkey but this is something that is difficult to measure in an acute settings and difficult to respond to in a complex emergency like the Syrian Crisis. Culturally adapted context specific health promotion activities are needed to be able to best meet these needs(Hassan et al 2015). However, to ensure that all interventions are adapted there must be community participation and empowerment. For this reason, this paper proposes using the empowerment approach as the basis for its individual and community level health promotion activities. Providing a bottom-up approach to health promotion. Running alongside this, there is still a need to tackle some of the upstream determinants of MHPSS such as poor access to education, employment and healthcare. It acknowledges that community–based interventions are more time consuming and more difficult to measure the impact or and hence fund. However, when it comes to the needs of Syrian Refugees Peter Ventevogel, senior mental health officer with UNHCR, has stressed we need to go beyond clinical services and strengthen community support mechanisms (Abou-Saleh & Hughes, 2015). Participation can lead to the closest form of context-adapted intervention as who better knows the needs and the challenges a population faces than population themselves. We should not just pay lip service to participation but see it as an integral part of making an intervention fit for purpose and at the root of all health promotion activities have an emphasis on the impact of the context on health and how we can work at multiple levels to improve health.